MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II

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MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR II

THORACIC SURGERY

Volume I

Prepared and published under the direction of

Lieutenant General LEONARD D. IIEATON

The Surgeon General, United Suites Army

Editor in Chief

Colonel JOHN BOYD Co VIES, Jr., MC, USA

Editor for Thoracic Surgery

FRANK B. BERRY, M.D.

Associate Editor

ELIZABETH M. MOFETRIDGE, M.A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D.C., 1963
SURGERY IX WORLD WAR II

Advisory Editorial Board

MICHAEL E. DEHAKEY, M. IX, Chairman

FHAXK B. BERRY, M.I). JOHN B. FLICK, M.1X

BRIAN BLADES, M.I). FRANK GLENN, M.D.

J. BARRETT BROWN, M.D. M. ELLIOTT RANDOLPH, M.D.

STERLING BUNNELL, M.D. (dee.) ISIDOR S. RAVDIN, M.D.

NORTON CANFIELD, M.D. JOSEPH R. SHAEFFER, M.D.

B. NOLAND CARTER, M.D. ALFRED R. SIIANDS, Jr., M.D.

EDWARD D. CHURCHILL, M.1X HOWARD E. SNYDER, M.D.

MATHER CLEVELAND, M.D. R. GLEN SPERLING, M.D.

DANIEL C. ELKIN, M.D. (dec.) BARNES YV'OODHAI.L, M.D.

ROBERT M. ZOLI.INGER, M.D.

Brigadier General DOUGLAS B. KENDRICK, Jr. (ex offieio)

Brigadier General JAMES E. GRAHAM (ex oflicio)

Colonel JOHN BOYD COATES, Jr., MC, USA (ex offieio)

The Historical Unit, United Stales Armi/ Medical Service

Colonel JOHN BOYD COATES, Jr., MC, USA, Director

Colonel REX P. CLAYTON, MSC, USA, Executive Officer

Colonel R. L. PARKER, MSC, USA, Special Assistant to Director

Lieutenant Colonel R. J. BERNI CCI, MC, USA, Special Assistant to Director

Major WARREN W. DABOLL, MSC, USA, Special Assistant to Director

Lieutenant Colonel DOUGLAS HESFORD, MSC, USA, Chief, Special Projects Branch

CHARLES M. WII.TSE, Ph. D., Litt. IX, Chief, Historians Branch

ERNEST ELLIOTT, Jr., Chief, Editorial Branch

Lieutenant Colonel LEONARD L. COLLIER, MSC, USA, Chief, Information Activities Branch

Major ALBERT C. RIGGS, Jr., MSC, USA, Chief, General Reference and Research Branch

HAZEL G. HINE. Chief, Administrative Branch

Library of Congress Catalog Card Number: 03-6000
THORACIC SURGERY

Volume I
MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department of

the U.S. Army in World War IT are prepared by The Historical Unit. U.S.

Army Medical Service, and published under the direction of The Surgeon

Genera], U.S. Army. These volumes are divided into two series: (1) The administrative or operational series; and (2) the professional, or clinical and

technical, series. This is one of the volumes published in the latter series.

VOLUMES PUBLISHED

ADMINISTRATIVE SERIES

Ilospitalization and Evacuation, Zone of Interior

CLINICAL SERIES

Internal Medicine in World War II:

Vol. I. Activities of Medical Consultants

Vol. II. Infections Diseases

Preventive Medicine in World War II:

Vol. II. Environmental Hygiene

Vol. III. Personal Health Measures and Immunization

Vol. IV. Communicable Diseases Transmitted Chiefly Through

Respiratory and Alimentary Tracts

Vol. V. Communicable Diseases Transmitted Through Contact or By

TJnhnoten Means

Surgery in World War II:

Activities of Surgical Consultants, vol. I

General Surgery, vol. II

Hand Surgery

Neurosurgery, vol. I

Neurosurgery, vol. II

0ophthalmology and Otolaryngology
VIII

Surgery in World "Win" II—Continued

Orthopedic Surgery in the European Theater of 0iteration*

Orthopedic Surgery in the Mediterranean Theater of Operations

The Physiologic Effects of Wounds

Vascular Surgery

Miscellaneous:

Cold Injury, Ground Type

Dental Service in World War II

Veterinary Service in World War II

Wound Ballistics
Authors

FliANK I!. BEKliY, M.D.

Deputy Assistant Secretary of Defense (Manpower-Health and Medical). Washington,

D.C. Professor of Clinical Surgery Emeritus, Columbia University, New York. X.Y.

Formerly Surgical Consultant, Seventh U.S. Army. Brigadier General. USA (Ret.'i.

LllIAX BLADES, M.D.

1'rofessor of Surgery, The George Washington University School of Medicine; and

Chief Surgeon. The George Washington University Hospital. Washington. D.C. Formerly Colonel. MC. AUS.

LYMAX A. P.KEWEK III, M.D.

Clinical Professor of Surgery and Chairman of the Section on Thoracic and Cardiac

Surgery, School of Medicine. Coma Linda University. Los Angeles. Calif. Formerly

Lieutenant Colonel, MC, USAR.

THOMAS II. BIREOUI), M.I).

1'rofessor of Thoracic and Cardiovascular Surgery, Washington University School of

Medicine, St. Louis. Mo. Formerly Lieutenant Colonel. MC, ACS.

P.. XOLAXD CAKTEK, M.D.

Professor of Surgery Emeritus. College of Medicine, University of Cincinnati, Cincinnati, Ohio. Formerly Colonel, MC. AUS.

MICHAEL E. DEP.AKEY. M.D.

Professor of Surgery and Chairman of the Department of Surgery, Baylor University

College of Medicine, Houston, Tex. Formerly Colonel, MC, AUS.

EKXEST A. Dorn, M.D.

Anesthesiologist, San Diego, Calif. Formerly Lieutenant Colonel. MC. USAR.

DWICIIT EJIARY HARKEX, M.D.

Associate Clinical Professor of Surgery, Harvard Medical School : Surgeon, Peter Bent

Brigham Hospital ; Chief of Thoracic Surgery, Mount Auburn and Maiden Hospitals.

Formerly Lieutenant Colonel, MC, AUS.

IX

(i.VHiSl-'—(>2
Foreword

With the publication of this volume, the first of two which tell the story

of thoracic surgery in World War II, there has been completed one more phase

of the historical project in which is being told the total story of the U.S. Army

Medical Department in World War II. One of my predecessors, the late Maj.

Gen. Merritte W. Ireland, considered the completion of the World War I medical history perhaps the most important achievement of his tour of duty in this

office. It gives me great satisfaction that some of the volumes of the far more

ambitious World War II medical history are being completed during my own

tour of duty.

It is with particular pleasure that I observe the publication of the volumes

on thoracic surgery. As commanding officer of the, 160th General Hospital in

the United Kingdom Base during World War II, I had the responsibility for

the thoracic surgery center established there. At this center, rehabilitation of

the Thoracic casualty, based on British concept, was carried out with an attention to detail not, I believe, achieved at any other installation during the war.

At this same center, as is related in detail in the second of the volumes on

thoracic surgery, there was also carried out a series of almost fantastically

successful operations for the removal of retained foreign bodies from the heart

and great vessels.

The story of thoracic surgery in World War II is told so fully in this

volume and the volume that follows that little additional comment is needed

in this foreword. Three special points, however, might be mentioned.

The first concerns the material collected on 2,2(>7 thoracic casualties by the

thoracic surgical teams of the 2d Auxiliary Surgical Group. These data,

unique in respect to both number of cases and details concerning them, are

evidence of what careful planning and systematic endeavor can accomplish

even under the stress of battle. Nothing like them exists in the previous

medicomilitary literature. They will serve as a point of departure for all

future studies of thoracic wounds.

The second point I would comment on is the system of chest centers, established with the practical purpose of assembling all casualties with the same

kinds of injuries under the same roof, so to speak. This system permitted the

most efficient use of thoracic surgeons, who were always in short supply, and if

resulted in an excellence of care which could not have been achieved had these

casualties been scattered through various nonspecialized hospitals under the

care of surgeons who, however competent they might be, were, most of them,

not thoracic surgeons.

Finally, I would point out that the thoracic surgery volumes, like all volumes in the historical series, are written with candor and frankness. The
XII FOREWORD

primary objective of this entire history is to relate events as they occurred. I

believe this objective has been fully achieved. It has certainly been achieved

in the thoracic surgery volumes. For example: The results of the management of thoracic wounds in 1944 and 194;*) were far better than they had been

in any previous war. Frequently they were brilliant. But these good results

followed some very poor results in the early months of the war, before policies

and practices in this Held had become standardized and when surgical procedures were often unnecessarily radical. Those early results, as well as the

reasons for them, are described in detail. Such instances of the frank statement of errors could be multiplied. A careful reading of this volume and of

the second thoracic surgery volume should mean that such mistakes will not

be made again in any future war.

As The Surgeon General, I am responsible for the preparation and publication of the volumes of the historical series. My grateful thanks go to the

authors and editors who have worked on them so devotedly and have produced

volumes of such outstanding merit.

Particular appreciation is due Dr. Frank B. Berry, Editor for Thoracic

Surgery, who came to the rescue of these volumes when the entire thoracic

surgery project had bogged down in delays and frustrations. That the task

has been carried to a successful conclusion is largely attributable to Dr. Berry's

personal enthusiasm, endless patience, and wise guidance.

LEOXAKD I). HEATOX,

Lieutenant, General.

The Surgeon Genera1.
Preface

The history of thoracic surgery in World War II comprises two volumes of

(lie. total series dealing with the history of the T'.S. Army Medical Department

in that War. The fact that it did not prove possible to tell the complete story

in any briefer compass is, in itself, an indication of the importance attached

to (his specialty in the Second World War.

The first volume contains a summary of the development of thoracic

surgery in previous wars, the general and statistical background of the World

War II experience, administrative considerations in the Mediterranean and

European theaters and in the Zone of Interior, the evolution of policies of

management, of chest wounds, and the routine of management of thoracic

casualties from their emergency care on the battlefield through their rehabilitation in chest centers.

The second volume is concerned with special types of chest injuries and

with the management of general and special complications, with particular

emphasis on the wet lung syndrome. Iiemothorax and hemothoracie eiupyenia,

and retained foreign bodies. It also contains a followup study, made in 1900

and 19G1. of 107 casualties who sustained chest wounds in the lWo-l.'i period.

The. history of thoracic surgery contained in these two volumes represents

the full dowering of this specialty in World War II. Its development, however, was bv a process of evolution. In spite of the advances in it between the

World Wars, the management of thoracic injuries in the early months of the

U.S. participation in the Second World War must be described as tentative.

It was based on the previous experience and the personal practices of individual

chest surgeons, whose number was small, and of general surgeons, whose experience, in this Held was limited and sporadic.

P>y the spring of 1944, a number of developments, including increasing

experience with combat-incurred thoracic wounds, permitted the standardization of policies and practices and led to more excellent results than had ever

before been achieved in chest trauma. These developments were as follows:

1. It became evident that plasma was not the answer to the problem of

resuscitation of combat casualties, including thoracic casualties, and that whole

blood was essential to prepare them for, and carry them through, the necessary

surgery. In February 1944. a blood bank was established in Xaples. Thereafter, blood was available in such amounts as were needed before, during, and

after operation, and all the surgeons who handled chest wounds could now

administer it according to the necessities of (heir patients.

2. With the advent of penicillin, the possibilities of thoracic surgery were

greatly expanded, and operations previously considered impossible became

feasible and safe.

XIII
XIV PREFACE

3. Efficient anesthetic apparatus was provided for the use of the anesthesiologists who, by training and experience, were especially qualified to give

anesthetics for chest surgery.

4. A routine for the management of chest injuries, with procedures properly spaced as to time and place of performance, was set up in the Mediterranean

theater by Col. Edward D. Churchill, MC, Consultant in Surgery to the theater

surgeon. It was derived from the wartime experience of the chest surgeons

who, in the preceding months, had applied their peacetime training and experience to the management of these injuries, and it was based on the concept

that the goal of resuscitation, surgery, and postoperative care was the restoration of normal pulmonary function.

The availability of blood was extremely important. The availability of

penicillin was extremely important. Expert anesthesia is always essential for

chest surgery. But it was the correct, properly timed and properly spaced

surgical management of chest injuries and their sequelae that was primarily

responsible for the outstanding results achieved in them in World "War II.

The routine of management of chest injuries set up early in 1044 included

prompt and adequate debriclement; the performance of thoracotomy in forward

hospitals only on strict indications; prompt and adequate measures to control

such potentially dangerous complications as wet lung; the management of

hemothorax by aspiration; the management of organizing hemothorax and

hemothoraeic empyema by decortication; and the judicious removal of retained

foreign bodies, whose presence seldom furnished the sole indication for thoracotomy in a field or evacuation hospital.

As a result of these policies and practices, lives were saved; morbidity

was reduced; and most thoracic casualties who survived their wounds were

returned to duty or separated from service -without the crippling sequelae

characteristic of so many thoracic injuries in World War I.

The fact that several circumstances favored thoracic surgeons in World

War II does not detract at all from their brilliant achievement. The epidemics of measles and influenza, with their sequelae of pneumonia and empyema,

which had plagued the surgeons of World War I did not occur in World

War II. In the interim between the wars, the United States had ceased to be a

rural nation and had become an urban nation, and most of the World War II

troops had long since been exposed to these diseases. Streptococcic infections

no longer held the terror they once held because the sulfonamides, which are

particularly useful in this type of infection, were already available and had

been well tested before the United States entered the Avar.

The evolution of the management of chest injuries in World War II

occurred in. the Mediterranean theater, in which fighting began in late 1942,

The thoracic surgeons in the European theater built their policies of management largely upon the experience in this theater, but they had ample time to

develop their own philosophy before the Normandy invasion.

In May 1943, Maj. Gen. Paul K. Uawley, Chief Surgeon, European theater,

visited the Mediterranean theater and observed the management of all varieties
PREFACE XY

of surgery. Later in the same year, Co], (later Brig. Gen.) Elliott C. Cutler,

MC, Senior Consultant in Surgery in the European theater, also visited the

Mediterranean theater. By this time, the experience of the first chest center

in the theater, at Bizerte, was available for analysis. The thoracic surgeons in

the European theater also leaned heavily on the extensive British experience,

particularly that of Mr. A. Tudor Edwards, Consultant in Thoracic Surgery

to the British Emergency Medical Service. As a result of these various contacts, the policies outlined in the booklet entitled "Manual of Therapy" published in the European theater in May 1944 represented a compendium of

previous experiences with thoracic injuries and their management, and they

served admirably when they were tested in combat.

The repeated references to the data of the 2d Auxiliary Surgical Group in

both these volumes are explained elsewhere, but the explanation might be

repeated here. The group material on 2,207 thoracic and thoracoabdominal

wounds, like the material on o,151 abdominal injuries analyzed in another

volume of this series, is available for reference because its collection was planned

in advance. Thanks to the foresight and insistence of Col. (later Brig. Gen.)

James H. Forsee, MC, commanding officer of the group, orders were given to

keep detailed records of individual thoracic casualties, and appropriate forms

were provided for this purpose. These data could not possibly have been collected after the event. As it is, while some details are understandably lacking,

the magnitude of the achievement is impressive, Nowhere else in the medicomilitary literature of "World War II or previous wars is there available for

analysis and reference such a large series of thoracic and thoracoabdominal

injuries.

Similar planning by the consultants in surgery of the Fifth and Seventh

U.S. Armies also produced important, though somewhat less extensive, data.

The development of specialty centers was one of the important medical

advances in World War II. Some of these centers existed in World War I,

but thoracic surgery had not yet reached sufficient stature to be included among

them. Specialty center's were established early in the Second World War,

and thoracic surgery centers were among the earliest to be set up, in the Mediterranean and European theaters as well as in the Zone of Interior. The concentration of thoracic casualties in these centers permitted the most effective

use of the always limited number of thoracic surgeons; greatly extended the

experience of these surgeons, and thus resulted in constantly improving care

of patients with these injuries.

The emphasis put upon rehabilitation in World War II was a continuation

of the similar, but less intensive, efforts in the same direction in World War I.

In World War II, this phase of the management of chest injuries probably

developed most intensively in the European theater, where circumstances were

highly favorable for the establishment of chest centers and where the influence

of the British emphasis upon rehabilitation was most apparent. In one form

or another, however, rehabilitation of chest casualties was uniformly practiced.
XVI PREFACE

It is one of the reasons why so many thoracic casualties could be returned to

duty and why Veterans' Administration hospitals are not caring for the army

of chest cripples who required multiple operations and years of hospitalization

after World War I.

Theater consultants in thoracic surgery were not appointed in "World War

II, but the consultants in surgery in both the Mediterranean and the European

theaters had a special interest in this field and exercised wise and helpful

guidance in it. Their efforts were supported, in turn, by the theater surgeons:

Brig. Gen. Frederick A. Blesse and Maj. Gen. Morrison C. Stayer in the Mediterranean theater and General Hawley in the European theater. The theater

surgeons encouraged meetings of consultants, at which it was possible to exchange ideas and after which information could be promptly disseminated.

Immediately after the war in Europe ended, the Consultant in Surgery,

Seventh U.S. Army, was ordered back to Naples, to consolidate the experiences

of the Seventh U.S. Army with that of the Fifth U.S. Army and thus provide

a broader perspective derived from the dual experience.

A special word should be said about the excellent liaison which existed

between thoracic and other surgeons also in the U.S. Army and their counterparts in the Allied armies. The consultants" meetings in the European theater

always included British surgeons, both in the United Kingdom Base and on

the Continent, where there were cordial relations with the surgeons of the

British 21 Army Group. In the Mediterranean theater, contacts with British

surgeons were chiefly local but no less cordial. At the larger medical meetings

of U.S. Army surgeons, such as those held in Xaples, British surgeons from

nearby hospitals were always in attendance.

Early in 19-h!, the theater consultant in surgery had frequent contacts with

the thoracic surgeons in the group of British hospitals near Algiers. Colonel

Churchill visited one of these hospitals and observed the work with penicillin

done by Dr. (later Sir) Howard Florey and his team. The chief of the surgical

service, 9th Evacuation Hospital (later Consultant in Surgery, Seventh U.S.

Army), also observed the work with penicillin and later visited several British

hospitals, including a field hospital, two casualty clearing stations, and a general hospital. Throughout the war, Colonel Churchill kept in close touch with

the British surgical consultants in the Mediterranean theater. Brigadier .1. M.

Weddell, BAMC, and Brigadier Harold Edwards, BAMC. The policies in

chest surgery established in this theater were influenced by the information he

received by personal contacts with Sir W. Heneage Ogilvie, from his earlier

British experience in the Middle East. Colonel Churchill also had early and

frequent contacts with Col. A. L. dAbreu, BAMC.

Early in the war, Colonel Churchill had the good fortune to know Col.

Etienne Curtillet, Professor of Surgery, University of Algiers and Chief

Surgical Consultant, French 1st Army. During the planning for the invasion

of southern France by the Seventh U.S. Army, the consultant in surgery to that

Army had many and useful contacts with Colonel Curtillet. which continued

throughout the entire campaign.
PREFACE XAH

The story told in these two volumes is tlius based upon a broad and varied

experience with thoracic injuries in World War II, during which the achievements in this field laid the foundations for the brilliant advances in it which

have occurred since the war. The emphasis in this history, it should be noted,

is factual. The aim has been to relate the events in chronicle form, with no

attempt at a critique of the motives behind, or the reasons for, the various

actions taken.

The story of thoracic surgery in these two volumes covers only the Mediterranean and European theaters and the Zone of Interior. For a number of

reasons, chest surgery in the Asiatic-Pacific theater will be discussed in the

volume dealing with surgery in those areas.

The type of warfare in this theater was very different. This war was

fought in scattered areas; on numerous, often widely separated islands: m

jungles: in a tropical climate that was humid as well as hot and in which rainfall was frequent and torrential: in an environment in which parasitic and

other tropical diseases furnished problems that were often more serious than

the problems of battle injuries; and in areas in which transportation and

evacuation were always slow and difficult.

It is small wonder that in the Asiatic-Pacific theater, infected hemothorax,

empyema, and other complications of chest injuries were more frequent than in

other theaters. It is a tribute to the skill and devotion of the surgeons who

worked in these areas that their incidence was not higher.

It wotdd be impossible to produce books of the range of these volumes on

thoracic surgery without (he painstaking and devoted assistance of a great many

persons and agencies. In the end, for a variety of reasons, the chief responsibility for the preparation of this material fell upon a relatively small number

of authors. It is a pleasure to make acknowledgment to them :

Dr. Brian Blades (formerly ('ok, MC). Consultant in Thoracic Surgery to

The Surgeon General and chief of the Thoracic Surgery Section at Walter

Peed General Hospital, Washington, P.C., during World War II.

Dr. Pyman A. Brewer III (formerly Maj., MC), who served with Thoracic

Surgical Team No. 2, 2d Auxiliary Surgical Group, in the Mediterranean

theater and later in the European theater.

Dr. Thomas IT. Burford (formerly Maj., MC), who served with Thoracic

Suro-ical Team No. ">, 2d Auxiliary Surgical Group, in the Mediterranean

theater.

Dr. B. Noland Carter (formerly Col., MC), Assistant Director, Surgical

Consultants Division, Office of The Surgeon General. Dr. Carter, in addition

to preparing the chapters which carry his name, reviewed the entire manuscript

and made helpful suggestions.

Dr. Michael E. DeBakey (formerly Col., MC), Chief, Surgery Branch.

Surgical Consultants Division, Office of The Surgeon General, and now chairman of the Advisory Editorial Board for Surgery.
XVIII PREFACE

Dr. Dwight E. Harken (formerly Lt. Col., MC), Regional Consultant in

Thoracic Surgery to the Senior Consultant in Surgery, European theater.

Dr. Harken also directed the chest center at the 160th General Hospital.

Mr. Milton C. Rossoff, Assistant Chief, Statistical Analysis Branch,

Medical Statistics Division, Office of The Surgeon General, collected and tabulated the official statistics for the thoracic surgery volumes.

Mr. Melvin J. Hadden was responsible for the artwork in both volumes.

He made usable many illustrations which originally seemed beyond salvage.

Grateful acknowledgment is also due to a number of the personnel of The

Historical Unit, U.S. Army Medical Service:

Maj. Albert C. Riggs, Jr., MSC, Chief, General Reference and Research

Branch, and Mrs. Esther E. Rohlader, Assistant Chief, provided much of the

basic data for these volumes and patiently and efficiently answered endless

queries and tracked down numerous obscurities to their final solution.

Mrs. Pauline B. Vivette, Assistant Chief, Editorial Branch, prepared both

volumes for publication.

Mrs. Hazel G. Hine, Chief, Administrative Branch, handled the multiple

details connected with the preparation of volumes issued under Government

auspices and also supervised the final typing of the manuscript.

Finally, a special word of appreciation is due to two other persons who

worked on these volumes:

Miss Elizabeth M. McFetriclge, Associate Editor for the surgical series of

volumes, who, after many discouragements, was able to bring together the

material prepared by the group of thoracic surgeons who worked in the Mediterranean and European theaters and to prepare it for publication.

Col. John Boyd Coates, Jr., MC, who lias been assigned bv The Suro-eon

General as Director, The Historical Unit, U.S. Army Medical Service^and

Editor in Chief of the history of the U.S. Army Medical Department in World

War II. Colonel Coates, who served in World War II as Executive Officer,

Medical Division, Third U.S. Army, saw the unfolding of the story of thoracic

surgery in the European theater and, during the campaign, was' in frequent

contact with the Consulting Surgeon, Sixth U.S. Army Group. His firsthand

knowledge has been useful, and his cooperation in all the -work on these two

volumes has been most helpful.

FRANK B. BEKRY. M.D.
Contents

FOREWORD.

PREFACE- _

Page

XI

XIII

Part I

INTRODUCTION

Chapter

I Historical Xotc (Frank B. Berry, M.D.) 3

Early Observation» ''

The Crimean War

The Civil War

World War I

Empycma in World War 1

Decortication in Fmpyema

The Period Between the World Wars

British Chest Surgery in World War II 30

German Chest Surgery in World War II 3o

Special Types of Wounds 38

Retained Intrathoracic Foreign Bodies -11

Wounds of the Heart and Pericardium -12

4

17

24

'28

II General Considerations of Thoracic Wounds {Frank B. Berry, M.D.) 51

Classification of Chest Wounds 51

Characteristics of Chest Wounds 51

54

50

Wounding Agents

Velocity of Missiles

Vulnerability of the Chest to Wounding 59

Incidence and Case Fatality Rates 60

Battlefield Deaths 64

Part II

ADMINISTRATIVE CONSIDERATIONS IN WOUNDS OF

THE CHEST

Chapter

III Administrative Considerations in the Mediterranean (Formerly North African) Theater of Operations (Lyman A. Brewer III, M.D., and Thomas II.

Burford, M.D.) p

The Consultant System ~'%

Thoracic Surgery Personnel 74
XX CONTEXTS

Chapter j>aiJ(,

III Administrative Considerations in the Mediterranean—Continued

Evacuation and Transport . _. 7,5

Training 70

Conferences and Meetings . . 82

Equipment 84

Blood Supply 90

Hospital Installations . 00

Auxiliary Surgical Groups . 102

Disposition \\Q

IV Administrative and Basic Clinical Considerations in the European Theater of

Operations (Dwight E. Harken, M.D.) ] l;i

Section I. Administrative Considerations

The Consultant System 11;-;

Personnel __ _ wj

Training __ [19

Dissemination of Information ]22

Supply and Equipment ]2ß

Thoracic Surgical Teams 128

Thoracic Surgery Centers 13]

Prisoners of War 137

Section II. Basic Clinical Considerations

Evolution of Clinical Policies 138

Manual of Therapy, European Theater. _ 1 -11

Reports of Chest Centers in the United Kingdom Base 146

V Administrative Considerations in the Zone of Interior (Brian Plades, M.D..

P. Noland Carter, M.D., and Michael E. DePaheij, M.D.) _' ](U

The Consultant in Thoracic Surgery 161

Subcommittee on Thoracic Surgery, Division of Medical Sciences,

National Research Council I (i;ä

Personnel Kj4

Training" __ 155

Anesthesia __ _ ]f;7

Equipment 157

Manual on Thoracic Surgery 167

Thoracic Surgery Centers 168

Reports of Thoracic Surgery Centers 173

Registry of Foreign Bodies 181

Part III

GENERAL MANAGEMENT OF WOUNDS OF THE CHEST

VI Evolution of Clinical Policies in the Mediterranean (Formerly North African)

Theater of Operations (Thomas II. Burford, M.Ü.) 18.5

General Considerations 185

Staging of Surgical Care 186

Official Policies in Chest Injuries 180

Early Experience in the Mediterranean Theater 193
COXTKXTS XXI

Pane

Chapter

VI Evolution of Clinical Policies in the Mediterranean—Continued

Development of Concept of Chest Injuries 19'

Formulation of Policies WS

Triage and Transportability -°-

Results of Therapy 2°'

Special Types of Wounds 2as

The Seventh U.S. Army 2U

VII Emergency Measures (hi/man A. Brewer III, M.I).)— - -- -----

21^

Management on the Battlefield -- -- -- -

L:> Management in Battalion Aid and Collecting Stations ___ __ -- - 216

Management in the Clearing Station 216

Transportation 218

VIII Diagnosis {human A. Brewer III, M.D.) 21!)

General Considerations^.. ^

)

'

)

History-Taking and Physical Examination 220

Clinical Picture 2;

U

Roentgenologic Diagnosis

IX Resuscitation and Preoperative Preparation {human A. Braver III, M.D.)— 23

241

General Considerations Ziil

Routine of Resuscitation 959 Thoracentesis_ __ --- -

9^Q Replacement Therapy "__

Emptying of the Stomach 2^

Resuscitation in Thoracoabdominal Wounds -o'

Response to Resuscitation -- -- -- -°°

Psychologic Considerations - - - 259

X Anesthesia {Ernest A. Doud, M.D.) 261

General Considerations -

hl

Equipment ^~

Preoperative Preparation j0-

rp , 263 Technique

Adjunct Therapv During Operation j6°

r> 1 -- 265 Bronchoscopy

XI Initial Wound Surgery {human A. Brewer III, M.D.) 269

General Considerations "_

Debridement 901

Traumatic Thoracotomy -

oi

Elective Thoracotomv

90A Special Technical Considerations "

ou

Catheter Suction and Bronchoscopy Immediately After Operation 290

Complications During Surgery -

J

-'

Postoperative Management ^',-

Chemotherapy and Penicillin Therapy 29°

XII Reparative Surgery {Thomas II. Burford, M.D.) -

JJ

General Considerations -

J

Delayed Primary Wound Closure 30°

Replacement Therapy M~

Reparative Surgery and the Learning Curve "

50S
XXI1 CONTENTS

Chapter Pagg

XIII Reconditioning and Rehabilitation (Dwii/ht E. Harken, M.D., B. Noland

Carter, M.D., and Michael E. DeBakeij, M.D.) 305

General Considerations 395

General Policies 307

Development of Program, Mediterranean Theater 311

The Program in the European Theater 314

The Program in the Zone of Interior 316

APPENDIXES

A Material on Thoracic Exercises Given to Patients at Thoracic Surgery Center,

160th General Hospital, European Theater of Operations 341

B Greeting from Commanding Officer, Baxter General Hospital, to Thoracic

Casualties 3J5

INDEX.

Illustrations

Figure

1 Sir Alexander Fleming

2 Sir Howard Florey

3 Chain of evacuation to oversea thoracic surgery center.

.347

30

30

77

SO

85

86

88

4 Unloading wounded at battalion aid station _ 7g

5 Air evacuation of wounded

6 Improvised portable suction machine

7 Improvised portable suction machine __

8 Transportation for auxiliary surgical group team

0 Officers' quarters at evacuation hospital on Anzio beachhead 95

10 Views in oversea thoracic surgery center 99

11 Mr. A. Tudor Edwards, British consultant in thoracic surgery, World War II. 116

12 Air evacuation, Continent to United Kingdom Base 133

13 Views in oversea thoracic surgery center J34

14 Oversea thoracic surgery center J35

15 Technique of drainage of empyema __ ]4§

16 Technique of ligation of thoracic duct laceration 152

17 Combined drainage of empyema and liver abscess 154

18 Emergency management of sucking chest wound „ _ __. _ 214

19 Emergency management of sucking chest wound ... 215

20 Emergency treatment of ambulatory chest casualties ... 217

21 Chest casualty with multiple associated wounds 221

22 Diagrammatic showing of chest wounds and associated injuries ... 222

23 Diagrammatic showing of chest wounds and associated injuries _ 223

24 Diagrammatic showing of chest wounds and associated injuries ... 224

25 Diagrammatic showing of chest wounds and associated injuries 225

26 Diagrammatic showing of chest wound and associated injuries 226

27 Diagrammatic showing of chest wounds and associated injuries 228

28 Bizarre course of missile causing chest wound 231

29 Roentgenogram showing track of missile in lung 235

30 Resuscitation of chest casualty •>;$()

31 Management of tension pneumothorax 251
CONTEXTS XXIII

Figure p«<Je

32 Management of tension pneumothorax 252

33 Improvised anesthesia apparatus 262

34 Position for posterolateral thoracotomy 273

35 Debridement of chest wound 274

36 Techniques of wound closure 276

37 Technique of plastic wound closure 277

38 Technique of closure of sternal defect 278

39 Technique of plastic closure of anterior sucking wound 279

40 Technique of rib approximation without pericostal sutures 280

41 Effect on rib of pericostal suture 280

42 Exposure in posterolateral thoracotomy 283

43 Burford technique of traumatic thoracotomy 284

44 Wound closure in Burford technique 285

45 Modified Harken technique for exposure of vessels in superior mediastinum

and base of neck - 286

46 Sites and techniques of drainage 289

47 Convalescent reconditioning exercises for bed patients 308

48 Exercises to restore shoulder function 312

49 Individually prescribed exercises for early postoperative period 319

50 Mild chest exercises shortly after operation 319

51 Basic thoracic exercises 320

52 Basic thoracic exercises 321

53 Basic thoracic exercises 322

54 Basic thoracic exercises 323

55 Basic thoracic exercises 325

56 Basic thoracic exercises 326

57 Basic thoracic exercises 32/

58 Basic thoracic exercises 328

59 Basic thoracic exercises 329

60 Basic thoracic exercises 330

61 Basic thoracic exercises 331

62 Basic thoracic exercises 332

63 Supplementary exercises 333

64 Supplementary exercises 334

65 Supplementary exercises 33o

66 Record of individual progress 336

67 Supervised group exercises 337

Tables

Number

1 Statistics of chest wounds before Crimean War 5

2 Data on anatomic, site and nature of injury in thoracic and thoracoabdominal

wounds, 1944 52

3 Data on causative agents and theaters of occurrence in chest injuries, 1944__ 55

4 Data on causative agents and year of occurrence in chest injuries, 1942-45. _ 56

5 Data on deaths by causative agents and theaters of occurrence in chest injuries,

1944 57

6 Data on case fatality ratios by causative agents in chest injuries, 1942-45.__ 58

7 Data on nature of traumatism and theater of occurrence in chest injuries,

1942-45 62
XXIV CONTENTS

Xu in bei- Page

8 Data on deaths by nature of traumatism and theater of occurrence in chest

injuries, 1942-45 63

9 Data on anatomic site and year of occurrence in thoracic and thoracoabdominal wounds, 1942-45 64

10 Data on deaths in thoracic and thoracoabdominal wounds by anatomic site

and year of occurrence, 1942-45 65

1 1 Data on deaths in action by anatomic site of wound and theater of occurrence,

1942-45 67

12 Data on deaths in action by anatomic site of wound and theater of occurrence,

1944 1 68

13 Anesthesia in Seventh I'.S. Army, November 1944-April 1945 264
Part I

INTRODUCTION
CHAPTER I

Historical Note

Frank B. Berry, M.D.

EARLY OBSERVATIONS

Military surgery is as old as man himself, and battle wounds of the chesr,

and fatalities from them, are as old as military surgery. Homer described

thoracic wounds vividly and with anatomic correctness. He also described how

arrows rebounded harmlessly from the plated steel breastplates worn by soldiers

during the Trojan War (1). It was not until World War II that U.S. Army

Air Force crews began to have a comparable form of protection with the provision of flak suits.' Later, in the Korean War, ground troops were provided

with plastic body armor.

Hand-to-hand fighting determined the character of all wounds for another

2,500 years. Gunpowder was invented early in the 13th century, but cannon and

gunshot were not employed effectively in the West until the Battle of Agincourt

in 1415. Hieronymus Brunsehwig (ß) of Strasbourg, in 1497, was apparently

the first surgeon to describe "Wound :s shot with a gonne."' Like other surgeons

of Ids time, he believed that, the damage was caused by "the venym of the

powder." This concept was dispelled by Pare some 40 years later.

Theodoric (3) was probably the first to describe the principles of debridement. in the latter half of the 13th century. He used the Latin word "abradantur" (abradere, to scrape off, to shave) and emphasized that the edges of the

wound should be thoroughly trimmed, that all fuzz and hair should be removed,

and that above all the wound must be thoroughly cleaned. Debridement was

described with clarity and vision by Thomas Gale in 1586, and it is ironic that

its principles and technique had to be learned over again in World War II,

more than three and a half centuries later.

Up to this time, no special attention had been paid to wounds of the chest,

nor was any special attention paid to them in the next two centuries. John

Hunter, who served as an Army surgeon in 1701, remarked that while little had

been done for them, something probably could be accomplished for the good

of the patient. His only contribution, however, was the tentative suggestion

that hemothorax might be treated by allowing the fluid to run out of the wound.

Baron Dominique Larrey, during the Napoleonic Wars, devised the system

of battlefield evacuation and triage—another lesson finally learned in full m

World War II—and also made certain recommendations for the management

of chest wounds. Because he had observed that results were poor in penetratingwounds in which the traumatic thoracic opening was larger than the glottis, he

3
* THORACIC SritGERY

recommended, as had John Hunter, that the casualty be placed on the wounded

side, to permit the blood to drain out of the chest cavity, and that the chest then

be closed. He described several patients in whom dramatic improvement had

occurred and recovery had followed when this plan was used. Closure of chest

wounds had been mentioned by John de Vigo early in the 16th century, and

Pare said that the practice was founded on reason and truth, though he recommended that the closure should not be effected for from 48 to 7-2 hours after the

injury, to prevent an accumulation of blood. Larrey's bold translation of advice

into practice represented the first really notable advance in the management of

these wounds.

THE CRIMEAN WAR

Fräser (.£), in the review of the literature reported in his small monograph

on wounds of the chest in the Crimean War, found little information on these

wounds as compared with wounds of the extremities and joints, which required

"showy manual ability." The single treatise entirely devoted to penetrating

wounds was by Mayer of St. Petersburg, and there were only :>:> reports of such

wounds in five British medical journals between 18-2r> and LSöo. Fräser also

commented on the small number of preparations of lung wounds in British

hospital museums; there were only seven at the Royal College of Surgeons,

three at St. Thomas* Hospital, two at St. George's Hospital, and one at University College. At Chatham there were none.

Fraser's monograph contains chapters on diagnosis, prognosis, and complications of wounds of the chest; wounds of the diaphragm with herniation are

discussed under complications. The Crimean experience made the author doubt

that many of the cases reported in the literature as recoveries were really wounds

of the lung. He regarded most of them, like most of the cases reported from

Guy's Hospital (table 1), as wounds in which the lungs had escaped damage and

only the pleura was involved. He shared the general opinion of others who

wrote on the subject that most deep wounds of the lung were fatal.

"Paracentesis thoracis" was recommended for injuries in which blood or

serum accumulated without a free mode of exit and in which movement of the

lung was impeded. It was recommended that it be performed without delay.

Fräser considered that there might be more danger in attempting to remove a foreign body than in permitting it to remain in situ, "seeing the

lengthened periods during which bullets may remain innocuous in the human

body," because in the attempt at removal a relatively minor wound might be

converted into a penetrating wound. He granted that there Mere cases in

which the presence of the foreign body might be productive of "serious mischief and danger," and he also advised the removal of some objects if "for no

other motive than great peace of mind which this event invariably induced in

the patient."

Venesection was routine at this time, but Fräser termed it "this murderous

act." He described a patient who recovered, after being bled 100 ounces in a

month, "at the expense of an empyema and thanks to an iron frame."
HISTORICAL NOTE

TABLE 1.—-Number of cheat wounds on the occasions named, and from the authorities quoted,

with the percentage of deaths to wounded, 1859

Action or authority Wounded Deaths

The Director-General's records prior to Crimean War_-

Crimea

Simpheropol (Russians) _

Toulouse ..

Quebec - --

Carlist War --

Paris, 1830.-.. _--

Paris, 1848 _. - --

Paris, 1850-- - -

Battle of Kilet _. ■■--

Battle of Idstead . .

Battle of Canton

M. Moniere -

M. Legonest__. ..

Guy 's Hospital Reports _...._.

Danish War (Report of Chief Surgeon Schytz. Total

wounded, 227) -

Dr. Kidd .. . - -

Total

Number N~ttmber Percent

39 27 70.0

474 135 28. 5

200 197 98. 05

106 50 50. 0

26 2 7. 07

29 27 100. 0

1 20 10 50. 0

9 4 44. 0

11 5 45. 5

21 11 50. 0

97 17 17. 0

4 4 100. 0

20 20 100. 0

(i 3 50. 0

2

72 9 12. 5

10 2 20. 0

30 24 66. 0

1, 180 547

1 De Lambale and Baudeus.

- Of this number, the lung was really wounded in two cases only.

Source: Fräser, Patrick: A Treatise upon Penctratine; Wounds of the Chest. London: John Churchill, 1859.

According to Fräser, 474 of the 12,094 wounds recorded in the Crimean

War (3.9 percent) involved the chest, and 185 of these (28.5 percent) were

fatal (table 1). Included in the chest wounds were 164 of the lung (1.35 percent of the total number of wounds), of which 180 (79.26 percent) were fatal.

The case fatality rate for wounds of the lung in the French Army was reported

as 91.6 percent.

THE CIVIL WAR

Of a total of 20:5,112 wounds recorded in the Civil War, 20,607 (8.1 percent) involved the chest, and 8,715 of these (42.3 percent) were penetrating

wounds (h). The overall case fatality rate for chest wounds was 27.8 percent

and for penetrating chest wounds 62.6 percent. A number of cases were reported in which complete recovery followed gunshot wounds of both lungs.

A number of recoveries were also reported after penetrating gunshot fractures

of the sternum, apparently because the causative missiles were of low velocity.

In 1863, Assistant Surgeon Benjamin Howard recommended to Brig. Gen.

William A. Hammond, The Surgeon General, that penetrating wounds of the

chest in which suppuration had not occurred should be managed by removal of

all foreign bodies; control of bleeding; paring of the edges of the wound;

closure by metallic sutures; and the application of an airtight dressing, so
6 THORACIC SURGERY

that the wound would be hermetically sealed. In this recommendation, the

implications of the physiology of chest wounds, their mechanics, and the

principles of wound suppuration and wound healing were all overlooked. Because of failure to realize that sealing the wound hermetically was only part

of the problem, infection was common, and a high case fatality rate was inevitably associated with this type of treatment.

Pneumothorax is mentioned in the Civil War history a number of times

but apparently seldom reached an alarming stage. Tension pneumothorax is

mentioned only a half dozen times.

Hemothorax, either alone or in combination with pneumothorax, was

recognized as a dangerous complication, particularly because of the extreme

dyspnea often associated with it. Early in the war, it was believed that the

surest way to arrest bleeding was by bleeding the casualty further. In the

Confederate Manual used during the war, however, venesection was described

as a time-honored absurdity, and it is doubtful that it was ever practiced by

any Confederate surgeon. The routine plan, when hemothorax was present,

was to try to identify the bleeding point, control it, and then employ such

general measures as cold acidulated drinks together with the administration of

digital is or opium. It was recognized that if the hemothorax was not absorbed,

empyema would result.

Thoracentesis was used to relieve the effects of effusions resulting from

acute and chronic pleurisy or from "traumatic pneumonia"' (a term used to

indicate infected hematoma, atelectasis, lung abscess, and other infectious

sequelae). This method was not used, as in World War II, to evacuate hemothoraces and promote rapid expansion of the lung.

Operation was sometimes necessary to control bleeding from the great

vessels. The usual procedure was to ligate only the proximal end of the vessel,

and it is not surprising that there were no recoveries in wounds of the axillary

artery, though there were 5 survivals in 25 casualties with wounds of the

subclavian artery.

Four recoveries were recorded in gunshot wounds of the heart. Patients

with wounds of the pericardium sometimes languished for several weeks with

suppurative processes, but, in one series of 51 cases, there were 22 recoveries.

It was noted that extreme dyspnea might accompany a wound of the heart

because of intrapericardial pressure, which could be relieved by paracentesis.

Wounds of the esophagus are not specifically mentioned in the Civil War

history, but a disproportionate amount of space is given to descriptions of

hernia of the lung. Such hernias, it was stated, were extremely uncommon

among British casualties at Waterloo as well as in the Crimean War. One

case, described in detail, was managed by the technique first described by

Tolandus of Parma in 1449 (1) and used successfully by Whittemore (6) in

1929 on nine patients. This technique, which amounts to a two-stage lobectomy, consists of creation of a hernia of the lung, followed by excision of the

protrusion after adhesions have formed.
HISTORICAL NOTE 7

WORLD WAR I

General Considerations

it is difficult for a modern surgeon to visualize the status of surgery at

l he end of the Civil War. Techniques of anesthesia were limited. Antisepsis

and asepsis were still undreamed of. Medical schools were poorly organized

and administered. Programs of interne and residency training did not exist.

Channels for dissemination of medical information were few. Within the

Army Medical Department, both order and system were lacking.

It is not surprising, therefore, that in the Franco-Prussian War, which

broke out in 1870, 5 years after the end of the Civil War, few advances were

made in the management of wounds. When World War I broke out in 1914,

enormous strides had been made in medicine and surgery, based on Pasteurs

work in bacteriology and Lister's work on antisepsis, out of which the modern

concept of aseptic surgery developed (7). During the last quarter of the 19th

century, Osier (8) wrote in 1902, physicians had become better trained and

equipped and disease was "understood more thoroughly, studied more carefully, and treated more skillfully." "The average sum of human suffering,"

he went on, "has been reduced in a way to make the angels rejoice."

The medical officers of World War I had reason to be thankful for these

advances, for the wounds they were called upon to treat were far more dreadful

than those of any earlier war (]). In 1892, the high-powered rifle had replaced the old muzzle loader, and, at about the same time, bullets were developed with thin steel, nickel, or copper jackets. Until World War I, the

preponderance of wounds had been caused by bullets and low-velocity missiles.

The United States was therefore completely unprepared for the extravagant

use of artillery, high explosives, and high-velocity missiles that was manifest

soon after the outbreak of the war in 1911. In World War I, about 70 percent

of all wounds were caused by high-velocity missiles and high explosives, and

their management created new and serious problems.

According to Iloche (£>), in the 11 million wounds sustained in the armies

of the United States, Great Britain, France, and Germany in World War I.

there were 600,000 wounds of the chest (6 percent), of which 5G percent were

fatal. Hoche's collected figures also show that of 12,350 soldiers killed in

action, 20 percent had chest wounds.

The U.S. statistics for chest injuries in World War I are open to some

doubt (JO). In a total of 174,296 injured, 4,595 (2.6 percent) had wounds of

the thorax; the case fatality rate was 24.05 percent. The British incidence

of chest wounds was 3.8 percent (11). Both these proportions are entirely at

variance, with the incidence of wounds of the thorax in other recorded wars.

In the U.S. statistics, it is possible that some wounds of the thorax are included with wounds of the neck and the back, which are listed separately.

In other recorded wars, including World War II, the incidence of chest

wounds was about 1: 12 (8 percent). In 55,000 wounded in the Seventh U.S.

Army in World War II, the incidence of chest wounds was 7.8 percent and the
8 THORACIC SURGERY

case fatality rate was 5.4 percent (p. (51). The figures for the Fiftli U.S. Army

are substantially on the same order. The figures for both armies are for the

campaigns of 1944 and 1945, during which the case fatality rate was lower

than it was in the early years of the war.

There were no chest centers in the U.S. Army during World War 1.

Patients with suppurative pleuritis were segregated in a few hospitals, but

they were usually cared for in the so-called septic surgery sections. With this

possible exception, all chest surgery was performed by general surgeons. At

the time, there were only a few surgeons who were qualified in this specialty

or who had any interest in limiting their surgical activities to it".

The Allied Experience 1914-17

When the United States entered the war in April 1917, effective methods

of treating almost all types of wounds had been established by surgeons of the

Allied armies. Among the exceptions were wounds of the chest, about which,

as Tales ('/') pointed out, there were still irreconcilable differences. These differences were caused, he continued, by the failure of many surgeons to understand the interdependence of the functions of the circulatory and respiratory

systems; to appreciate the contributions of these functions to the powers of

resistance, defense, and repair; and to understand further that these powers

must be conserved and developed if immediate recovery were to be facilitated

and the extent and duration of subsequent disability were to be reduced. Nonetheless, in spite of this confusion. U.S. surgeons had the general experience of

their Allies to build upon when they first encountered wounds of the chest.

The British experience.—Before 1916, according to Gask (11. la), British

surgeons practiced a policy of noninterference in chest wounds for three

reasons:

1. The experience in the South African War. in which, because the ground

was dry and wounds were chiefly caused by rifle bullets, this policy was generally successful.

2. The belief that it would be fatal to open the chest cavity without the

aid of some form of pressure chamber.

3. The belief that manipulation of the lung would provoke fast and fatal

bleeding.

Experience showed that all of these assumptions were wrong, and by the

time the United States entered the war, British surgeons were doing a considerable amount of intrathoracic surgery. First, the need for wound excision

(debridement) had been recognized. Eater, the need for thoracotomy. at least

in some cases, became evident. Surgeons began to lose their fear of the open

chest, and their successes further encouraged them to perform many bold and

well-conceived operations previously considered impossible. The development of blood transfusion also made them bolder, especially in the management of thoracoabdominal wounds, the results of which, in some hands, showed

a great deal of improvement.
HISTORICAL NOTE 9

Sir Gordon Gordon-Taylor (13), however, began his account of chest

surgery in World War II with the statement that it was strange that, in spite

of the numerous chest injuries encountered, it was not until 27 July 1917

that a memorandum was issued to medical officers of the British Expeditionary

Force calling attention to the value of dealing with open pneumothorax by

immediate temporary closure of the chest wall by suture. His explanation

of the delay was that experiences were disseminated much, more slowly in

World War I than in World War II.

Until the end of the war, empyema remained the principal anxiety of

British surgeons and the principal cause of poor results. During the war,

however, the disadvantages of expectant management in many cases of hemothorax, especially those in which clotting and infection were present, had

become evident. In 1918, while on a surgical mission to the United States,

Grey Turner (14.) suggested the use of decortication in some cases of old hemothorax, in which, lie pointed out, the lung was likely to be found imprisoned

in a sort of sheath of organizing blood clots that extended to the diaphragm

and interfered with its normal movement. It was most interesting, he continued, to see the lung during decortication reappear "from its coat of mail-

'

and begin to reexpand normally. He "sighed" for anesthetic apparatus that

would facilitate the operation by permitting a ready change from ordinary

inhalation anesthesia to positive intrapulmonary pressure.

The war left the British, as it did the Americans, a large legacy of patients with chronic empyema, encysted hemothorax, and retained foreign

bodies with chronic suppuration, as well as many chest cripples, with rigid

and greatly deformed cbests.

The French experience.—Before the United States entered World War 1,

Pierre Duval (15) of the French Army medical service had made some important observations on chest surgery:

The first of these observations concerned the concept, current, at the outbreak of the war, that thoracic surgery should not be performed until the

casualty had reacted from his initial shock. As a result of this policy, Duval

pointed out, the chief causes of death in chest wounds at battalion aid stations

were hemorrhage and mechanical asphyxia due to an open thorax. In 3,153

admissions to hospital units in Army areas, the death rate in the most forward units was 15 percent, against an overall rate of 20 percent.

Duval fully realized the difficulty of setting up clear-cut indications for

immediate surgery in thoracic wounds, but he nonetheless urged that if signs

of hemorrhage were persistent, the wound should be promptly opened and

the damage sought for and repaired, whether it was in the chest wall or in

the lung. Debridement of wounds of the soft parts and of the extremities was

already being practiced with considerable success, and he saw no reason why

a contaminated lung and pleura should not be similarly treated. In a series

of 500 chest injuries with pneumothorax managed by the usual methods, there

were 195 infections. In contrast, in 193 injuries which Duval had handled

personally in the Battle of the Somme, there were only 31 infections in the 141

G53CS1V—02 ?,
10 THORACIC SURGERY

shell wounds and no infections at all in the 49 bullet wounds. His personal

results proved his point that septic sequelae were far more numerous and more

serious in wounds caused by high explosives than in bullet wounds, which

either were immediately fatal or ran a relatively benign course.

Duval also advocated that all shell fragments and other retained foreign

bodies should be promptly removed, under local infiltration with procaine

hydrochloride, and that the chest then be tightly closed without drainage. As

technique improved, he said, the general surgical principles and practices employed in gunshot wounds were being applied little by little to wounds of the

lung. "Let us dare to hope," he concluded, "that those who follow in our

steps may soon have many more numerous and more brilliant successes."'

The U.S. Experience 1

General principles and practices.—Patients with uncomplicated chest

wounds were not prone to shock unless there was considerable hemorrhage.

According to Yates (7), it was often wise to defer transfusion—which was

given in small amounts and to few casualties—until after the lung had been

reinflatecl at operation.

All emphasis was placed upon the prevention and treatment of infection,

particularly upon its treatment. With respiratory infection so prevalent and

the grave type of pneumonia caused by the beta hemolytic streptococcus so

frequent (p. 19), this was probably inevitable. Nonetheless, as one looks

back now, it is somewhat perplexing that more attention was not directed

toward the physiology and the spatial dynamics of the chest.

First aid was limited to hemostasis of the parietal wound, with temporary

closure of an open thorax by strapping a firm, thick, broad pad over the wound

by means of adhesive tape reinforced by a swathe. This method was preferred

to initial suture of the wound, which often resulted in spreading subcutaneous

emphysema.

The indications for immediate surgery of thoracic wounds were established as:

1. Aspirating (sucking) wounds.

2. Large retained foreign bodies.

3. Severe bone injury.

4. Complicated lesions of the diaphragm.

5. Extensive hemorrhage and suspected infection, particularly anaerobic

infection.

The arguments advanced for the various methods of management of chest

wounds in World War I sound much like the discussions in World War IT

concerning the indications for thoracotomy and the advantages of formal thoracotomy at the site of election versus thoracotomy at the site of the wound.

1 As a matter of convenience, special types of wounds and special complications of thoracic wounds,

including empyema, are discussed under separate headings later in this chapter.
HISTORICAL NOTE 11

There were four possible methods of treatment, as Yates (7) pointed out

in an analysis of a personal series of 104 injuries:

1. Simple debridement or excision of parietal wounds.—This method, combined with aspiration or suitable drainage of hemothorax, was a satisfactory

routine method of treatment for wounds which were not too serious. Surgery

was followed by systematic exercises to produce early and complete recovery.

2. Limited thoracotomy (the traumatic thoracotomy of World War II).—

It consisted of debridement and exploration through the wound of entrance

or exit, with little or no enlargement of the traumatic wound. Limited thoracotomy was indicated when the wound was small, the damage slight, and the

lung readily inflated. At operation, accumulated blood and fluid were aspirated

before closure. Local bleeding could usually be cared for through the same

wound, and small wounds of the lung were closed. Missiles were removed

whenever it was feasible. If they lay next to large blood vessels, they were

always sought for and removed.

3. Thoracotomy of necessity (a term no longer used).—This operation was

little more than a more extensive application of limited thoracotomy. It was

used when debridement and limited thoracotomy revealed unexpected lesions

that required immedia/ e, more radical intervention. It was used upon casualties who were so severely wounded that both parietal and deep repair had to

be managed through a single opening. Its advantages were (1) its greater

rapidity and (2) the avoidance of an elective incision, so that the integrity of

the parietes was not impaired by the trauma superimposed by such an incision

upon the destruction wrought by the projectile. There were also disadvantages, including frequent failure to obtain sufficient exposure for satisfactory

intrathoracic surgery, as well as the temptation to escape the risk of an increased

surgical mortality by performing an operation less complete than was necessary

to obtain complete recovery.

4. Thoracotomy of election.—The separate incision afforded sufficient exposure for a satisfactory examination of the pleural cavity and permitted repair

of most visceral and diaphragmatic lesions. An elective incision healed well

and imposed little disability.

Great importance was attached to prevention of soiling by final, thorough

toilet of the pleural cavity and wound. When necessary, the lung was sutured

into the defect in the parietal pleura. Blocking of the phrenic nerve with

1 percent cocaine was advised.

A firm and airtight parietal closure was considered imperative in all

injuries.

The possibility of tension pneumothorax was recognized in World War I,

as was the possibility of rapid collection of fluid with increase in the mediastinal pressure. The nature of acute hematomas of the lung was not, however,

fully appreciated. The process was termed "splenization,;' and resection was

the preferable treatment. This method was contrary to the usual practices in

World War II, when the pathologic process was more clearly understood.
12 THORACIC SURGERY

Generally speaking-, when patients were seen early and operation could be

performed within 8 hours, the ease fatality rate was about 4 percent. When

delay was over 24 hours, there was a 10-fold increase in the case fatality rate.

According to Yates (7), the use of primary, and even of early, drainage

of the pleural cavity after operation was generally condemned, because open

methods were employed, and with them, collapse of the lung was inevitable.

It was recognized, however, that proper drainage reduced the incidence of

empyema ; the official history simply states that some type of drainage tube was

used, provided with some device to prevent the entrance of air, and that the

earlier it was used, the better were the results. It was also pointed out that

disastrous pleurisy could be limited if primary drainage were employed for

large wounds with open pneumothorax, foreign bodies, and lacerations of the

liver and diaphragm. The principle of closed underwater drainage was not

as well established, even by the end of the war, as it has since become.

The possibility of postoperative accumulations of serum was realized in

World War I, as was their frequency, and routine aspiration was used as

necessary as a precaution against this complication. When aspiration was

properly employed, the necessity for later open operation was considerably

reduced.

Air replacement.—Air replacement as a means of collapsing the lung and

thus controlling hemorrhage was first suggested by Chassaignac in a thesis

written in 1835. In 1941, Berry (16) and Lambert, unaware of the early

recommendation, suggested the procedure for uncontrolled bleeding in hemopneumothorax on the basis of their success with it in a personal case. They

emphasized that the method had only a limited field of usefulness.

In World War I, artificial pneumothorax was extensively used in Italian

military hospitals. The technique had been introduced by Forlanini in Italy

and by J. B. Murphy in the United States for treatment of tuberculosis and

other diseases of the lung and pleura, and Morelli (17), Forlanini's pupil, and

Bastianelli (IS) adapted it to wounds of the chest in which hemothorax was a

feature. The routine was to aspirate the chest incompletely and replace the

blood withdrawn by air, the amount of air to be injected being determined by

readings of intrapleural pressure on a pneumothorax apparatus. If the apparatus was not available, the practice was to replace with air half of the

volume of fluid removed. The procedure was repeated in 72 hours and carried

out as necessary thereafter to achieve gradual clearing of the chest.

Air replacement was contraindicated in thoracoabdominal wounds. It

was also not employed when the injected air would escape through parietal

or pulmonary wounds or when it would be difficult to introduce it because of

adhesions. Surgery was indicated in these circumstances.

Air replacement never won favor on the medical services of the other

Allies, perhaps because, by the time the method had been popularized in Italy,

other Allied surgeons were beginning to employ a more aggressive approach in

wounds of the chest.
HISTORICAL NOTE 13

Anesthesia.—The chief reason for the higher case fatality rate in thoracic

.surgery as compared with the rate in abdominal surgery was the disturbance

of the normal intrapleural pressure relations which occurred when air entered

through the incision into the chest. Fear of the consequences of an open

pneumothorax was the chief reason for delay in the development of chest

surgery {10).

The solution of the problem of anesthesia for chest surgery began when

Meltzer and Auer {20) of the Rockefeller Institute introduced their simple

method of insufflation intratracheal anesthesia as a substitute for the cumbersome and inconvenient techniques previously used for this purpose. By their

method, it was now possible to administer an inhalation anesthetic at the same

time that a surgical incision was made into the pleura.2

In spite of the simplicity of this method of avoiding collapse of the lung

during thoracic surgery, it was employed only infrequently during World

War I for three practical reasons:

1. The necessary equipment was seldom available.

2. Few anesthesiologists were familiar with the technique.

3. Few surgeons, as already mentioned, were qualified to undertake thoracic

surgery.

Research studies in the American Expeditionary Forces.—In the period

between the Chateau-Thierry operation, in July and August 1918, until after

the Armistice on 11 November 1918, a research unit composed of medical officers,

nurses, and enlisted men was detailed to various field hospitals and mobile units

in zones of active combat ('/'). Its personnel was appointed by the Chief Surgeon, American Expeditionary Forces, and its mission, specified by the Chief

Surgical Consultant, American Expeditionary Forces, was in substance as

follows:

1. To discover the physiologic interrelationship between the circulatory

and respiratory mechanisms, in order to determine the functions which need

protection to assure the largest opportunities for immediate and remote

discoveries.

2. To develop the simplest effective surgical methods compatible with

physiologic requirements.

3. To apply these methods to the wounded whenever there was any possibility of saving life, without regard to the high mortality rate that would

inevitably accompany the gravest risks.

1. To follow each fatality with an autopsy, to determine what should not

be done.

5. To trace the results in casualties who recovered and thus discover the

dependence of degrees of functional rehabilitation upon the methods employed,

in order to develop better methods.

2 This technique, naturally in a cruder form, had been suggested by the late Dr. Rudolph Matas

as early as 1000 but had then attracted no attention.
1J. THORACIC SURGERY

6. To make a final report which would indicate how soldiers suffering from

intrathoracic injuries could be more certainly protected against death and

disability.

This was a comprehensive mission, and it was undertaken late in the war.

In spite of these handicaps, a number of important observations were made:

1. A strong and active individual, with good vital capacity, could survive

a wide partial opening in the chest even when it was produced suddenly.

2. A comparable individual, weakened by exhaustion, exposure, hemorrhage, and infection, could scarcely tolerate a small opening.

3. The objective of management should be to protect and restore the function of the external respiration and to assure the integrity of both the circulatory

and the respiratory units. This was obviously a difficult task.

4. When surgical procedures were necessary, the respiratory physiology

must be understood, and every effort must be made to avoid leaving an open

pneumothorax or a pyothorax. These two complications were the principal

causes of postoperative disability and death.

5. Differential intrathoracic pressure was necessary for safety during

surgery. It was best achieved by the use of a tight-fitting gas-oxygen apparatus

such as had been recently developed by Gwathmey.

6. To lessen postoperative discomfort, injection of the phrenic nerve within

the chest with 1 percent procaine hydrochloride should be part of each surgical

procedure.

7. In the aftercare of the patient, breathing and body exercises should be

emphasized, to restore parietal movement, pulmonary elasticity, and normal

intrapleural relations.

Thus, as World War I drew to a close, many of the principles of management of thoracic wounds that were to prove basic in World War II were

beginning to be developed and understood. In World War II, the emphasis

upon chest exercises in the chest centers in the communications zone was

regarded as a new and major contribution to thoracic surgery, but, as this

record shows, the policy had been developed in World War I. The importance

of these exercises had also been recognized in certain civilian centers long before

the outbreak of the Second World War. Patients were ambulated early, and

exercises were demonstrated to them, though the degree of regimentation possible in the Army, one of the factors which made these exercises so useful in

wartime chest surgery, was naturally not achieved in civilian practice.

Postwar conference.—After the Armistice in November 1918, a group

of senior Allied medical officers met in Paris for a general discussion of war

wounds (?'). The moderator of the symposium Avas Brig. Gen. John M. T.

Finney, Chief Consultant in Surgery, American Expeditionary Forces. Among

the points discussed relevant to thoracic wounds were the following:

1. Col. George Crile, MC, listed hemorrhage, shock, and wounds of the

chest as among the conditions making casualties nontransportable. Maj. Gen.

Sir Anthony A. Bowlby (British) added that "all completely smashed limbs

should never be removed from the field ambulance": that, is, from the installa-
HISTORICAL NOTE 15

tion which corresponded to the U.S. Army field hospital in World War II.

It should be noted that neither authority mentioned thoracoabdominal nor

abdominal wounds as contraindications to transportation after wounding.

2, Colonel Crile inquired whether the experience in the Argonne had produced any new data, particularly in connection with shock and hemorrhage.

Lt. Col. Walter B. Cannon, MC, mentioned the importance of placing blankets

under, as well as over, patients, who lost heat by perspiration and because of

their wet clothing and their contact with wet stretchers. He had seen patients

in shock with four blankets over them and none under them. The discussion

brings to mind similar errors at the front in World War II.

8. Colonel Crile inquired whether morphine was contraindicated in

abdominal perforations and in thoracic injuries. Lt. Col. John L. Yates,

MC, who was later to write the chapter on chest surgery in the World War I

official Medical Department history, replied that in a series of 130 patients with

chest injuries, lie had seen only 2 upon whom morphine had apparently had

a bad effect. He was inclined to think that the bad results in these and other

cases could be attributed not to morphine per se but to too much morphine;

he suspected that these patients had had earlier injections of morphine that

had not been recorded on their cards. He saw no objection to the judicious use

of morphine in chest injuries.

Again one is reminded of the World War II experience, in which bad

effects arose from the overgenerous administration of morphine and its unnecessary use and not from the drug itself.

4. When votes were taken as to how casualties with through-ancl-through

chest wounds tolerated transportation, the replies were: badly, 8, and well, 28.

A variety of opinions were expressed: well after a week; poorly if the wounds

were caused by shrapnel, but well if they were caused by rifle bullets; well if

the patients had not been operated on and were not in shock; badly if the

wounds were severe intrathoracic injuries or operation had been performed and

healing had not yet occurred.

5. A vote on the comparative status of wounds observed in base hospitals

after treatment by various measures favored the following techniques: simple

dry gauze, 13; the Carrel-Dakin technique, 12; petrolatum-impregnated gauze,

5." Dichloramine-T, some protective agent, BIPP (bismuth, iodine, and petrolatum paste), flavine, and rubber tubes secured a scattering of votes. Xearly

all observers emphasized the risk of packing the wound tightly; lightly placed

surface dressings were considered all that was necessary.

fi. When the criteria for secondary wound closure (the delayed primary

wound closure of World War II) were discussed, all present voted for bacteriologic control plus clinical judgment when both were practical. When they

were not, the- vote for clinical judgment alone was 10 and for bacteriologic

control alone, ;">. The optimum period for closure was considered to vary from

3 or 1 days to 10 or 12 days after wounding. Again the discussion is reminiscent

of the lessons that had to be relearned in World War II.
16 THORACIC SURGERY

7. Indications for thoracic surgery in the forward area were listed as a

second chest wound; serious hemorrhage; large effusions; indriven bone fragments; large foreign bodies; a collapsed lung on the same side as the wound;

considerable comminution of the ribs; infection; hemothorax with tension;

pnemnothorax with tension; foreign bodies in the heart, pericardium, or

mediastinum; bilateral chest injuries; and anaerobic infection accompanying

hemothorax.

8. Indications for operation in the base were listed as empyema: lungabscess; secondary hemorrhage; sinuses caused by foreign bodies; pus pockets;

hemothorax with symptoms, which was to be treated by repeated aspirations

as necessary; infected hemothorax, for which the treatment was radical

thoraeotomy.

9. All present voted for thoracic surgery under local infiltration when this

technique was possible. When it was not, 18 preferred gas-oxygen anesthesia;

9, ether; 2, chloroform; 3, morphine and atropine; and 1, warm ether.

The symposium closed with a discussion of various techniques of thoracic

surgery.

Conclusions from the World War I experience.—Colonel Yates (7), in

a detailed analysis of a personally managed series of 104 chest wounds, listed

the errors which had been made in them, including failure to appreciate the

inherent seriousness of the wound; inadequate preoperative preparation; and

a number of unwise surgical procedures. When these cases were analyzed

according to the first operation performed, Colonel Yates arrived at the

following conclusions:

1. Partial wound excision, usually with paracentesis, is sufficient to protect the least seriously wounded casualties and to hasten recovery without added

risk.

2. Limited thoraeotomy (p. 11) is applicable to the treatment of less

seriously wounded casualties if deep repair can be effected through slight enlargement of the wounds of entrance and exit and if the bulk of a hemothorax

can be aspirated by large cannulas introduced through a defect in the parietal

pleura.

3. Thoraeotomy of necessity, which is a more extensive application of

limited thoraeotomy, should be used when immediate deep repair is required

and when there are reasons for using the parietal wound to secure closure.

4. Thoraeotomy of election will find wider application in the future as a

primary procedure. If two-stage procedures are practical, it is the preferred

secondary procedure. "Indeed," Colonel Yates concluded, "with the development of simple and effective methods of primary drainage, thoraeotomy of

election may prove to be the safest treatment of massive pnemnothorax unless

the patient's condition be poor."

At the conclusion of his chapter on thoracic wounds in the official history

of the U.S. Army Medical Department in World War I, Colonel Yates made

some general observations reminiscent of the observations made by Col. Edward
HISTORICAL NOTE 17

I). Churchill, MC, Chief Consultant in Surgery in the North African (later

Mediterranean) theater in World War II. These observations were embodied

in the circular letters issued by the Office of the Surgeon, Headquarters, North

African theater and later embodied in War Department Technical Bulletin 147,

issued from the Office of The Surgeon General in March 1945 (p. 201).

Success -was possible in the management of thoracic wounds, wrote Colonel

Yates, if personnel competent to furnish treatment and materials essential for

treatment were so organized and disposed that the wounded could be well and

properly served. From a medical standpoint, service to the wounded man was

all-important, From a military standpoint, service to the fighting man was

most important. The exaggerated individualism of civilian surgeons, Colonel

Yates continued, led them to misunderstand, or to fail to appreciate, the responsibilities of their colleagues in the Regular service to Army organization and

administration. Similarly, medical officers of the Regular service apparently

underrated the personal aspirations of physicians and nurses to provide their

patients with the best possible care. On both sides, there was lack of preparation to fulfill their obligations, and neither side hesitated, justly or unjustly, to

hold the other side responsible for its own deficiencies.

Colonel Yates concluded:

An Army must bo an autocratic organization, but many evils peculiar to autocracies

can be minimized. This can be accomplished effectively so far as the Medical Corps of the

U.S. Army is concerned by developing cooperation in advance. Civil surgeons can and

should prepare themselves not merely to give professional services hut to give them under

the restrictions of military methods, the worst attribute of which is inflexibility. Similarly,

the officers of the Regular Medical Corps, kept directly in contact with progress and changing requirements of surgical practice, will And more liberal interpretation of regulations,

which are fixed products of past experiences and often are literally opposed to immediate

necessities. National security should he enough of an incentive to produce the necessary

personal adaptation and coordination of effort.

As experiences in a later war were to prove, there is no category of wounds

to which these generalizations are more applicable than wounds of the thorax.

EMPYEMA IN WORLD WAR I

In World War I, the U.S. experience -with thoracic conditions was concentrated chiefly upon the treatment of infection, and, more specifically, upon

the treatment of the infected pleura {21). This was partly because of the

numerous epidemics of measles and pneumonia that occurred in camps after

this country entered the war and partly because of the worldwide epidemic of

influenza and pneumonia in 1918 and 1919.

In the voluminous literature on empyema that appeared after World War

I, very little attempt was made to separate posttraumatic organizing hemothorax and subsequent hemothoracic empyema from metapneumonic or synpneumonic empyema, in spite of the significant differences between the two

groups of cases. The explanation, advanced by both British and U.S. surgeons

053681'—G2 4
18 THORACIC SURGERY

in World War II, is probably that the influenzal empyemas so overshadowed

the traumatic variety in both numbers and importance that the separate identity

of the posttraumatic variety was not realized. It is remarkable, nonetheless,

that these differences were not more clearly appreciated by the military surgeons

who had observed the large numbers of empyemas during World War I.

The Empyema Commission

During the second half of 1917, pneumonia, in part primary and in part

secondary to measles, was causing approximately 65 percent of all deaths in

the U.S. Army. The Surgeon General, in an attempt to find some means to

combat this terrible loss of life, appointed a commission to study pneumonia in

its clinical, pathologic, and bacteriologic aspects. One of the far-reachingresults of the work of this commission was the determination that the beta

hemolytic streptococcus was playing the principal role in many cases of pneumonia and was giving rise to an entity which the commission termed interstitial

bronchopneumonia.

Because empyema constituted such an important complication of pneumonia, especially when the pneumonia was of the hemolytic streptococcic

variety, The Surgeon General, in the early spring of 1918, created another

commission to take up research work where the first research commission (p. 13)

had left, off. This commission, later known as the Empyema Commission, carried out its work at Camp Lee, Ya. It had two groups of members. The

continuous members were Maj. Edward K. Dunham, MEC; Maj. Evarts A.

Graham, MEC; Maj. James F. Mitchell, MEC; Capt. Alexis A'. Moschcowitz,

MEC; Maj. Ralph A. Kinsella, MEC; Capt. Eichard D. Bell, MEC; and Lt.

Franklin A. Stevens, MEC. The temporary members were Capt. William L.

Towers, SC; Capt. Clifford C. Hartman, MEC: Lt. Frederick D. Zeman. MEC;

Lt. Milton B. Cohen, MEC; Miss Maude H. Hays, dietitian; Miss Bessie E.

Stocking, artist; and Miss E. Pauline Jacobs, secretary.

When the Commission began its work, there were two major problems to

be solved. The first, as already mentioned, was the development of empyema as

a sequel to the pneumonia that was itself a sequel of measles, meningitis, and

influenza. The second problem, which was extremely acute, was the prohibitively high case fatality rate associated with the standard routine of early

operation as soon as empyema was diagnosed.

Immediate problems.—The management of empyema had been a subject

of discussion for many years before World War I. Arguments were heated

and acrimonious, with the protagonists of one method or another holding

firmly to their opinions. One group defended early operation. Another group

held out just as stoutly for repeated aspiration or aspiration and pneumothorax. Roe (£2), in England, for instance, recommended paracentesis thoracis

as a curative measure in both empyema and ''inflammatory hydrothorax." In
HISTORICAL NOTE 19

the United States, Bowditch (23) of Boston, in 1852, had urged that pleuritic

effusions be managed by repeated aspiration.

When the United States entered World War I, early operation was routine

in empyema that developed after the stage of resolution of pneumonia had

begun. The infection was usually pneumococcic in origin, and the pathologic

process found at operation was characterized by walled-off cavities of varying

sizes filled with thick pus. The surgeons of World War I, who were chiefly

conversant with this type of empyema, had either forgotten that beta hemolytic

streptococcic empyema also exists or had failed to recognize the differences

between it and the pneumococcic type. The differences were considerable. The

hemolytic streptococcic type developed very early, sometimes concomitantly

with the pneumonia itself. It was characterized by the presence of large

quantities of thin, purulent fluid, which accumulated rapidly. Most important,

the walled-off cavities that were characteristic of pneumococcic empyema were

completely absent; in the early stages of the beta hemolytic streptococcic variety

of empyema, there was no attempt at walling off at all.

One reason that empyema was so dreaded by most surgeons was their lack

of understanding of the pathologic process and its correction. As a result,

drains were incorrectly placed. Drainage tracts were permitted to close too

soon. Some surgeons followed the example of Mozingo (££), who believed, as

was later proved false, that a cavity could be sterilized and then left alone with

its residual pneumothorax.

For all of these reasons, empyema was often allowed to become chronic,

and patients drifted from one clinic to another. JSTO thought was given to

physiotherapy or to early ambulation and active exercise, to help the lung

reexpand and prevent a shrunken, deformed, and stiff chest. When the errors

and misunderstandings associated with empyema in civilian practice were carried over into wartime practice, the results of management were intolerably bad.

Physiologic Concepts in World War I

Early in World War I, the physiologic concepts of the respiratory mechanism were surprisingly erroneous (10). The prevailing belief was that the

niediastinal pleura constituted a more or less rigid partition between the two

pleural spaces, so that the result of an open pneumothorax would be the collapse

of the lung of the affected side, without any effect at all on the opposite, uninvolved side.

More important than, the error of this concept was the significance, read

into it, that the former fear of a pneumothorax associated with intrathoracic

surgery was groundless, since the worst that could happen would be the temporary collapse of a single lung. Many experienced surgeons removed shell

fragments from the lung without any special equipment for combating the

effects of pneumothorax, and in their astonishment over the survival of their
20 THORACIC SURGERY

patients, they drew extravagant and unwarranted conclusions from their results. One of these conclusions was that no special protection was necessary

against the effects of pneiunothorax. Duval of the French Army and Moynihan of the British Army, both highly experienced and capable surgeons, said

Graham, helped to create the dangerous impression that operations on the

chest could be performed quite as safely as abdominal operations, without heed

to any possible complications from pneiunothorax. Duval (15) stated unequivocally that it was quite as safe to handle the lung and operate on it at

thoracotomy as it was to handle a coil of intestine and operate on it at laparotomy. Surgery of the lung, he remarked, "does not require any of those pressure chambers which the genius of the Germans invented and their persuasion

made us think necessary."

As Graham (10) pointed out in his 195T review of the development of

thoracic surgery, an accurate knowledge of the effects of pneiunothorax was

considerably more than an academic matter. It was a requirement of fundamental importance. The full development of chest surgery, including the

management of empyema, was impossible until this knowledge was available

and fully utilized. It was the comprehension of the importance of respiratory

physiology (hat so sharply differentiated the practices and results of chest surgery in World War I and World War II (p. 198).

Work of the Empyema Commission

The experimental work on dogs carried out at Camp Lee, under the direction of Major Graham and Captain Bell, included studies on the comparative

physiology of animals and humans; studies on pneumonia and empyema in

both species; and studies on normal and diseased animals when the intact chest

and the open chest were filled with sterile fluids and infected fluids.

Changes of concept—As the result of these studies, the following conclusions on pneiunothorax were possible:

1. In a normal chest, in which there is no thickening of the mediastinal

pleura, alteration of the pressure in one pleura! space produces almost the

same alteration in the contralateral space. It could be concluded, therefore,

that an open pneiunothorax on one side affects the other side also, though not

quite to an equal degree.

2. The lethality of an open pneiunothorax depends upon its size and the

vital capacity of the patient, just as the research unit operating in Europe had

also demonstrated (p. 14). A unilateral pneiunothorax would be fatal if the

opening were beyond the size which the vital capacity of the patient could withstand. If his vital capacity were high, a much larger opening could be withstood than if it were low. If the vital capacity were so greatly reduced that

its level approached that of the vital air requirement, then a very small,

unilateral opening could be fatal.

Practical application.—The conclusions derived from the experimental

work of the Empyema Commission had immediate practical applications. At
HISTORICAL NOTE 21

this time, an epidemic of acute streptococcic empyema was raging in U.S.

Army camps. The usual method of treating it was to resect a rib and establish

open drainage of the involved pleural space as soon as the diagnosis was made.

The case fatality rate averaged 30.2 percent and was as high as 90 percent in

some series. The principal cause of death, the studies of the Commission

showed, was open pneumothorax, created by surgical means during the period

of acute pneumonia. Operation was being done on patients whose vital

capacity was already seriously lowered by their pneumonic disease. It was

still further lowered, sometimes to the lethal level, by the establishment of an

open pneumothorax.

The policy recommended by the Commission was:

1. Careful avoidance of open pneumothorax during the active period of

the pneumonic disease.

2. Early sterilization and obliteration of the empyema cavity.

3. Maintenance of the patient's nutritional status.

By this policy, simple aspiration every 3 or 4 days was substituted for

suxgery during the acute pneumonic stage, or closed drainage was instituted.

The object of treatment was to prevent fluid accumulations from becoming

large enough to cause dyspnea. Even before the Commission had advocated

this policy, it had become evident in some civilian hospitals that these patients

did better under repeated aspiration or with closed techniques of drainage than

by early, open drainage, but it was not until the work of the Commission was

published that the rationale of the improved results became clear.

When the purulent exudate had become thick, when recovery from acute

pneumonia had occurred, and when the empyema could be presumed to be

localized, open drainage, usually with rib resection, could safely be performed.

As a rule, these criteria could be met in about 10 days. By delaying the institution of open drainage until the pus had become thick, the surgeon made his

opening into an abscess cavity instead of into the free pleural cavity. By the

delay, the harmful effects of open pneumothorax were avoided in patients who,

because of their extensive pneumonic process, were already dyspneic and often

cyanotic. If a little air entered the pleural cavity when deferred surgery was

instituted, it did little harm then because, with the clearing of the pneumonic

process, the vital capacity had increased. Furthermore, the mediastinal pleura

had become stabilized as the result of edema and inflammatory induration, and

it was therefore less likely to be crowded over into the contralateral pleural

cavity and to compress the lung on that side.

When the new plan of management became generally effective, results

promptly improved. At Camp Lee, for example, the case fatality rate fell from

40 percent to 4.3 percent. At Fort Eiley, Kans., Maj. William J. Stone, MC,

chief of the medical service and in charge of the pneumonia wards, reported

convincing comparative figures: In a series of 85 patients with empyema treated

by the old plan of early, open operation, the case fatality rate was 61.2 percent.

In a second series of 96 patients treated by early aspiration and late surgery,
22 THORACIC SURGERY

the case, fatality rate was 15.G percent. In a third, later series treated by the

same methods, the case fatality rate was 9.5 percent.3

Chronic Empyema

There is no doubt that the majority of cases of chronic empyema that

were the residua of World War I were the result of ill-timed and poorly

planned early management. Col. William L. Keller, MC (2J), reporting on

a large series of patients observed after the war, found that 75 percent had

"accessory" pockets of infection; 15 percent, had foreign bodies in situ, including drainage tubes and bismuth paste; and 90 percent had osteomyelitis of

the ribs. Beta hemolytic streptococcus had been the infecting agent in this

series, and in most cases, drainage had been instituted too early, before localization had occurred. Many patients therefore developed total empyemas,

the majority of which were inadequately drained, and, as a result, residual

pockets of infection formed and persisted.

Three types of operations had been developed to deal with these chronic

empyemas:

1. In 1879, Estländer (20) recommended removal of the ribs overlying

the pleural cavity. This operation was essentially a limited extrapleural

thoracoplasty.

2. In 1890, Schede {27) went one step further and recommended the

removal of the tough, edematons fibrous pleura overlying the pleural cavity

along with the ribs.

3. In 1893. Fowler {28) in the United States and Delorme (29) at the

Val-de-Gräce Hopital in Paris recommended that chronic empyema be managed by decortication. This operation, which became the preferred surgical

treatment for organizing hemothorax and hemothoracic empyema, is discussed

in detail elsewhere (p. 24).

Tufliers (30) personal statistics for these operations in World War I were

as follows:

1. When the Estliinder operation was used, the case fatality rate was 18

percent: 50 percent of the patients were classified as cured and 32 percent

required additional surgery.

2. When the Schede operation was used, the case fatality rate was 28 percent and 50 percent of the patients were cured. The remainder were not

followed.

3 Dr. Berry -writes of these matters from personal experience. In April 101S. just after ho hail

entered the Army, he "was assigned to the hospital at Fort Riley. Here he -worked under Major Stone

and also served as assistant to Maj. George Draper. MC. of New York City. Major Draper "was then

studying the bacteriology and epidemiology of pneumonia and meningococcic cerebrospinal meningitis

both at the Fort Riley Hospital and among the troops of the SOth Division in training at nearby

Camp Funston. Dr. (then Lieutenant) Berry's work was done in the laboratory nnder the immediate

tutelage of Dr. Edward C. Rosenow, one of the most distinguished bacteriologists of the time, who had

been asked by the Army to work as a civilian on the problem of hemolytic streptococcus in milk and

other dairy supplies and food, as well as among human carriers.—.1. B. C, Jr.
HISTORICAL NOTE 23

3. When the Delorme operation was used, the case fatality rate was 15

percent and 48 percent of the patients were cured. The remainder were not

followed.

Both the Estländer and the Schede operations had many disadvantages.

They left considerable deformity. They were attended with considerable risk.

The'chest was always infected. The postoperative course was long and trying.

The surgery necessary required patience, tact, and a profound knowledge of

surdcal^principles as\vell as a clear understanding of respiratory physiology.

Colonel Keller (25), at Walter Reed General Hospital, Washington, D.C..

made outstanding contributions to the courageous and successful treatment of

many of the empyema casualties of World War I.

Hemothoracic Empyema

In World War I, aspiration was favored as the initial treatment of hemothorax- it led to early recovery and return to duty. The bad results of

organized hemothorax were realized, as was the fact that infection could be

anticipated in 25 percent or more of all such cases. As the war progressed,

therefore there was growing agreement that in cases of massive clotting,

thoracotomv, with mechanical cleansing of the pleura and tight wound closure,

was the procedure of choice. It was carried out by three methods:

1. Mere debridement of the wounds of exit and entrance.

2. Formal thoracotomy at the site of election, with the repair of wounds

of entrance and exit.

3. Removal of foreign bodies, with resection and suture of the lung according to the indications.

' Also as the war progressed, postoperative airtight drainage came to be

considered better than repeated aspiration, and early ambulation and activity

were recommended. Thus at the end of World War I, there existed the prototype of the methods of treatment of hemothorax and organizing hemothorax

used with such brilliant results in World War II.

Many observers in World War I recognized that the late results of an

inadequately treated or neglected hemothorax could be extremely serious.

They included pulmonary compression, thickening of the pleura, immobility

of the diaphragm, poor pulmonary expansion, shoulder drop, scoliosis, and

dyspnea (which might be incapacitating).

The dangerous possibilities of secondary infection of hemothoraces were

also recognized. Soltau (31) reported the presence of gas-producing organisms

in 48 percent of infected cases and of streptococci in 40 percent, The seriousness of these observations is apparent when it is recollected that 75 percent or

more of wounds of the chest were associated with hemothoraces.

Hemothorax associated with thoracic injuries provided all the conditions

favorable for pleural infection. They included lacerated tissue, the unyieldingcostal parietes. exudation that was more rapid than compensatory absorption
24 THORACIC SURGERY

(with resulting- increase in the hemothorax), and the presence of retained

foreign bodies and of bacteria, The presence of blood in any amount was

irritating and could lead to a serofibrinous serositis. With the development of

hemothorax, the blood was defibrinated by the physiologic movements of the

chest, and the fibrinous exudate spread over the entire pleural lining. Infection readily followed.

"When an acute pyothorax was added to the burden of recent wounds and

exposure, it became an extremely serious complication, particularly when, as

often happened, the casualty could not receive the personal, individual attention he could have received in civilian life. Chronic pyothorax, even when

it was treated as superbly as it was by Colonel Keller, inevitably caused

material disability.

DECORTICATION IN EMPYEMA

Development of Operation

Numerous observers, beginning with Laennec, had noted that in chronic

empyema, the lung beneath the thickened membrane was often normal and that

its reexpansion was often prevented not by pulmonary disease but by a false

membrane deposited on the pleural surface.

Delorme (29), in 1893, was the first to make practical application of this

observation in a "tuberculous" abscess of the chest wall with intrapleural extension. The operation consisted of the removal of two ribs and of the thickened membrane overlying the parietal pleura and the lung. The next year, at

autopsy, he removed a leatherlike membrane from the lung 0f a patient who

had had tuberculous pleurisy for 6 months and had died after rib resection.

When the membrane was removed, the underlying lung was found healthy and

expansile.

Delorme's first decortication for empyema was performed in January 1894

(32), on a patient who had been ill for 4% years. The case was apparently

highly favorable because, as he described the operation, as soon as the peel was

split, the lung began to burst forth, much as the pulp of an orange appears

when it is peeled, and full pulmonary reexpansion occurred. The end results

were excellent. Two years after he had performed the operation, Delorme

applied the term "decortication" to it (33).

Although Delorme devised the operation of decortication, he was not the

first to employ it on the indication of empyema. This distinction belongs to

Fowler (28), who performed the operation in 1893, in line with his contention

that the fibrous investment of the pleura in chronic suppurative disease must

be removed before pulmonary expansion could be achieved. His patient, a

35-year-okl woman, had been ill with empyema since January 1891; five thoracenteses and open drainage had all been unsuccessful. The mass of cicatricial

tissue which he dissected free from the thoracic wall, diaphragm, pericardium.
HISTORICAL NOTE 25

and lung occupied three-fifths of the right pleura! cavity. Within 28 days, the

lung had completely reexpanded, and the good results led Fowler to suggest

the possibilities of this method for other instances of old empyema that had

resisted the means ordinarily employed for their cure.

Delorme clearly described the pathologic process in chronic empyema as

a "shell" or "false membrane," and neither he nor Fowler mentioned the removal of thickened pleura in their reports. It is odd, therefore, that the totally

erroneous idea soon developed that decortication was the removal of thickened

pleura. This incorrect concept persisted in many quarters until World War II.

The term "pleureetomy" was, in fact, employed by C. H, Mayo and Beckman

(34,) in 1914 and by Newton (35) in 1916. On the other hand, Dowd (36), in

1909, stated that the firm exudate in empyema became so incorporated with the

pleura that the resulting membrane resembled a thickened pleura, and the

pathologic process was also correctly conceived of by Lilienthal (37) and by

Spencer (38) in 1915, by Grey Turner (14) in 1919, by Moynihan (39) in 1920,

and by Graham (40) in 1924.

Indications and Results

In spite of the unquestioned soundness of the concept of decortication, the

operation never became widely popular until World War II. Its clangers,

which were real enough, were overemphasized, and although some surgeons

advocated it on strict indications, others would have nothing to do with it.

Delorme (41), in 1912, had pointed out that patients with posttraumatic

empyema were particularly favorable candidates for decortication. Grey

Turner (14), in a postwar discussion of chest wounds, described empyema following hemothorax as more serious than the empyema seen in civilian practice,

and for this reason he considered drastic measures such as decortication more

justified in its management. Moynihan (39), among others, emphasized the

importance of freeing the lung from constricting adhesions when thoracotomy

was performed for the removal of missiles; he thought, in fact, that many times

liberation of the lung was more important than the removal of the foreign

body.

Decortication was mentioned in the report of the Empyema Commission

in World War I (?A), but the members had no great enthusiasm for it. Their

remarks, in substance, were as follows:

This operation, like the Estländer and Schede operations for empyema,

carries a high mortality rate, and the patient who submits to the serious risk

which it entails has little assurance of complete relief. Extensive decortication is usually attended by serious hemorrhage. In many instances, a complete

operation is impossible because the fibrous tissue on the surface of the lung is

only part of a more general fibrosis of the whole lung, and projections of scar

tissue extend from the surface deep into the lung substance. Colonel Keller

(%5), in 1922, made much the same point. He considered decortication suitable
26 THORACIC SURGERY

for some patients, but he qualified the recommendation with the sound warning

that nothing could effect reexpansion of a lung which had become fibrotic.

The Empyema Commission recognized the benefits of chemical decortication with Dakhrs solution in some cases of empyema, and Gurcl, in a discussion

of the operation at the 1946 meeting of the American Association for Thoracic

Surgery (Ifi), recalled that this technique had been used successfully by British

surgeons in World War I when hemothoraces could not lie evacuated by aspiration. Gurd also mentioned that during World War I. he and some of his

associates made it a practice, when they were operating for empyema, to remove

a fragment of rib sufficiently large for the hand to be introduced into the chest,

so that what amounted to a very early decortication could be carried out with

sponges.

It was entirely logical that decortication should not have attained wide

popularity when it was first introduced:

1. The operation was usually performed only on poor risk patients, who

had been ill for months or years.

2, The long duration of hemoorganization or suppuration had usually resulted in enormous thickening and organization of the visceral pleura, while

formation of fibrous synechiae between the constricting membrane and the

pleura had resulted in such a degree of cellular intimacy between the pleura

and the investing layer of organized exudate that the operation was almost

doomed to failure when it was undertaken. In addition, the lung had frequently

become fibrotic.

?,. If a complete operation was attempted in the face of these conditions,

dangerous hemorrhage could result, or bronchopleural fistulas might follow.

Complete operations were therefore not the rule. Usually, only the outer

surface of the lung and the fissures were liberated. No attempt at visceroparietal, mediastinal, or pericardia! separation was made. A compromise

operation was sometimes employed, consisting of deep crosshatching over the

thickened visceral pleura, sometimes with liberation of the lung along with

the circumference of the cavity, the patch of thickened pleura over the cavity

being left intact, This operation was sometimes combined either with a

thoracoplasty or with a Scheele type of operation, with removal of the overlying parietal pleura.

4. Anesthesia for chest surgery was entirely inadequate.

5. Blood transfusions were seldom employed.

6. Chemotherapy and antibiotic therapy were not available, and surgery

in the presence of fresh suppuration was therefore particularly hazardous.

As a result of these unfavorable conditions, the case fatality rate in decortication was high. The statistics which Violet (,f?) collected in 1904 covered

160 operations. Although 41.9 percent of the patients were entirely well and

12.5 percent improved, the case fatality rate was 12.5 percent. In 1915,
HISTORICAL NOTE

Lilienthal (-J7) reported 23 decortications on patients ranging in age from

16 months to 53 years. There were 18 cures, but there were also 4 deaths.

Hedblom (U), »i 192°; reported on 30 of 150 patients with empyema

treated by decortication, with 1 hospital death; 3 later deaths from other

causes; 15 primary cures; and 5 additional cures after secondary operations.

At the time of the report, three patients had persistent sinuses, and three

were, still under treatment.

By far the best results reported for decortication before World War II

were by Eggers {/tG) in 1923, 140 operations with only 5 deaths (3.4 percent).

Decortication in World War II

As these various facts show, decortication was an operation whose real

potentialities were not fulfilled when it was first introduced, in World War I,

or in the interim between the wars. Not until the North African campaign

in World War II was it finally appreciated that infection of the pleura m

an otherwise healthy chest, most often from a neglected hemothorax with

clotting and organization, was entirely different from empyema resulting from

disease&within the lung; that is, pneumonia. In July 1943, at the chest center

established by Colonel Churchill at the 53d Station Hospital, Bizerte, Map

Thomas IT. Burford, MC, performed the first decortication, with strikingly

successful results.

The idea of decortication in organizing hemothorax came to him, Major

Burford related, not because of the past record of the operation but from

the British operation known as "turning out the clot." This procedure was

used in hemothoraces in which aspiration, for one reason or another, was not

satisfactory. After the patient had been stabilized to the point at which

mediastinal shift was unlikely, a limited thoracotomy was done, the clot was

scooped out, and drainage instituted.

The firmness of the exudate or peel, which the British repeatedly emphasized, led Major Burford to speculate that it might be worthwhile to cut

through it and see what lay underneath. He had the opportunity at the

chest "center in Bizerte when two patients with organizing hemothoraces of

almost precisely the same degree came under his observation. He used one

of them, an American soldier, as a control, treating him by the standard

routine. The other patient, a German prisoner of war, was treated by thoracotomy and decortication. A small incision in the pleura revealed that it was

entirely normal. When the incision was extended, normal lung, to the surgeon's surprise and delight, herniated through the opening. The peel was

Then pulled off the lung, just as one would pull off a glove. The patient

made an excellent recovery.

Vfter this demonstration, decortication was brilliantly developed m the

Korth African theater by Major Burford, Maj. (later Lt. Col.) Paul C.
28 THORACIC SURGERY

Samson, MC, and their associates. It proved not only safe but strikingly

successful in the management of organized hemothorax and liemotlioracic

empyema. The optimum time for its performance was within 3 to 6 weeks

after wounding. At this time, there were few organizing adhesions between

the overlying exudato or peel and the underlying healthy lung. It was therefore possible to strip off the peel, with complete reexpansion of the lung,

just as Deforme had observed this phenomenon when he introduced the

operation 50 years earlier.

THE PERIOD BETWEEN THE WORLD WARS

There were three reasons for the founding of the American Association

for Thoracic Surgery in 1918, (1) the awakening realization of the importance

of chest physiology, (2) the work of the Empyema Commission, and (3) the

development of surgery for pulmonary tuberculosis. The major portions

of the first programs of the association were occupied with problems of

empyema and tuberculosis.

At this time, acute empyema and chronic empyema were both so common

and so much a part of general surgical practice that it was seriously debated

whether this condition should even be included in thoracic surgery. During

the years between the wars, unfortunately, the lessons of World War I that

were so ably recorded in the official medical history of the war were forgotten.

Until the advent of the sulfonamides in the late 1930;s, chest surgeons continued to concern themselves with the management of empyema by aspiration,

closed drainage, various techniques of irrigation, and open thoracotomy, as

well as with collapse operations for chronic empyema.

Hemothorax was not a major problem in civilian injuries of the lungs

and pleura, which were chiefly crushing or were caused by bullets or small

weapons such as ice picks. Games Weeks (46), a surgeon for the New York

Police Department, from his experience with a small group of patients with

bullet wounds of the chest, recommended prompt evacuation of hemothoraces,

to permit reexpansion of the lung and to avoid protracted invalidism.

By the end of the period between the World Wars, whole blood transfusions were being freely used in civil practice. The significance of Robertson's (4.7) work in World War I, however, had not been read aright, and

the profession had been lulled into a false sense of security by erroneous

concepts of blood substitutes. Therefore, as the United States entered the

war, the entire emphasis was upon plasma and the so-called blood substitutes,

and no preparations were made for the use of whole blood in quantity, upon

which, during the war, the chief emphasis was to be placed for resuscitation

and for preparation for surgery.

During the period between the wars, there was a dramatic development

in thoracic surgery. This was partly from the impetus received in this field

during World War I and the return to civil life of young surgeons who
HISTORICAL NOTE 29

had seen the possibilities in it. Also during this period there were enormous

advances in anesthesia for chest surgery. In addition, and perhaps most important of all, interne and residency systems in the United States were developed,

and many young thoracic surgeons were well trained and ready to take over

where their pioneering predecessors had left off.

The United States was catapulted into World War II, in which it fought

in three major theaters, each of which, in turn, produced its own peculiar

diseases and problems. By this time, preventive medicine was a highly developed specialty. In World War II, therefore, there were no serious epidemics in military camps in the United States, as in World War I, nor was

there a worldwide epidemic of influenza. Pneumonia had been on the decline

for many years, and the sulfonamides, and later penicillin, were available as

powerful therapeutic agents. As a result, infection was never a serious problem, and attention could be focused upon (1) the proper surgical treatment

of wounds by methods that rested upon a sound anatomic and physiologic

basis, and (2) early wound closure, with restoration of as nearly normal

function as possible.

It was realized from the beginning by the theater consultants in surgery

(Colonel Churchill in the Mediterranean theater, and Col. (later Brig. Gen.)

Elliott C. Cutler, MC, in the European theater) that adequate initial surgery

furnished the surest means of preventing infection. It was also promptly

recognized by them that plasma was not an adequate substitute for blood,

which was provided and utilized in steadily increasing quantities.

In the Mediterranean theater, under the guidance of Colonel Churchill,

the attention in chest wounds was centered on the status of the lung rather

than, as in World War I, upon the pleural space. The physiologic disturbances incidental to wounding, which required prompt treatment, were managed in the most forward hospital unit, sometimes by very simple measures,

sometimes by extensive surgery. Emphasis was placed upon adequate

resuscitation, measures to secure prompt reexpansion of the lung, and rehabilitation. Chest centers for expert reparative surgery and convalescent care

were established in the communications zone.

As a result of the principles and policies developed for their management, empyema and other complications of chest wounds were relatively

infrequent, and the mortality rate was surprisingly low. The treatment of

these wounds probably reached its zenith in the period extending from the

spring campaigns of 1944 to the end of the war. The explanation is obvious:

Blood banks were established in all theaters of operations and in the United

States, to supply blood for oversea use. About this time, penicillin (figs. 1

and 2) became available in quantities sufficient for general use. Perhaps most

important of all, the personnel of hospitals and auxiliary surgical groups now

included large numbers of well-trained thoracic surgeons who had not only

profited by their training and experience in the United States but who were

also veterans in the surgerv of combat-incurred chest trauma.
30 THORACIC sruoEitY

FIGITBE 1.—Sir Alexander Fleming, who

discovered penicillin in 192S.

FIGUEK 2.—Sir Howard Florey, who took

up Fleming's work and extracted the

essential compound from the liquid in

which penicillin grows.

BRITISH CHEST SURGERY IN WORLD WAR II

By 1939, when Britain entered World War II. there were a number of

favorable circumstances in the management of war wounds (13, 48). Gordon-Taylor (13) listed them as follows :

1. Important information concerning- combat-incurred chest wounds had

been gained by the observation and secondary treatment of the pensioners
HISTORICAL NOTE JJL

of World War I. A great deal had thus been learned about the late results

of retained foreign bodies, imperfectly treated hemothorax, and the management of chronic empyema.

2. The technique of anesthesia for chest surgery was well developed.

3. The importance of blood replacement was realized, and blood banks

had been established.

4. One-stage lobectomy had been introduced, and radical chest surgery

of an extent that had previously been impossible was now feasible.

5. The importance of physical therapy and active chest exercises, to

prevent deformity and respiratory impairment, had come to be realized.

6. Thoracic surgeons had been trained in increasing numbers in recent

years. This group, together with the residue of chest surgeons who had

gained their experience in World War I, provided a nucleus of competent

Thoracic surgical personnel for both the Armed Forces and the special

Emergency Medical Service centers in the United Kingdom.

The British also had excellent equipment for thoracic surgery, which was

looked upon with envy by U.S. chest surgeons in the early days of the war,

before their own equipment reached the optimum quantitative and qualitative levels later attained. Before this desirable situation developed, the generosity of the British War Office made it possible for U.S. surgeons to obtain

a good deal of much needed equipment,

Administrative Considerations

The British Medical Service had a civilian consultant in chest surgery,

Mr. A. Tudor Edwards, but had no Army consultant in this specialty. The

greatest number of chest injuries incurred in combat were not handled

hi Army installations but in the Emergency Medical Service centers in the

United Kingdom. Mr. Tudor Edwards controlled their organization, which

was based on a regional system. Some regions, because of shortages of

specialized personnel, were undesirably large. Surgeons attached to various

hospitals often acted as consultants for much larger areas.

These centers continued the primary treatment initiated by Army surgeons and cared for practically all casualties with chest wounds returned to

the United Kingdom. The period between the outbreak of the war and the

heavy fighting in May 1940 provided the opportunity for them to become well

organized and highly developed. They were therefore in an excellent state

of i-eadiiiess when the first battle casualties began to arrive in May 1940 and

when the enormous numbers were received shortly afterward from Dunkirk.

In the emergency, the chest centers could not limit their admissions to thoracic

casualties, but the attempt to direct all chest casualties to them was generally

successful.

Soon after the British entered the war, plans were made for the formation

of special chest units, but they had not been implemented by the time of the
90 THORACIC SURGERY

Battle of France. Two small surgical chest units, which were later organized

for service in the Middle East, worked in Italy, and two similar units were

established after the Normandy landings. No special provisions were made

for chest surgery in Burma, but a unit was preparing to go to India when the

war ended.

Clinical Considerations

Air-raid casualties.—The British learned a great many lessons from the

casualties of air raids, both before Dunkirk and during the entire war. There

were exceptional opportunities for early treatment—much earlier than was

possible under battlefield conditions—because the injuries so often occurred in

close proximity to hospitals. Many casualties survived who might not have

lived had they sustained similar injuries in the field.

During the air raids, even very severely wounded casualties were often

treated by primary thoracotomy, -with complete wound excision, evacuation of

hemothorax, and resection of damaged lung, and were discharged from the

hospital within 3 weeks.

Crushed and so-called stove-in chests were frequent, from falling masomy

and from traffic accidents in the blackout, as well as from bomb injuries. Paradoxical respiration, a serious feature of these injuries, was easily controlled by

effective strapping over a pad laid over the damaged portion of the chest.

Two complications were characteristic of air-raid injuries. One was severe,

acute dilatation of the heart, which occurred so rapidly that in some of the

earlier cases, before its importance was realized and a routine of treatment

adopted, the casualty did not survive. The second was the accumulation of

tracheobronchial secretions (the wet hing of U.S. surgeons), which had to be

evacuated promptly to prevent purulent bronchitis, atelectasis, and fatal pneumonia. Broiichoscopy was employed if simpler methods, including catheterization, did not achieve prompt results.

Combat casualties.—In the period before Dunkirk, the British, according

to their official history (48), made many errors in the management of chest

injuries because they ignored the principles of primary wound management

that they should have known well. Almost all casualties who receivecl initial

wound surgery underwent wound repair without wound excision or provision

for drainage. When they were received in the British Isles, almost every wound

thus treated was heavily infected, and many patients were seriously'ill with

intrathoracic infections. Ironically, many casualties who had received only

first aid, with the simple application of a field dressing, were in much better

condition and presented no such sepsis as has just been described. Men who had

been left untreated on stretchers for 3 or i days because their injuries seemed

so severe that treatment was not considered practical owed their lives to the

fact that their wounds had not been sutured.

These patients with severe intrathoracic infections required weeks and

months of treatment. They demonstrated again the importance of correct
HISTORICAL NOTE 33

initial wound surgery and the risk of suturing an unexcised or imperfectly

excised chest wound.

In the North African theater, the British chest surgeons, like U.S. medical

officers, learned the important lesson that war wounds of the chest must be

treated in two phases:

1. Patients with gross disturbances of the cardiorespiratory system furnished the real emergencies of traumatic chest surgery. If these physiologic

derangements were not promptly corrected, they could be fatal. Initial treatment must therefore consist of standard resuscitative measures, including the

administration of blood and oxygen, closure of a sucking pneumothorax, and

correction of mediastinal displacement by early aspiration of air and fluid.

2. The second phase of management consisted of measures to prevent infection, or its treatment if it had developed. These procedures included repeated

aspirations of the chest by needle, or by major thoracotomy if aspiration failed,

decortication as indicated, and the institution of physiotherapeutic measures

designed to encourage normal breathing and prevent thoracic deformity. The

prewar concept that wounds of the lungs would be widely excised or even

treated by lobectomy was not put into practice. D'Abreu, in fact, knew of only

one lobectomy performed in Italy. The U.S. experience was much the

same (vol. II, ch. I).

Hemothorax and hemothoracic empyema —As the British experience

progressed, certain facts concerning hemothorax and subsequent empyema

became evident:

1. Clotting could be expected in from 5 to 10 percent of all hemothoraces.

The U.S. experience pointed to a somewhat higher incidence.

2. The incidence of clotting Avas increased by inadequate or delayed

aspiration.

3. Clotting was more likely to occur when thoracic damage was considerable.

The theory that thromboplastic substances were liberated in severe injuries and

that clotting was increased in this variety was supported by the observation

that it was much more frequent in massive damage produced by a rapidly moving bullet from a rifle or a machinegun. It was thought possible that the

presence of Staphylococcus aureus, which produces no fibrinolysin, might play

a part in the incidence of clotting.

The British recognized three stages or forms of clotted hemothorax:

1. Multiple pockets containing air and fluid demonstrable on roentgenograms and associated with major degrees of pulmonary collapse. At operation

in these cases, fluid was found entrapped among masses of organized or organizing fibrin.

2. Massive blood clots, which really represented a pleural hematoma rather

than an organizing fibrinothorax and which required prompt removal. These

patients had higher fever than was present in patients with the simple type of

clotting, and there was rapid diminution of chest movements, associated with
34 THORACIC SURGERY

notable flattening. If the lung became atelectatic, bronchial breathing and

pyrexia might lead to an erroneous diagnosis of pneumonia.

3. Hemothorax with clotting and low-grade infection. In this variety of

hemothorax, the organisms were usually encased in fibriiious masses, and the

bacteriologist required the clot as well as specimens of pleural fluid for satisfactory aerobic and anaerobic cultures.

Early in the war, it was the British practice to delay aspiration of hemothoraces from 36 to 48 hours, because of the fear of bleeding. Air replacement

was also advocated. The latter practice was soon dropped, and it gradually

became the routine to aspirate the chest promptly, particularly when surgery

was not needed to repair the parietal wound or to control hemorrhage. This

policy, according to Tudor Edwards (Iß), was based on the following

objectives:

1. To relieve intrapleural pressure.

2. To eliminate blood, which is an excellent culture medium.

3. To prevent massive clotting.

4. To secure early reexpansion of the lung and thus limit the area of involvement if infection should occur.

5. To shorten the period of invaliclism.

Whenever it was practical, the British preferred to perform all thoracenteses in a separate room fully equipped for the purpose and in the charge

of a trained orderly. When this arrangement was possible, from 20 to 30

aspirations could be handled daily. The procedure was explained to the patient,

who was told that it would cause him little pain or discomfort. The site of

puncture was decided by the study of roentgenograms in two planes. It Avas

a common error to go in too low. The fluid was examined routinely by smear

and culture. Serial roentgenograms were taken during the postoperative

period, and the necessity for subsequent aspiration was determined by staff

conferences. Breathing exercises were part of the routine management.

The British, like U.S. Army surgeons, were somewhat slow to realize the

importance of distinguishing between posttraumatic empyema, which gave rise

to a far higher incidence of chronicity if not properly treated, and metapneumonic empyema. They explained the delay, as did U.S. surgeons, by the

fact, already noted, that this difference was not emphasized as it should have

been at the end of World War I, because the plethora of cases of influenzal

empyema completely overshadowed the small number of cases of posttraumatic

empyema.

By the end of 1943, the British had learned that clotted hemothorax was

best handled by what they termed "turning out the clot," through a small intercostal incision. The chest wall was sutured at the conclusion of the operation,

and the secondary effusion was aspirated regularly.

This technique, although it greatly reduced the risk of empyema, was

not always followed by satisfactory reexpansion of the lung. Decortication.
HISTORICAL NOTK *>D

which had been introduced by Major Burford of the 2d Auxiliary Surgical

Group (p. 27), proved the answer to this problem and came into general use.

The majority of surgeons considered that results were greatly improved by

temporary intercostal drainage, especially when several tubes were used, with

one or more in the apex of the pleural cavity. Other surgeons closed the chest

and relied on aspiration and instillation of penicillin.

When decortication came into general use, results were secured far more

prompt!}', and were far better, than the results achieved by rib resection and

drainage. Casualties treated by the latter method usually required months

of hospital treatment and, despite it, often went on to develop chronic empyema,

which had to be managed by elaborate thoracoplastic procedures and which

often resulted in permanent disability.

Tudor Edwards (P), in a presentation at the Inter-Allied Conference

on War Medicine in January 1945, produced evidence of the improved results

accomplished by early aspiration. In World War I, the British incidence of

empyema had been 37 percent, In 249 chest injuries studied in 1943, the

incidence of empyema had been 21.0 percent when aspiration was delayed

beyond 48 hours and 12.5 percent when it had been clone earlier. In 1.083

casualties treated in chest centers in the united Kingdom between D-day and

30 September 1944, after early aspiration had become routine, there were

only 148 cases of empyema. 8.7 percent. There were only 9 deaths in these

1,083 chest injuries, 5 in the first 251 patients received in the chest centers

and 4 in the remaining 1,432 patients. Penicillin, while invaluable in infected

thoracic wounds, did not play a major role otherwise in the satisfactory results.

What mattered most was that the pleural cavity be kept dry. If this was

accomplished, infection did not gain a foothold.

GERMAN CHEST SURGERY IN WORLD WAR II

On 3 May 1945, an Allied Force Headquarters directive made captured

German prisoners who were wounded or ill the responsibility of the Fifth U.S.

Army medical service (SO, SI). The following week after the final German

surrender in Italy, the theater surgeon, Brig. Gen. (later Maj. Gen.) Joseph I.

Martin, directed that a number of qualified U.S. Army medical officers, among

(hem Lt. Col. (later Col.) Howard E, Snyder, MC, Consultant in Surgery to

the Fifth U.S. Army surgeon, visit German medical installations and make a

complete survey of them.

Administrative Considerations

Casualties with chest injuries, like other casualties with major wounds,

were usually evacuated to the rear from the German medical installation

(Hauptverbandplatz) that corresponded with the U.S. Army clearing station.

In a more forward station (Truppenverbandplatz), which corresponded with
36 THORACIC SURGERY

a U.S. Army battalion aid station, an occlusive dressing had been applied

to an open chest wound and, if necessary, tracheotomy had been performed.

Shock therapy had also been instituted (physiologic salt solution, external heat

by electric heaters, Coramine (nikethamide) or Periston).

The German medical field manual listed the thoracic surgery to be performed at the Hauptverbandplatz as tracheotomy, closure of open chest wounds,

and aspiration of the pericardium if cardiac tamponade was present. Blood

and blood substitutes were also administered here.

Definitive primary surgery for patients with transportable chest wounds

was performed at the Feldlazarett, which corresponded to a U.S. Army evacuation hospital. In very busy times, all casualties requiring major surgery might

be evacuated to the general hospitals (Kriegslazaretten) assigned to an army

group, to permit the units farther forward to care for men who would be able

to return to their units within a reasonable time after operation. At such times,

it was not unusual for patients with serious wounds to receive no surgery at all.

The German system of medical care was extremely flexible, but its flexibility

tended to favor the lightly wounded at the expense of the seriously wounded,

the group to which U.S. Army medical officers gave first priority.

Clinical Considerations

Most of the patients with chest wounds whom Colonel Snyder observed

in the German hospitals that he surveyed had been wounded weeks and months

earlier. Their generally pale and anemic appearance was in contrast to the

healthy appearance of most patients in U.S. Army hospitals. Clinical practices

in the German medical service explained the difference: The Germans used

blood in little more than homeopathic amounts, and their almost complete lack

of aseptic techniques accounted for the prevalence of wound infection, the

extent of which was many times more frequent than in U.S. Army hospitals

and almost incomprehensible in the year 1945, regardless of military circumstances. About GO percent of the chest patients had empyema, and Colonel

Snyder was informed that this complication could be expected in about this

proportion of shell-fragment wounds and in about 30 percent of all bullet

wounds.

Opinions expressed by German surgeons concerning the management of

chest injuries varied widely in details but were in general agreement in respect

to most principles. The information secured was, in substance, as follows:

Shock of some degree was present with most chest wounds, and, unless

there was a wide-open pneumothorax or a severe and menacing hemorrhage,

its management took precedence. When there was serious internal bleeding

or an increasing hemothorax, constant observation of the casualty was necessary, for shock might merge into collapse and the patient might bleed to death.

When large numbers of wounded men were received at the same time and the

surgeons were busy in the operating rooms, a junior medical officer, or whoever
HISTORICAL NOTE 37

else might be available, was appointed to make so-called collapse examinations,

to be certain that a failing circulation and serious hemorrhage would be

detected before they became irreversible.

Surgery was not performed in perforating thoracic wounds unless rib

fragments had been indriven. The policy of early, repeated aspiration in

hemothorax, which was routine in U.S. Army hospitals, was not employed in

German hospitals, and there seemed no routine technique of management for

this complication. Some surgeons said that aspiration was never employed

unless it was required to relieve dyspnea associated with a large hemothorax

or hemopneumothorax. Others said that aspiration was performed within the

first 5 days after wounding. One consulting surgeon said that this had been the

practice earlier in the war unless respiratory difficulties demanded immediate

relief but that it had recently become the policy to employ aspiration as soon

as the casualty recovered from shock, usually within 48 hours after wounding.

The treatment of empyema seemed rather more uniform. Closed intercostal (von Biilow) drainage was instituted as soon as infection or purulent

exudation became evident. The catheter was attached to a water-seal bottle,

which was usually converted into a Wangensteen-like suction apparatus by the

use of two additional bottles. Drainage was continued until the cavity was

obliterated. If this had not occurred at the end of 6 months after wounding,

the empyema was considered chronic, and thoracoplasty and clecortication were

performed by a modified Schede technique. Rib resection was seldom used.

Only a small number of patients with thoracoabdominal wounds were

observed in the German hospitals. None of the wounds were extensive, and in

all instances, surgery had been limited to laparotomy with simple closure of

the thoracic wall wound. No patients were encountered who had been treated

by the transdiaphragmatic technique that was regarded so favorably by U.S.

thoracic surgeons (vol. II, ch. Ill). When inquiries were made about this technique, the replies were vague. One surgeon stated that the thoracic approach

might be used if the chest wound was large and the intra-abclominal wound

small.

No facilities were provided for gas anesthesia or for positive pressure

delivered by an anesthetic machine. A good machine was available for oxygen

therapy, but it seemed to be seldom if ever used for expanding the lungs during

intrathoracic surgery. No endotracheal tubes were seen, and no thoracic

surgeon or anesthesiologist mentioned the endotracheal technique. Most

anesthesia for chest surgery was supplemented by Pentothal sodium (thiopental

sodium) given intravenously.

Since there were no facilities for positive pressure at operation and no

well-trained anesthesiologist experienced in anesthesia for chest surgery, it was

concluded that German casualties with chest wounds could not have had the

advantages of modern intrathoracic and transdiaphragmatic surgical techniques.
38 THORACIC SURGERY

SPECIAL TYPES OF WOUNDS

Thoracoabdominal Wounds

The British experience in the World Wars.—Thoracoabdominui wounds

are discussed only briefly in the official British medical history of World War I.

Gask {12), "writing in 1910, noted that because of the protection afforded to

the right side by the liver, the majority of these wounds were on the left side.

He believed that the diaphragm could be repaired efficiently only from above.

The preferred procedure was to open the chest, suture the diaphragm, deal

with the chest injuries according to the indications, and then perform laparotomy if there was evidence of injury to hollow abdominal viscera. If a shell

fragment had lodged in the substance of the liver, it might be necessary to

remove the missile through the thoracotomy, excise any devitalized hepatic

tissue, and then suture the diaphragm. Wounds which involved the diaphragm

were apparently very troublesome; Lockwood and Nixon (52) considered their

repair more important than the repair of any hollow or solid abdominal organ.

The discussion of thoracoabdominal wounds in the British history of

World War II begins with the steadily improving prognosis of these injuries

in World War I (53). In the Somme offensive in 1917, the recovery rate was

18.7 percent; all of the survivors had injuries of solid viscera only. In November 1917, General Bowlby reported to the Surgical Congress at Val-de-Griice

a recovery rate of 49 percent, and an almost similar rate was reported a fewmonths later by Sir Cuthbert Wallace. The best results of the war, a recovery

rate of 66.6 percent, were reported by Gordon-Taylor in the Hunterian Lecture

in 1919, as the work of a group of Fourth British Army surgeons in the autumn

of 1918. Maj. Charles Saint reported a recovery rate of more than 80 percent,

but the experience included only 22 cases, in only 2 of which hollow viscera were

involved. The situation was much the same in the 53 cases reported by Maj.

John Anderson, in which the recovery rate was 79.2 percent.

Several series of thoracoabdominal injuries are mentioned in the official

British medical history of World War II: 208 cases, with a case fatality rate

of 38.0 percent; 59 cases, with a case fatality rate of 46 percent; a collected

group of surgical cases, ranging in number from 10 to 78, in which the case

fatality rate ranged from 8.3 percent in 12 cases (1 death) to 60 percent in

15 cases (9 deaths). The average case fatality rate was estimated at about

30 percent. As in the U.S. experience, the mortality rate depended upon the

number of organs injured, whether the injured organs were solid or hollow,

and the number and severity of the associated injuries. Emphasis was placed

on the high incidence of thoracic complications likely after even promising

surgery for thoracoabdominal wounds.

Associated hemothoraces required particularly careful attention because

these patients were particularly prone to develop lower lobe atelectasis, massive

pleural clotting, and empyema.
HISTORICAL NOTE 39

The popularity of the transthoracic approach was somewhat less among

British than among U.S. surgeons, who found it increasingly useful as the war

progressed. The explanation is probably that the British had relatively few

thoracic surgeons assigned to their casualty clearing stations. A few British

surgeons, after visiting forward U.S. medical installations, adopted the transthoracic approach and found it satisfactory. Even from the beginning of the

war, of course, a surgeon with a thoracic bias would approach the thoracoabdominal wound from above if he were certain that the injuries were confined

to the upper quadrants of the abdomen.

There was general agreement among British surgeons that the transthoracic approach was indicated:

1. In injuries of the spleen.

2. In right-sided thoracoabdominal wounds in which the only abdominal

injury was in the liver. In such cases, repair of the diaphragm was impossible

from below but simple from above.

If the thoracic wound was too high in the chest wall to permit free access

to the diaphragmatic area, even after excision of the wound and traumatic

thoracotomy, it was the British practice to deal with the wound of entry first

and then carry out formal thoracotomy in the region of the eighth and ninth

ribs. When a separate abdominal approach was employed, the wound of the

chest was dealt with first.

The U.S. experience in World War I.—Thoracoabdominal wounds do

not appear in the index of either the surgical volumes or the statistical volumes

o f the history of the U.S. Army Medical Department in World War I. Nevertheless, the seriousness of wounds involving the diaphragm was well recognized,

as was the risk of bile leakage from an injured liver in right-sided thoracoabdominal wounds.

On the whole, there was fairly general agreement that when thoracoabdominal injury was suspected, it was best to attend to the chest injury first,

partly because chest surgery was better tolerated than abdominal surgery and

partly because more favorable conditions for laparotomy were thus established.

It the chest wound was of the sucking type, it was mandatory to take care of

it first. If it was small and if the major damage seemed to be in the abdomen,

then the abdominal wound was handled first. In the chapter on abdominal

injuries in the official U.S. history (54), Col. Burton J. Lee, MC, called attention to the straight vertical incision, beginning near the thoracic wound, used

by the French Army surgeon, Pierre Duval. Repair of both the thoracic and

the abdominal injury was possible through this incision.

In a report on thoracoabdominal injuries in 1920, Charles Gordon Heyd

(55) pointed out that early in the war, all injuries of the diaphragm were repaired through the abdomen. It was only when chest surgery was established

on a rational basis that repair through a thoracotomy approach was found to
40 THORACIC SURGERY

be easier. It was also found possible, as the war progressed, to deal with certain intra-abdominal injuries through an enlargement of the diaphragmatic

wound. Surgery through this approach was usually limited to the reduction

of herniated viscera and the repair of injuries of the liver, the spleen, and portions of the cardiac end of the stomach. Injuries of the colon were also occasionally repaired through the diaphragm.

Heyd concluded that a critical review of the immense collective experience

of World War I suggested that there should be a wider application of major

thoracotomy to deal with wounds involving the diaphragm and the viscera immediately subjacent to it.

The Spanish Civil War experience.—Since Trueta's (56) book on the

Spanish Civil War experience was written from the standpoint of soft-tissue

wounds and fractures, thoracoabdominal wounds do not appear in the index.

In Jolly's (57) text on the same experience, there is mention of 26 such wounds

observed in 238 abdominal injuries (11 percent). There were 123 recoveries

in the total series, 10 of which occurred in the 2(5 thoracoabdominal wounds.

Not included in the series are a number of cases in which only the liver was

injured and operation was not considered to be indicated because hemorrhage

did not threaten life.

Jollv's impressions derived from his experience with these wounds in the

Spanish Civil War were in substance as follows:

The operation selected should depend upon three considerations, (1) the

type and direction of the wound; (2) the type of projectile; and (3) most important, the amount of damage to thoracic and abdominal viscera.

The transdiaphragmatic operation should be reserved for wounds in which

there is (1) extensive damage to the chest, manifested by intrathoraeic hemorrhage or open pneumothorax; (2) a large diaphragmatic perforation, with or

without herniation; and (3) a wound of exit in the upper abdomen, indicating

the course of the projectile. Transdiaphragmatic laparotomy is limited to the

left side unless one considers suture or tamponade of the liver by a right-sided

transpleural approach as a laparotomy.

The abdominal approach should be used in longitudinal wounds or wounds

of considerable obliquity, in which it appears impossible to explore the abdominal cavity adequately by the transdiaphragmatic approach. Chest injuries are cared for first, and the diaphragm is repaired from above.

Both chest and abdominal cavities should be closed without drainage with

the single exception of operations in which tamponade of the posterosuperior

surface of the liver has been necessary. Even in such cases, an attempt should

be made to convert the open pneumothorax into a closed wound. Suture of

lacerations of the liver should be carried out when feasible. If tamponade is

necessary, the wound track should be separated from the pleural cavity by

high suture of the diaphragm to the parietal pleura above the chest wound.
HISTORICAL NOTE 41

RETAINED INTRATHORACIC FOREIGN BODIES

Early observations.—Many of the older reports of retained intrathoracic

foreign bodies, like those of retained intracardiac foreign bodies, are of doubtful authenticity. A truly authentic case, however, was reported by Moore

(58), in 1842. The wound, incurred in action at sea in 1796, was stuffed with

clothing, some of which was coughed up 18 months later. The patient, a

captain in the French merchant marine, continued on active duty for many

years and had an exciting life. He participated in a number of active engagements, was twice captured by the enemy, and was once shipwrecked for 7 days.

For the last 15 years of his life, his health was continuously poor. At autopsy,

it was found that the shot, which was in the pulmonary substance on the right

side, had entered between the fourth and fifth ribs, fracturing the fourth rib

on the right. The diaphragm was at the level of the fifth rib, and the affected

lung was a third of normal size.

As Collis and Qvist (48) expressed it, the tendency has always been to be

"hypnotized" by the presence of large foreign bodies and to think immediate

operation is essential. The early idea was to remove the objects whenever possible. Fräser (4), in his monograph on chest injuries in the Crimean War, told

the story of the gallant officer, who, after being "poked at" for a long time by

the surgeon, finally inquired about the point of the procedure. The surgeon

said that he was searching for the bullet, and the wounded man replied, "I wish

you had said so earlier, because you will find it in my waistcoat pocket."

Surveys of many series of cases in subsequent wars all indicate that while

retained foreign bodies frequently, sooner or later, produce grave consequences,

they may also continue completely asymptomatic. The difficulty is that there

is no way of distinguishing one group of cases from the other.

The World War I experience.—No really reliable data on retained foreign bodies were collected during World War I. The chief controversy concerned the management of symptomless objects. There was general agreement

that large objects (more than 2 cm. in any one dimension) should be removed,

but there were sharp differences of opinion about smaller fragments or bullets

in the absence of hemoptysis or of a clear inflammatory reaction about the

object; in the latter circumstances, removal was recommended, regardless of

size.

The British observed that rifle bullets and small pieces of shell lodged in

the lung and pleural cavity seldom caused any disability and that, in the

absence of infection, their presence did not delay the return of the soldier to

full duty. Unless symptoms were present, therefore, they preferred to leave

the objects in situ. In contradistinction to this general point of view, Grey

Turner (14), in 1919, stated that after 4 years of military experience, he was

more and more impressed by the fact that retained foreign bodies, no matter

where they were situated, were likely to cause trouble.

653C81V—62 5
42 THORACIC SURGERY

The psychosomatic aspects of retained foreign bodies played a part in

their management from the Crimean War on (4). In the Civil War (-5), it

was found that "the peace of mind -which the extraction of the foreign substance invariably induces in the patient is in itself a strong reason for using

every judicious means for their removal." In World War I, Grey Turner

(14) noted that patients received in home hospitals often complained of persistent shortness of breath and other irritative symptoms or simply suffered

from the knowledge that they harbored foreign bodies. Even soldiers on

pension. who did not have to fear return to military service, were apprehensive about them.

During World War I, a great deal of attention was paid to techniques

of removing foreign bodies, including the blind nuoroseopic-triangulation

technique of Petit de la Villeon and the use of the Hirtz compass.

The British experience in World War II.—Early in World War II, it

was the British practice to remove foreign bodies from the lung routinely,

even if they caused no symptoms (13, J+8). After 50 operations had been performed in one unit, removal of these objects was abandoned as unjustified

unless it could be accomplished as part of thoracotomy performed on some

other indication. As experience accumulated in air raids, the policy was developed of removing any fragment larger than 1 by 0.1 cm. Wedge resection

of the lung, to include the foreign body, was the preferred technique, with

the idea that damaged lung tissue should not be left in situ to become a source

of future trouble.

Typical of the British military experience is d'Abreu's report of 339 retained missiles found in 1,000 thoracic wounds, of which 51 were in the

mediastinal and cardiac tissues (13). Of the 221 objects in the lung, 100 were

removed and 2 others could not be found; there were 2 deaths in the 102 operations. Of the 49 objects in the pleura, 44 were removed and 1 could not be

found: there were no deaths.

Nicholson (cited by d'Abreu (13)), who reported 26 instances of empyema in 39 patients with retained intrapleural foreign bodies, had no doubt

of the menace of subsequent infection and late hemoptysis in all such cases,

though he granted that several years must elapse before the real risks could

be proved. Most surgeons who advocated removal of foreign bodies on the

ground of what might happen in the future agreed that there was no real

urgency about operation.

WOUNDS OF THE HEART AND PERICARDIUM

The gravity of wounds of the heart has been recognized from ancient

times. Aristotle's view that the heart alone, of all viscera, cannot withstand

serious injury prevailed for many centuries.

It was not until 1895, according to Ramsdell's (59) excellent review in

1934, that the first attempt to suture a wound of the human heart was made,

by Cappelan of Norway. He failed. In March of 1896, Farina of Italy
HISTORICAL NOTE 43

failed in a similar attempt. In the light of these failures, Stephen Paget's

(60) remark, made shortly after Farina's attempt, seemed entirely justified:

"Surgery of the heart," he said, "has probably reached the limits set by Nature to all surgery; no new method, and no new discovery, can overcome the

natural difficulties that attend a wound of the heart."

The words had scarcely been uttered when they suffered the fate of many

another medical generalization. In September 1896, Beim of Frankfurt successfully sutured a stab wound of the right ventricle. In 1909, Peck collected

from the literature 160 cardiac operations, 59 of which were successful. After

successive additions to this collected series by Pool in 1912, Ballance in 1920,

Smith in 1923, and Schoenfeld in 1927, Eamsdell, in 1934, tabulated 428

cardiac operations with 233 recoveries (55.5 percent). In the medical literature in the United States, 55 of these cases were recorded, in which there were

39 recoveries (70.8 percent). It is a pity that Ballance's (61) suggestion in

the Bradshaw Lecture in 1920 has not been followed, that suture statistics be

made up on the basis of whether or not the heart was opened at operation. In

his collection of 150 surgical cases, in which the case fatality rate was 31.57

percent, 63 wounds were combat incurred; there Avere 16 deaths (26.03

percent).

The World War I experience.—Wounds of the heart do not appear in

the index of the statistical volume of the history of the U.S. Army Medical

Department in World War I, and they are dismissed briefly in the text of the

surgical volume (7) : Early operations on the heart and pericardium were

infrequent because the wounds were either promptly fatal or were treated

expectantly. Cardiac wounds disclosed by operation were "easily remedied,

requiring little more than simple suture," The approach to wounds of such

gravity is surprisingly casual.

A number of successful operations for cardiac wounds were done in the

latter part of World War I by French surgeons, chiefly Pierre Duval. When

there has been no confirmation by post mortem or exploration, however, it is

often difficult to accept all recorded cases of cardiac wounds as authentic, and

even exploration may not furnish absolute proof. DAbreu (IS), in his account of war wounds of the chest in World War II, questioned whether any

of the four cases of early removal of a metal fragment from the heart recorded by Makins in the British official history of World War I (62) was

"indubitably extracted from one of the heart chambers" except the missile

removed by Fräser. At any rate, this patient recovered, as did Sampson's

patient, who was operated on for a wound of the left ventricle. In the other

two cases recorded by Makins, both instances of bullets in the cardiac wall,

death followed surgery.

As d'Abreu observed, inspection of specimens in war museums attests

the gravity of all wounds of the heart, whether they are caused by high-velocity missiles, shell fragments, or spicules of bone. Makins commented in the

British medical history of World War I that the War Office Collection of

specimens illustrated every lesion described from accumulated experience of
44 THORACIC SURGERY

the whole history of surgery but contributed little or nothing not already

gleaned from the classical literature of cardiac surgery. The magnificent

British War Office Collection of specimens in the Eoyal College of Surgeons

was largely destroyed by enemy action in May 1941, but, fortunately, drawings exist of most of them.

According to Makins {62), wounds of the heart involve the right ventricle, the left ventricle, the right auricle, and the left auricle in the descending

order of frequency. In his opinion, the anatomic incidence corresponds with

the relative degree of exposure of the cardiac surfaces toward the front of

the body, plus the relative size of the, area presented by the external aspect of

each chamber. The published records, as well as the specimens in the War

Office Collection, substantiated the great frequency of ventricular wounds

and suggested that, in many instances, both ventricles were implicated. A possibly misleading feature of the War Office Collection, Makins noted, was that,

with four exceptions, all the specimens were secured from patients who survived their wounds long enough to reach the hospital. Limited as was the

British experience in World War I, he concluded, it showed that "rare" conditions were more frequent than previously supposed, and it also afforded

evidence "that the treatment of injuries to the heart has now become a definite

and promising field for the surgeon."

Cardiac surgery between the World Wars.—Wounds of the heart do not

appear in the indexes of either Trueta's {56) or Jolly's {57) books on the

Spanish Civil War. Between the World Wars, however, the writings of Tuffier,

Duval, Carrel, Graham, Beck, Cutler, Bigger, Elkin, and others recorded

successive advances in cardiac surgery. During this period, the basic techniques

were developed that were used so successfully for the management of these

wounds in World War II. Elkin's {63) cumulative study of 61 cases from

Emory University Division of Grady Hospital, Atlanta," Ga., published in

1944. may be taken as typical of the status of civilian traumatic cardiac surgery

at the time the United States entered World War II. In the first 38 patients,

all treated before 1940, there were 16 deaths (42 percent). Seven of the fatalities were caused by infection. In the 23 patients treated after this date there

were 5 deaths (22 percent), none of which was caused by infection. The

lowered case fatality rate and the absence of fatal infection could not be attributed to chemotherapy; penicillin was not yet available, and the sulfonamides

were used in only one case in the series. The improved results were attributed,

instead, to more careful surgical technique and more precise preoperative

preparation, particularly the use of intravenous replacement therapy.

The British experience in World War II.—The British experience with

wounds of the heart in World War II does not seem to have been extensive;

these injuries do not appear in the index of the surgical volume of the official

history. D'Abreu {13), in the supplement on chest surgery in the British

Journal of /Surgery, described several small ventricular wounds treated by

suture but devoted his chief attention to retained foreign bodies. He mentioned 4 or 5 isolated cases in which they were removed and also reported 51
HISTORICAL NOTE 45

cases, out of 339 cases of retained missiles, in which foreign bodies were

retained in the mediastinal and cardiac tissues. Operation was undertaken

in 30 cases, and the objects were successfully removed in 28. There were two

deaths. One patient died on the operating table after an uneventful operation,

and the other in 24 hours, "with the heart in fibrillation." In the latter case,

the object, which lay in the wall of the left ventricle, had not been removed

because of the friability of the heart muscle. Two of the missiles removed were

in contact with the thoracic aorta, and another Avas removed from the lumen

of the subclavian vein, which was sutured without subsequent edema.

Retained foreign bodies.—The first operation for a foreign body in the

heart seems to have been performed by Gerard in 1834. Between 1900 and

1938, according to Decker's (<%) 1939 review of the literature, 109 cases were

recorded. In nine instances the object passed out of the heart and into the

arterial circulation. In the remaining 100 cases, there were 8 deaths in the 47

patients treated surgically and 16 in the 53 patients treated conservatively.

The authenticity of case reports in which neither operation nor autopsy was

performed is sometimes open to doubt, as just mentioned, and there were the

usual arguments as to what harm was likely if retained objects were ieft in

situ. Delorme cited the history of a veteran of the Napoleonic Wars who lived

for 52 years with a round bullet fixed by adhesions in the pericardia! sac and

whose only complaint was that he could not lie on his left side, but the sequence

of events was often much more serious.

Migrating missiles, said d'Abreu (IS), were followed in "marathon pursuit" as they moved from body cavity to body cavity. He continued:

During the 1914-19 and 1939-45 conflicts, the existence of a fragment of metal in

the heart wall or within one of the cardiac chambers seemed to provide an irresistible

challenge to surgical courage and enterprise. The swirlings and gyrations of bullets and

fragments of high explosive were watched by radiologist and surgeons with the same

interest, that "astronomical observers bestow on minor planets," and these fluoroscopie

seances only served to whet the avidity of operators to rid the owners of their unpleasant

tenants.

Blast Injuries

Blast injuries, a form of chest injuries which occur from exposure to the

detonation of some high explosive, were not described as such in World War I.

Their characteristic manifestations, however, were recognized. There were

a number of references to the finding of dead soldiers on the battlefield, after

explosions, without any external injury or any serious external injury, often

with the nose and mouth full of bloodstained fluid. Thomson (65) found 24

such cases in 250 chest Mounds. This incidence is close to the 10-percent incidence reported in the U.S. Medical Department history of the First World

War (/'). In this history, these injuries are described as involving the viscera

alone and as due to indirect violence or sudden and considerable changes in

atmospheric pressure resulting from nearby explosions.

Blast injuries were also reported in the Spanish Civil War. Perhaps for

(hat reason, but more likely because of the injuries caused by indiscriminate
4G THORACIC SURGERY

bombing early in World War II, there was a considerable outpouring of interest, as manifested by numerous special reports and experimental studies in the

literature (66), (vol. II, ch. I). As a matter of fact, at least in land warfare,

blast injuries proved an almost inconsequential cause of injury and death among

U.S. troops.

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HISTORICAL NOTE 47

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Wiesbaden 9 : 41-141, 1890.

28. Fowler, G. R.: A Case of Thoracoplasty for the Removal of a Large Cicatricial

Fibrous Growth Prom the Chest, the Result of an Old Empyema. M. Rec. 44: 838-839,

30 Dec. 1893.

20. Delorme, E. : Contribution ä la Chirurgie de la poitrine. Assoc. franc, de chir.,

Paris 7 : 422-428,1893.

30. Tufficr, Tli. : The Treatment of Chronic Empyema. Ann. Surg. 72 : 206-287, September 1920.

31. Soltau, P. B.: Wounds of the Chest. (Research Society, American Red Cross in

France, June 1918.) War Med. 2: 1-5, August 1918.

32. Delorme, E. : Nouveau traitement des empyemes chroniques. Gaz. d'hop. 07 : 94-96,

25 Jan. 1894.

33. Delorme, E. : Du traitement des empyemes chroniques par la decortication du

poumon—resultats, indications technique. Assoc. franc, de chir., Paris 10: 379-389, 1896.

34. Mayo, C. II., and Bookman, E. : Visceral Pleurectomy for Chronic Empyema. Ann.

Surg. 59 : 8S4-S90, June 1914.

35. Newton, A.: A Case of Chronic Empyema Treated by Visceral Pleurectomy. M. J.

Australia 1: 7-S, 1 Jan. 1916.

36. Dowd, 0. N. : Persistent Thoracic Sinus Following Empyema: A Report of Fifteen

Cases Treated by Decortication of Lung and Thoracoplasty. J.A.M.A. 53: 12S1-12S5,

16 Oct. 1909.

37. Lilienthal, H.: Empyema: Exploration of the Thorax With Primary Mobilization

of the Lung. Ann. Surg. 62 : 309-314, September 1915.

3S. Spencer, W. G.: Decortication for Traumatic Empyema With Complete Collapse

of Lung. Brit. M. J. 1: 796-797, 8 May 1915.

39. Moynihan, B.: The Surgery of the Chest in Relation to Retained Projectiles. Brit.

J. Surg. 7 : 444-480, April 1920.

40. Graham, E. A.: A Reconsideration of the Question of the Effects of an Open

Pneumothorax. Arch. Surg. S : 345-303, January 1924.

41. Delorme, E.: Sur un cas de decortication pulmonaire (operation de Delorme)

pratiquee par M. le Dr. L. Picque, Chirurgien des hOrtaux par M. Delorme, rapporteur.

Bull. Acad. de med., Paris 3 (ser. 67) : 267-276,1912.

42. Samson. P. O, and Burford, T. H.: Total Pulmonary Decortication; Its Evolution

and Present Concepts of Indications and Operative Technique. J. Thoracic Surg. 16:

127-153, April 1947.
48 THORACIC SURGERY

43. Violet (de Lyon) : De la decortieation pulmonaire dans l'empyeme chronique.

Arch. gen. de med. 193 (vol. 1, series 10) : 657-67S, 1904.

44. Hedblom, C. A.: The Treatment of Chronic Empyema. Ann. Surg. 72 : 288-320,

September 1920.

45. Eggers, C. : Radical Operation for Chronic Empyema. Ann. Surg. 77: 327-353,

March 1923.

46. Weeks, C.: Personal Communication.

47. Robertson, 0. H. : Transfusion With Preserved Red Blood Cells. Brit. M. J. 1:

691-695, 22 June 1918.

48. Thoracic Surgery. In History of the Second World War. United Kingdom Medical Series. Surgery, edited by Sir Zachary Cope. London: Her Majesty's Stationery

Office, 1953. Brock, R. C.: General Survey, pp. 545-558. D'Abreu, A. L.: Experience of

Thoracic Surgery Gained in the Central Mediterranean Theater of War, pp. 55S-575.

Collis, J. Leigh, and Qvist, G. : Thoracic Surgical Experience in the Campaign in N.W.

Europe 1944-45, pp. 576-5S5.

49. Tudor Edwards, A.: Thoracic Surgery in War : In the Field and at the Base. In

Inter-Allied Conferences on War Medicine 1942-1945 ; Convened by the Royal Society of

Medicine, edited by H. L. Tidy. London, New York. Toronto: Staples Press Ltd 1947

pp. 127-131.

50. Brig. Gen. Prof. I-I. Burkle de la Camp. Advisory Surgeon to the Officer in Charge

of the Medical Service of the Army of the Southwest. Subject: Report of Experience

Gained During the Entire Work of the Medical Service from 1939 to 1945. Reference:

Oral order issued by the Officer in Charge of the Medical Service of the Army of the Southwest to prepare a report on the experience acquired, for submission to the American

Occupation Authorities, Merau, June 1945.

51. Snyder, Howard E. : Fifth U.S. Army. In Medical Department. United States

Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington : U.S. Government Printing Office, 1962, pp. 333-464.

52. Lockwood, A. L., and Nixon, J. A.: Observations on War Surgerv of the Chest.

Brit. M. J. 1: 105-109, 20 Jan. 1918 ; 1: 145-148, 2 Feb. 191S.

53. Gordon-Taylor, Gordon : Abdominal and Thoraco-Abdominal Injuries. In History

of the Second World War. United Kingdom Medical Series. Surgery, edited by Sir

Zachary Cope. London: Her Majesty's Stationery Office, 1953, pp. 179-216.

54. Lee, Burton J.: Wounds of the Abdomen. In The Medical Department of the

United States Army in the World War. Washington : Government Printing Office. 1927

vol. XI, pt. 1, pp. 466-46S.

55. Heyd, C. G.: Thoraco-Abdominal Injuries: Some Technical Procedures Developed

by the War. Ann. Surg. 72 : 370-375, September 1920.

50. Trueta, J. : The Principles and Practice of War Surgery With Reference to the

Biological Method of the Treatment of War Wounds and Fractures. St. Louis : The C. V.

Moshy Co., 1943.

57. Jolly, Douglas W. : Field Surgery in Total War. New York: Paul B. Hoeber

Inc., 1941.

58. Moore, E. : Case of Gunshot Wound of the Lung, Where the Ball Lodged Fifty Years.

Lancet 1: 67-69, 16 Jan. 1842.

59. Ramsdell, E. G.: Stab Wounds of the Heart. Report of a Case Successfully

Sutured and a Resume of 428 Cases Reported to January 1, 1932. Ann. Surg. 99 : 141-151,

January 1934.

60. Paget, Stephen: The Surgery of the Chest. Bristol: John Wright & Co 1S96

p. 121.

61. Ballance, C.: The Surgery of the Heart (Bradshaw Lecture). Lancet 1: 1-5,

3 Jan. 1920 ; 1 : 73-79, 10 Jan. 1920; 1 :134-139,17 Jan. 1920.
HISTORICAL NOTE 49

02. Makins, G. H.: Injuries to the Pericardium and Heart. In History of the Great

War Based on Official Documents. Medical Services. Surgery of the War. London: His

Majesty's Stationery Office, 1022, vol. I, pp. 431-475, passim.

63. Elkin, D. C.: Wounds of the Heart. Ann. Surg. 120: 817-821, December 1944.

04. Decker, H. R.: Foreign Bodies in the Heart and Pericardium—Should They Be

Removed ? J. Thoracic Surg. 9 : 62-79, October 1939.

65. Thomson, F. G.: Notes on Penetrating Chest Wounds. Brit. M. J. 1: 44-46,

13 Jan. 1940.

66. DeBakey, M.: The Management of Chest Wounds; Collective Review. Internat.

Abstr. Surg. (Supp. to Surg. Gynec. & Obst.) 74; 203-237, March 1942.
CHAPTER II

General Considerations of Thoracic Wounds

Frank B. Berry, M.D.

CLASSIFICATION OF CHEST WOUNDS

Wounds of the thorax are divided basically into two groups, (1) nonpenetrating wounds of the chest wall, and (2) intrathoracic wounds, which

may be either penetrating or perforating. In a penetrating intrathoracic

wound, the wounding agent has penetrated into the pleura, and there is no

wound of exit. In a perforating wound, the missile has completely traversed a

segment of the pleura! cavity.

Statistics prepared by the Medical Statistics Division, Office of The

Surgeon General, Department of the Army, bear out the clinical impression

that penetrating wounds of the chest were several times more frequent in

World War II than perforating wounds (table 2).

It was generally agreed by those with experience in the reparative phase

of management of thoracic wounds that the perforating type of injury was

less likely to be associated with complications than the penetrating type:

1. In the perforating type of wound, there were no retained foreign bodies

to invite infection, and the likelihood of immediate threatening symptoms

because of gravely disturbed physiology was far less.

2. There was less tissue destruction in bullet wounds, which accounted for

a much higher proportion of perforating wounds than did shell fragments.

CHARACTERISTICS OF CHEST WOUNDS

Even chest surgeons with a wide experience in civilian practice had had

little or no experience with the type of chest wounds encountered in World

War II unless they had also served in World War I, and the number in this

category was very small.

The chest injuries with which medical officers had dealt in their pre-Army

experience were most often stab wounds or low-velocity bullet wounds of the

closed, penetrating type, in which extensive tissue damage, serious cardiovascular disturbances, and infectious sequelae, while they might occur, were

not the rule except for the neglected hemothorax, with the resulting fibrothorax.

In the 1,187 chest injuries reported by Bolancl (1) from the Emory University

Division, Grady Hospital, Atlanta, Ga., in 1936, empyema and other serious

infections occurred in less than 2 percent of all cases. In the 553 cases reported

by Elkin (ß) from the Emory University Division, Grady Hospital, for the

51
5*2 THORACIC SURGERY

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54 THORACIC SURGERY

same year, the rate of infection was 1.4 percent. The same proportion of infections occurred in the 2,091 chest injuries collected by DeBakey (3) from Charity Hospital of Louisiana at New Orleans for the 5-year period ending in 1936,

and hemothorax was a factor in only 13.8 percent of the cases.

In combat-incurred wounds of the chest in World War II, this situation

was reversed. Tissue and structural damage was extensive and serious because

the majority of injuries were caused by shell fragments. Hemothorax occurred

in 75 percent or more of all cases. Finally, although infectious complications

were far less frequent than in World War I, they were still more frequent than

in civilian practice.

WOUNDING AGENTS

Incidence.—The tendency to employ wounding agents with greater destructive ability in successive wars is evident from the figures. In the American

Civil War, approximately 9 of every 10 wounds were caused by low-velocity

bullets and only 1 by high explosive shell fragments (4). In later wars,

this ratio was reversed. In World War I, approximately 7 of every 10 wounds

were caused by high explosive shells (5). In World War II, the ratio was

about eight wounds caused by shell fragments to every two caused by bullets.

The implications as to the increased severity and destructiveness of the resulting wounds are clear.

The same situation occurred in chest wounds as in other wounds. In the

Civil War, only 12.5 percent of all wounds of the thorax were caused by high

explosives. In 1944, the year in which the majority of U.S. Army wounds

were sustained, only 5,502 of the 25,064 admissions 1for chest wounds were

reportedly caused by bullets from rifles, machineguns, and other similar

weapons (table 3). A like proportion was maintained for the entire war

(table 4).

Case fatality rates.—There was a striking difference in both World Wars

in the case fatality rates of bullet wounds and wounds resulting from high

explosive shells. In World War I, among 20,662 wounds in U.S. troops

caused by rifle and pistol bullets and involving all areas of the body, the

case fatality rate was 4.7 percent, compared to a rate of 7.2 percent in 52,106

wounds caused by shell fragments. The respective case fatality rates in

wounds of the chest were 31.9 percent and 46.6 percent (5, 6).

Similar differences in the case fatality rate were evident in World War

II, as is shown in tables 5 and 6. In 1944, for instance, 663 of the 2,010

deaths occurred in 5,502 wounds caused by bullets, while 1,120 occurred in

the 16,841 wounds produced by exploding shells, tables 3 and 5.

1

The Medical Statistics Division, Office of The Surgeon General, Department of the Army, defines

wound admissions as instances in which a wound was reported as the primary cause for the patient's

being hospitalized for medical treatment or otherwise treated in an excused-from-cluty status. In

the tables used in this chapter and prepared by this Division, such variables as the causative agent,

the nature of the traumatism, and its anatomic location pertain to the admission diagnosis.
GENERAL CONSIDERATIONS OF THORACIC WOUNDS 55

TABLE 3.—Number of admissions 1for battle injuries and wounds of the thorax in the U.S.

Army in 1944, °V causative agent and theater 2

[Preliminary data based on tabulations of individual medical records]

Causative agent

Bomb and bomb fragments

Shell, shell fragments, and flak

Bullet, machinegun, rifle, etc

Landmine, boobytrap

Grenade and grenade fragments

Explosion of ammunition, weapons, etc

War gases, screening smoke, incendiaries _.

Firearms, mechanism or effects of discharge

of.

Aircraft, excluding aircraft weapons

Parachute jump

Boat sinking and accident

Tank, tractor, caisson

Motor vehicle, passenger and cargo

Vehicle, other and unspecified

Cutting or piercing instruments

Fire, hot liquid, or objects

Fall or jump, twisting, turning, lifting,

slipping, etc

Other and unspecified—

Outside

continental

United

States s

Total.

Number

544

1C, 841

5, 502

518

478

107

23

47

155

60

49

40

64

16

31

9

220

360

Europe

25, 064

Number

315

12, 494

3, 914

329

261

59

17

41

100

42

33

32

54

12

18

5

131

240

Mediterranean

Number

110

3, 515

681

163

91

30

1

4

21

11

7

7

9

4

18, 097

ChinaliurmaIndia

Number

2

61

58

2

9

Southwest

Pacific

66

61

4, 783 145

Number

107

493

584

13

69

10

1

2

21

5

4

1

10

1

17

40

Central

and

South

Pacific

Number

10

274

262

11

4S

8

3

1, 37S 652

i Excludes cases carded tor record only.

2 There were no records of admissions for injuries or wounds of the thorax during 19« in the Middle East, North

America, or Latin America.

3 Includes 9 admissions aboard transports.

Characteristics of bullet and shell-fragment wounds.—The different

characteristics of the two types of wounds offer some explanation of

the different mortality rates. Bullet wounds have the following general

characteristics:

1. They are likely to be sharply localized penetrating wounds or simple

through-and-through wounds, with a small puncture point of entry and a

somewhat larger exit. This is especially true of wounds produced by bullets

from small-caliber arms. When the wound is simply penetrating, the bullet

obviously has lost most of its velocity. For example, there is the penetrating

wound caused by a bullet in the suprasternal notch, in which the bullet had

penetrated only the skin, without any damage to the deeper structures.

2. In bullet wounds, tissue contamination and structural damage are

likely to be limited and localized. The amount of the damage depends entirely

upon the velocity already expended by the bullet. If the bullet is still truly
56 THORACIC SURGERY

TABLE 4.—Number of admissions ifor battle injuries and wounds of the thorax - in the U.S.

Army, by causative agent and year, 1942-4-5 3

[Preliminary data based on tabulations of individual medical records]

Causative agent

Bomb and bomb fragments

Shell, shell fragments, and flak

Bullet, machinegun, rifle, etc

Landmine, boobytrap

Grenade and grenade fragments

Explosion of ammunition, weapons, etc

War gases, screening smoke, incendiaries

Firearms, mechanism or effects of discharge

of

Aircraft, excluding aircraft weapons

Parachute jump

Boat sinking and accident

Tank, tractor, caisson

Motor vehicle, passenger and cargo

Vehicle, other and unspecified

Cutting or piercing instruments

Fire, hot liquid, or objects

Fall or jump, twisting, turning, lifting,

slipping, etc

Other and unspecified

Total

Number

873

27, 591

10, 608

1,037

987

262

39

115

252

102

75

78

115

31

81

17

480

683

43, 426

1942

Number

37

111

140

1

3

5

21

328

Number

114

1, 645

545

123

33

i

37

18

17

7

13

2

11

1

31

109

2,791

Number

544

16, 841

5, 502

518

478

107

23

47

155

60

49

40

64

16

31

9

220

360

25, 064

1915

Number

178

8,994

4,421

395

473

72

16

60

57

23

7

29

38

13

38

7

229

193

15, 243

1 Excludes cases carded for record only.

2 Excludes thoracoabdominal region.

3 Includes admissions in December 1941. Excludes cases wounded or injured in action in the Philippine Islands in

1941 and 1942.

in the high-velocity range, it causes the usual explosive damage to the tissues

along its path. Because of the differences between tissue and muscle and

bone, this damage, of course, varies, and is less for lung tissue. This is well

described in the volume on wound ballistics ('/).

3. The track of a bullet is long and narrow and is marked by coagulation

and searing of the tissues through which the missile passes, together with

more or less distant tissue damage depending upon velocity.

4. Carcliorespiratory disturbances occur less frequently in bullet wounds

than in the larger wounds so commonly caused by shell fragments. Because

of the perforating character of the wound, the wounds of entrance and exit

tend to be relatively sealed, so that, barring extensive hemorrhage within

the chest, or damage to a larger bronchus with the resulting rapid accumulation of hemothorax or tension pneumothorax, there is less physiologic

disturbance.
GENERAL CONSIDERATIONS OF THORACIC WOUNDS 0(

TABLE 5.—Number of deaths 1among admissions in 1944- f

or battle injuries and wounds of

the thorax in the U.S. Army, by causative agent and theater of admission 2

Causative agent

Outside

continental

United

States 3

Europe

MediterraneanChina- South- Central

Burma- west and

India Pacific South

Pacific

Bomb and bomb fragments

Shell, shell fragments, and flak

Bullet, machinegun, rifle, etc

Landmine, boobytrap

Grenade and grenade fragments

Explosion of ammunition, weapons, etc_-

Firearms, mechanism or effects of dis

charge of

Aircraft, excluding aircraft weapons

Tank, tractor, caisson

Vehicle, other and unspecified

Cutting or piercing instruments

Other and unspecified

Total

Number

40

1, 120

663

41

10

3

1

6

3

2

2

119

Number

21

840

457

26

4

1

1

3

2

Number

14

231

61

12

4

1

Number Number Number

5

32

92

3

1

1

15

45

1

95 13

2,010 1, 451 339 10 144 65

1 Consists of all admissions which ended in death, not necesarily due to the injury or wound causing admission or

necessarily occurring during the year of admission.

? There were no records of admissions for injuries or wounds of the thorax during 1944 in the Middle East, North

America, or Latin America.

3

Includes 1 death among admi-sions aboard transports.

Bullet wounds have also certain unfavorable characteristics:

1. Bullets that strike the thoracic cage tangentially or emerge from the

chest in an erratic course sometimes produce larger defects in the chest wall

than normally expected.

2. Bullets can cause considerable contusion of the structures through which

they pass, or, in the case of a high velocity, very superficial Avound of the

chest wall, which is almost of a searing nature, they might indeed cause a

complete reflex temporary dysfunction of the hemithorax, with resulting

atelectasis of the underlying lung. The writer personally has seen two such

instances.

3. Bullets often traverse greater distances than shell fragments, and their

tendency to involve more than one body cavity is conspicuous.

Fragments of high explosive shells, bombs, and mines have the followingcharacteristics :

1. They are likely to produce gi'eat destruction of tissue because of their

irregular shape, frequently large size, and high spin.

2. When a shell fragment is the causative missile, the wound in the

chest wall is likely to be larger, open injuries more frequent, and multiple

injuries also more frequent than when a bullet is the wounding agent.
58 THORACIC SURGERY

TABLE 6.—Number of admissions and case fatality ratios for battle injuries and loonnds of

the thorax iin the U.S. Army, by causative agent, 1942-/t5

[Preliminary data based on tabulations of individual medical records]

Causative agent

Admissions 2 Admissions

resulting

in death 3

Case

fatality

ratio

Nu

Bomb und bomb fragments

Shell, shell fragments, and flak

Bullet, machinegun, rifle, etc

Landmine, boobytrap

Grenade and grenade fragments

Kxplosion of ammunition, weapons, etc

War gases, screening smoke, incendiaries

Firearms, mechanism or effects of discharge of

Aircraft, excluding aircraft weapons

Parachute jump

Boat sinking and accident

Tank, tractor, caisson

Motor vehicle, passenger and cargo

Vehicle, other and unspecified

Cutting or piercing instruments

Fire, hot liquid, or objects

Fall or jump, twisting, turning, lifting, slipping, etc

Other and unspecified

Total

10,

1,

mber

873

591

60S

037

987

262

39

115

252

102

75

7S

115

31

81

17

4S0

683

Number

67

SSO

316

100

26

Percent

7. 7

6. S

12.4

9. 6

2. 6

2. 7

1

10

43, 426

1

195

3, 613

. 9

4.0

3. S

. 9

6.5

4. 9

. 2

28. 6

8.3

1 Excludes thoracoabdominal region.

- Excludes cases carded for record only. Includes admissions in December 1941. Excludes cases wounded or injured

in action in the Philippine Islands in 1941 and 1912.

3 Consists of all admissions which ended in death, not necessarily due to the injury or wound causing admission or

necessarily occurring during the year of admission.

3. As a consequence, hemorrhage, shock, and cardiorespiratory disturbances are more frequent and severe because of the sharply deranged cardiorespiratory physiology.

4. Shell fragments carry into the tissues with them fragments of bone,

bits of clothing, and other foreign contaminants. Because of the resulting

contamination, the incidence of infection is therefore higher than in wounds

caused by bullets.

5. High explosive shell fragments are retained much oftener than bullets.

Nicholson's and Scadding's (8) figures are typical. In an analysis of 291 penetrating wounds of the chest treated in British forward installations in the

Middle East, they found retained foreign bodies in 91 percent of such wounds

but in only 32 percent of the wounds caused by bullets.

6. For these various reasons, open operative intervention is necessary

more often in shell-fragment wounds than in bullet wounds. The wounds

are frequently difficult to manage, and both morbidity and mortality rates

are somewhat higher.
GENERAL CONSIDERATIONS OF THORACIC "WOUNDS 59

VELOCITY OF MISSILES

A careful distinction must be made between high-velocity and low-velocity

missiles. The fragments of a shell containing high explosives have an extremely high velocity immediately following the explosion, but this initial

velocity is subject to a very rapid decay and so, as a rule, when the missiles

strike, they have lost much of their original speed and are well within

the low-velocity range. The modern bullet in its effective trajectory range

is almost always a high-velocity agent. Two bullets from an automatic

weapon that strike the chest in close proximity to each other, for example,

are likely to produce much greater damage than the sum of the two injuries

if the hits are farther apart.

While the disruptive effect of high-velocity missiles on tissues is far

greater than that of low-velocity missiles, it is also proportional (1) to the

density of the tissues affected and (2) to whether secondary missiles consisting

of bone fragments are developed. Structures of lesser density sustain appreciably less damage than structures of higher density. In this respect, the

lung, which is the least dense of all body structures and which, in its totally

expanded state, is of little greater density than the atmosphere, is unique.

High-velocity missiles that traverse the pulmonary tissue therefore often cause

surprisingly little pulmonary damage. The high immediate lethality of highvelocity wounds of the chest is apparently directly related to the percentage

chance of damage to vital structures, particularly the heart and great vessels.

If the high-velocity missile does not inflict a mortal wound, then it often

traverses the chest with considerably less damage to the thoracic contents

than is caused by a low-velocity shell fragment.

The type of missile and its inherent velocity are thus the chief determinants of the type of thoracic wound produced. Other determinants include

the size and course of the missile (p. 55), the distance of the casualty from

its point of origin, and his position when he was wounded (p. 230).

VULNERABILITY OF THE CHEST TO WOUNDING

Definition of chest wounds.—It is regrettable that up to this time there

has been no agreement as to exactly what portion of the body constitutes

the chest. Without a generally accepted definition, there has naturally been

disagreement in the statistics for chest wounds.

Beebe and DeBakey (9) quoted Churchill's demarcation of the surface

areas of the body, in which he defines the chest as follows:

* * * On the surface * * * Hie simplest line is one that approximately follows the

lower limits of the pleural cavities. In front, this line passes from the lower end of

the sternum obliquely downward along the costal margin to the 8th intercostal space.

A horizontal line carried around the body to meet the corresponding point on the other

side will pass approximately over the midpoint of the 11th rib and the spine of the

first lumbar vertebra. The chest region as described includes the entire circumference

of the trunk and is not interrupted posteriorly by a "back" or a "spine".
60 THORACIC SURGERY

Earlier wars.—It is unfortunate that this, or some other, anatomic specification has never come into general use. On the other hand, however the

chest may be defined and delimited, it presents a large target area, and it

is therefore logical to expect that it would sustain a correspondingly large

number of battle wounds. Since it houses vital structures of the first order,

it might also be logically expected that these wounds would be followed by

a large number of deaths.

In addition to the size of the target which the various areas of the body

present, their exposure varies with the special types and circumstances of

combat, as well as with the relative degree of protection afforded by the position of the body, the clothing worn, the terrain, the availability of foxholes and

trenches, and similar considerations. Any or all of these factors may account

for the differences between the actual and expected distribution of body injury.

Modern offensive weapons have a much greater wounding potential, with

correspondingly greater lethality, than older weapons. In spite of this, the

incidence of combat-incurrecl injuries of the chest has remained substantially

the same in successive wars of the past 100 years (p. 5). It seems reasonable

to assume, therefore, that the most important single factor controlling the incidence of chest wounds is, as in all other wounds, the factor of body area

exposed. The exhaustive study of wound ballistics made by Col. Ashley W.

Oughterson, MC, in the Southwest Pacific Area (10) makes this clear. He and

his associates could not accept the aiming of missiles as an explanation of the

location of hits.

INCIDENCE AND CASE FATALITY RATES

Hoche's (11) extensive studies of 11,000,000 war wounds in English,

French, American, and German casualties in World War I showed that 6 percent were wounds of the chest. Only wounds of the limbs, head, face, and neck

exceeded wounds of the chest in frequency. The total case fatality rate was 8

percent. The rate for wounds of the chest was 56 percent, this being second

only to the case fatality rate of 68 percent in abdominal wounds. In a special

study of 12,350 fatalities, Hoche found that wounds of the chest seemed to be

the primary cause for 20 percent of all deaths, in comparison with 11.8 percent

for wounds of the abdomen and pelvis, 47 percent for wounds of the head, and

9.9 percent for wounds of the limbs.

Official figures for the U.S. Army in World War I show 174,296 admissions for all battle injuries exclusive of gas injuries (5). Of these wounds,

4,595 (2.6 percent) involved the chest. The case fatality rate for all wounds

was 7.73 percent and for chest wounds 24.05 percent.

Attention has been called elsewhere (p. 7) to the incredibly low incidence

of both British and U.S. chest injuries recorded in World War I and to the

possible explanation, that some wounds of the thorax in the U.S. records are

hidden in wounds of the back or the shoulder area, which are listed separately.
GENERAL CONSIDERATIONS OF THORACIC WOUNDS 61

With these exceptions, the incidence of chest wounds in all recorded wars has

been close to 8 percent.

World War II.—Official figures for U.S. Army casualties in World War II

show that in a total of 599,788 battle wounds and injuries (table 7), 20,810

were fatal (table 8). Of the total wounds and injuries, 43,426 (7.24 percent)

were wounds of the chest (table 9), of which 3,613 (8.3 percent) were fatal

(table 10). These figures cover all casualties who survived to be hospitalized

but do not cover those who died on the battlefield or in battalion aid stations or

collecting or clearing stations. Not all of the 3,613 fatalities were necessarily

due to wounds of the chest, but every casualty who died had such a wound.

Statistics for the Tunisian campaign in 1942-43 are not satisfactory, but

as far as can be estimated from them, not more than 6 or 7 percent of the

casualties who reached forward evacuation hospitals, corps clearing stations

(in which surgery was then done), and the single surgical hospital operating

in the area had wounds of the chest. In contrast, of approximately 50,000

casualties treated in Fifth U.S. Army hospitals in 1944, about 9 percent of

the 46,000 hospitalized in evacuation hospitals had wounds of the chest {12).

The remaining 4,000 casualties, practically all of them seriously wounded and

nontransportable, were treated in field hospitals; 25 percent had thoracic

wounds.

As these figures indicate, there was a remarkable increase during the course

of the war in the number of casualties who survived to reach a hospital. One

undoubted reason for the improvement, as well as for the improvement in case

fatality rates, was the development and utilization of field hospitals, staffed

with auxiliary surgical group teams, close to the frontline (p. 92).

It was naturally to be expected that the farther forward casualties with

thoracic wounds were treated, and the larger the number of seriously wounded

casualties treated, the higher would be the case fatality rates. In 4,320 chest

injuries, for instance, in Seventh U.S. Army hospitals, the total case fatality

rate was 5.4 percent, but it was 8.7 percent in field hospitals as compared with

3.3 percent in evacuation hospitals.

In an analysis of 22,246 admissions to Fifth U.S. Army hospitals between

1 August 1944 and 31 May 1945, Lt. Col. (later Col.) Howard E. Snyder, MC,

Consultant in Surgery, Fifth U.S. Army, and Capt. (later Maj.) James W.

Culbertson, MC (13), found that intrathoracic and thoracoabdominal wounds

accounted for 6.29 percent of all admissions and 28.2 percent of all deaths over

this special period. In an analysis of 1,450 deaths in Fifth U.S. Army hospitals,

including 39 cases in which the casualties were dead on arrival, these same

observers found that 212 of the deaths were the result of thoracoabdominal

wounds and 138 the result of intrathoracic wounds. The combined proportion

of deaths (24.1 percent) was exceeded only by the deaths in intra-abdominal

wounds (28.1 percent, 408 fatalities).

In spite of the increase in the lethal potential of modern weapons of war,

there was an encouraging reduction in the case fatality rate for chest wounds as
62 THORACIC SURGERT

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GENERAL CONSIDERATIONS OF THORACIC WOUNDS 63

TABLE 8.—Number of U.S. Army personnel who died of battle injuries and wounds lduring

1942~45,2by nature of traumaiism and theater of admission

[Preliminary data based on tabulations of individual medical records]

Underlying cause of death

Outside

continental

United

States 3

Europe

Mediterranean

Middle

East

ChinaBurmaIndia

Southwest

Pacific

Central

and

South

Pacific

North

America

Number Number Number Number Number Number Number Nu mber

All injuries 20, 810 12, 521 3,733 11 127 2, 936 1, 431 30

Fractures:

Simple 359 140 118 5 59 32 2

Compound 3,313 2,229 549 2 16 334 174 6

Comminuted 2, 290 1,605 352 1 7 221 99 4

Other 1,023 624 197 1 9 113 75 2

Total fractures._ 3,672 2, 369 667 2 21 393 206 8

Traumatic amputations, avulsions, etc.. 1,763 1, 302 198 1 2 158 101 1

Wounds, penetrating... 6,499 4, 142 1,385 4 31 632 291 9

Wounds, perforating 3,565 1, 997 630 1 23 667 239 o

Wounds, lacerated ._ 1,641 1,033 271 7 240 90

Wounds, abraded or

contused _ _ 69 49 14 1 4 1

Wounds, unqualified 1,828 484 382 2 23 574 356 4

Crushing 109 41 38 5 16 9

Burns _ 263 106 51 1 9 65 27 1

Other traumatisms. _ . _ 1,401 998 97 5 187 111 2

i Among cases who reached a medical treatment facility. Excludes those who died in enemy prisons.

2

Includes 22 deaths in December 1941 among admissions in Central and South Pacific. Excludes 120 who died of

wounds (TAGO source) in the Philippine Islands in 1941 and 1942.

3

Includes 21 deaths among admissions aboard transports.

World War II progressed. Figures from the Office of The Surgeon General

published in 1944 indicated that approximately 8 percent of casualties with

chest wounds were dying as a result of their wounds. The Fifth U.S. Army

surgeon's annual report for 1944 showed considerably better results (12). During 1944, the case fatality rate for Fifth U.S. Army field hospitals, in which the

most severely wounded were treated, was 12.6 percent, but the rate in evacuation

hospitals was 4.8 percent and for all Army hospitals 6.7 percent.

An analysis of the 2,267 intrathoracic wounds (including 903 thoracoabdominal wounds) treated by the thoracic surgical teams and other teams of the

2d Auxiliary Surgical Group (1£) showed the effects of experience in what

might be termed a learning curve. For the entire period in which this group

was active, the operative case fatality rates (on U.S. casualties) for the periods

prior to 1 May 1944 and after 1 May 1944 are as follows: trained thoracic

surgeons 8.28 percent and 7.08 percent, respectively; against 13.17 percent and

8.82 percent for general surgeons, respectively.
64 THORACIC SURGERT

TABLE 9.—Number of admissions 1for battle injuries and wounds of the thorax and thoracoabdominal region in the U.S. Army, by anatomic site and year, 1942-45 2

[Preliminary data based on tabulations of individual medical records]

Anatomic site 1942-45 1942 1943 1944 1945

Thorax:

Thorax, generally _ _ _ _

Number

18, 918

6, 872

5, 257

1, 956

3, 0S2

33

7

13

22

33

59

10

5

3

(182)

5,075

131

4

69

235

Number

255

9

Number

2, 160

49

Number

10, 221

4, 538

2, 931

1, 152

1, 852

15

6

11

13

20

32

6

2

3

(105)

3, 068

67

3

37

144

Number

6, 282

Thoracic wall, generally

Posterior thoracic wall _

2, 276

2, 326

Axilla 8

28

126

305

1

670

Ribs _ _

Heart:

Heart, generally

Auricle, left _

897

17

1

Auricle, right_ 9

9

Ventricle, right 13

Pericardium

Myocardium

1 1 25

4

Heart, other 3

Total heart _ _ _ _

3

(1)

3

3

(2)

50

3

3

(74)

Lungs

Trachea

Bronchi _ _ _

1, 954

61

1

Mediastinum

Pleura

Thoracic duct

3

2

29

S9

Esophagus

Diaphragm

Thorax, other

30

105

1, 510 24

1

4

86

16

48

882

13

53

518

Total 43, 426 328 2, 791 25, 064 15, 243

Thoracoabdominal region _ _ _ _ 3, 233

—!—

1, 752 1, 481

1 Excludes cases carded for record only.

2

Includes admissions in December 1941. Excludes cases wounded or injured in action in the Philippine Islands in

1941 and 1942.

3 Figures in parentheses arc subtotals.

In the opinion of the surgeons who worked in the Mediterranean theater,

the improvement in the case fatality rate and in the general results in thoracic

wounds could be attributed in large part to the establishment of uniform and

consistent policies of management for these wounds after March 1944 (p. 199).

BATTLEFIELD DEATHS

Surveys of the causes of deaths on the battlefield are infrequent. Only two

seem to have been conducted in World War I. In 1916, Sauerbruch (15) reported that of 300 soldiers who died on the battlefield, 30 percent had wounds

of the chest. In a similar survey of 469 battlefield deaths, Loeffler (16)
GENERAL CONSIDERATIONS OF THORACIC WOUNDS 65

TABLE 10.—Number of deaths 1 among admissions for battle injuries and wounds of the thorax

and thoracoabdominal region in the U.S. Army, by anatomic site and year of admission,

1942-45

[Preliminary data based on tabulations of individual medieal records]

Anatomie site 1942-45 1942 1943 1944 1945

Thorax:

Thorax, generallyThoracic wall, generally

Number

2, 599

56

135

39

147

18

1

3

2

5

14

Number

30

Nmnber

208

Number

1, 369

40

80

27

119

10

Number

992

16

Posterior thoracic wall 55

Axilla _ _ _ ______ 12

Ribs ___ _ 2 5

1

21

Heart:

Heart, generally 7

1

Auricle, right

Ventricle, left _ _ .

2

2

4

9

1

Ventricle, right 1

Pericardium

Myocardium

Heart, other

Total heart

Lungs

Trachea

Bronchi

2

(43)

450

26

1

2

(D

1

1

-'(27)

265

15

2

(15)

183

10

Mediastinum 4

9

1

6

3

Pleura 3

Thoracic duct _ _ _ _ _

Esophagus

Diaphragm

Thorax, other _ _ _ _

6

53

46

4

25

32

2

28

14

Total . 3, 613 33 216 2, 010 1, 354

Thoracoabdominal region 698 436 262

1 Consists of all admissions winch ended in death, not necessarily due to the injury or wound causing admission or

necessarily occurring during the years indicated. (The year shown is year of admission.)

:

Figures in parentheses arc subtotals.

reported that 29 percent had chest injuries. It is recognized that all statistics

obtained in this manner are inaccurate. For one thing, the tagging of the

bodies is done by medical corpsmen who are not qualified to make diagnoses.

For another, many bodies are so badly mutilated that even professionally

trained medical officers would often have difficulty determining the cause of

death.

Special study.—The only study of battlefield deaths carried out in World

War II covered the examination of 1,000 bodies. It was conducted by Capt.

William W. Tribby, MC (17), and his associates of the 2d Medical Laboratory

in four U.S. military cemeteries in Italy, between 29 April and 6 November

1944.
66 THORACIC SURGERY

In his introduction to Captain Tribby's report, Brig. Gen. (later Maj.

Gen.) Joseph I. Martin, then Surgeon, Fiftli U.S. Army, stressed the difficulties

under which the investigation was conducted. On numerous occasions, it seemed

that lack of time, obstinately bad weather, the need for secrecy, the hardships of

working under battlefield conditions, and the constantly changing military

situation would all contrive to halt the work, which was being done as an additional duty by the hard-pressed personnel of a very active field laboratory.

Unless these circumstances w

Tere understood, General Martin pointed out, the

"monumental scope" of the undertaking also would not be realized.

The work was done in military cemeteries for a number of reasons, including the fact that the bodies were received in them in large enough numbers to

make the investigation feasible within a reasonable period of time. The study

was unselective, except for the requirement that the bodies be in fit condition

for positive identification of the location and extent of the wounds.

Every wound was probed, and its extent was determined as exactly as

possible, but all examinations were external. The inaccuracy caused by limitation of the investigation to external examinations was fully realized, but

experience with the first few bodies, in which autopsy was attempted, proved

that a continuation of the attempt would have made the investigation entirely

impractical. Had autopsies been possible, numerous additional wounds might

well have been found, particularly in bodies in which the wounds were too small

to be probed satisfactorily.

In most instances, it was not possible to determine the position of the

casualty at wounding; those who actually saw the death occur were usually

not present when the body was tagged. In many instances, also, it was impossible to determine the wounding agent.

Chest wounds were defined, in addition to anterior wounds of the thoracic

region, as all wounds located posteriorly above the level of the first lumbar

vertebra and all wounds of the axillary region and the region of the shoulder

girdle unless the injury extended into, or was distal to, the head of the humerus.

These criteria generally agree with the definition of wounds of the chest suggested by Churchill (p. 59).

Data elicited concerning wounds of the chest in these 1,000 cases were as

follows:

Of the 312 single wounds, 84 were in the chest.

In the 171 bodies in which the wounds were multiple and were confined to

portions of the body above the diaphragm, 120 wounds of the chest were found.

The data show that 572 wounds of the chest were found either singly or in

various combinations of injuries both above and below the diaphragm. No

other region of the body above the diaphragm was affected more often than the

chest. Next in order of frequency were the lower extremities, which were

wounded in 327 bodies.

Of the 572 wounds of the chest, 422 (73.8 percent) were sufficiently grave to

account, in themselves, for the fatality. Of the 2,385 wounds found in the 1,000
GENERAL CONSIDERATIONS OP THORACIC WOUNDS 67

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GENERAL CONSIDERATIONS OF THORACIC WOUNDS 69

bodies, 1,426 (59.8 percent) were sufficiently grave to explain why death

occurred.

The diagnosis on the emergency medical tag proved erroneous in 276 of

the 572 wounds of the chest (48.3 percent). This was the second smallest proportion of errors, the smallest proportion (35.7 percent) being in 154 of the 432

head injuries. These errors were, for the most part, inevitable: Accurate diagnoses could not be expected unless the body could be stripped of all clothing

and examined by a medical officer.

The investigation was conceived as one further step to improve the protection of the soldier on the field of battle. It showed that in 202 of the 1,000

fatalities, the casualties could not have been saved from death by any type of

body armor. Body armor, however, might well have averted a number of the

572 wounds of the chest in this series.

Official statistics.—Official figures for casualties killed in action and for

those who died of wounds show a total of 213,976 according to the figures of

The Adjutant General's Office and 213,030 according to those of the Office of

The Surgeon General. The discrepancy is slight and seems to relate to the

manner of classification of the deaths.

Of the 192,220 casualties killed in action whose wounds were classified by

anatomic site (table 11), 17,957 (9.3 percent) had wounds of the thorax and

319 (0.16 percent) thoracoabdominal wounds. These figures for the 1942-45

period cover all theaters. The figures for 1944, the year in which the largest

number of casualties occurred, are presented in table 12.

References

1. Boland, F. K.: Chest Wounds in Military and Civil Practice. Mil. Surgeon 81(8) :

175-193, September 1937.

2. Elkin, D. C.: Wounds of the Thoracic Viscera. J.A.M.A. 107(3) : 1S1-1S4,

18 July 1936.

3. DeBakey, M.: The Management of Chest Wounds; Collective Review. Internat.

Abstr. Surg. (Supp. to Surg. Gynec. & Obst.) 74: 203-237, March 1942.

4. Medical and Surgical History of the War of the Rebellion. Surgical History.

Washington: Government Printing Office, 1870, pt. I, vol. II, pp. 4:66-050.

5. The Medical Department of the United States Army in the World War. Washington : Government Printing Office, 1925, vol. XV, pt. 2, pp. 1023-1024, passim.

6. The Medical Department of the United States Army in the World War. Washington : Government Printing Office, 1927, vol. XI, pt. 1, pp. 62, 68, 342-442.

7. Medical Department, United States Army. Wound Ballistics. Washington: U.S.

Government Printing Office, 1902.

8. Nicholson, W. F., and Scadding, J. G.: Penetrating Wounds of the Chest; Review

of 291 Cases in the Middle East. Lancet 1: 299-303, 4 Mar. 1944.

9. Beebe, Gilbert W., and DeBakey, Michael E.: Battle Casualties: Incidence, Mortality, and Logistic Considerations. Springfield : Charles C Thomas, 1952, p. 89.

10. Oughterson, Ashley W., Hull, Harry O, Sutherland, Francis A., and Greiner,

Daniel ,L: Study on Wound Ballistics—Bougainville Campaign. In Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing

Office, 1962, pp. 2S1-43G.
70 THORACIC SURGERY

11. Hoche, Otto: Wehrchirugische Behandlung Verwundeter und Verletzter. Berlin:

Urban & Schwarzenberg, 1940, p. 27.

12. Annual Report, Surgeon, Fifth U.S. Army, 1944.

13. Snyder, Howard E., and Culbertson, James AY.: Study of Fifth Army Hospital

Battle Casualty Deaths. An Analysis of Case Reports From Field and Evacuation Hospitals on 1,450 Fatally Wounded American Soldiers. A preliminary report in three volumes.

Gardone Riviera, Italy, September 1945. [Official record.]

14. Betts, R. II., Samson, P. C, Brewer, L. A. III. Shefts. L. II.. and Burford, T. II.:

Thoracic Wounds. Thoracoabdominal Wounds. In Forward Surgery of the Severely

Wounded. A History of the Activities of the 2d Auxiliary Surgical Group, 1942-45, vol. 2,

pp. 411-591. [Official record.]

15. Sauerbruch, F. : Kriegscliirurgische Erfahrungen. Uebersichtsreferat mit besonderer Berücksichtigung der Thorax-mid Abdominalschüsse. Cor.-Bl. f. Schweiz. Aerzte,

Basel 46:1315-132S, 191G.

16. Loeffler, cited by Walker, K. M.: The Protection of the Soldier in Warfare. Proc.

Roy. Soc. Med. 33 :607-614, July 1940.

17. Tribby, William W.: Examination of One Thousand American Casualties Killed

in Action in Italy. Report to Surgeon, Fifth U.S. Army, 1944, 6 vols. [Official record.]
Part II

ADMINISTRATIVE CONSIDERATIONS

IN WOUNDS OF THE CHEST
CHAPTER III

Administrative Considerations in the Mediterranean (Formerly North African) Theater

of Operations

LymanA. Brewer HI, M.D., and Thomas H. Burford, M.D.

THE CONSULTANT SYSTEM

A consultant in thoracic surgery was not appointed in any theater of

operations during World War II. While this was unfortunate, in view of

the number (p. 61) and gravity of thoracic and thoracoabclominal wounds, the

results of the omission were not so serious as they might well have been:

1. Col. Edward D. Churchill, MC, Consultant in Surgery, Office of the

Surgeon, Headquarters, Mediterranean Theater of Operations, U.S. Army,

had a special interest, and a long experience, in this field, as did Maj. (later

Col.) Howard E. Snyder, MC, Consultant in Surgery to the Surgeon, Fifth

U.S. Army, which operated in this theater.

2. Col. Frank B. Berry, MC, Consultant in Surgery to the Surgeon,

Seventh U.S. Army, was also particularly interested in this field.

3. In the Office of the Chief Surgeon, Headquarters, European Theater of

Operations, U.S. Army, the Chief Consultant in Surgery, Col. (later Brig.

Gen.) Elliott C. Cutler, MC, had been one of the pioneers in thoracic surgery.

It was therefore possible for all of these officers, while carrying out their

general responsibilities as consultants in surgery, to supervise and encourage

the work in thoracic surgery. Their functions included:

1. Evaluation, with recommendations for correction as necessary, of the

physical conditions in winch surgical patients were cared for.

2. Evaluation of equipment and supplies, with recommendations for such

changes as were indicated.

3. Evaluation of the training, experience, and proficiency of medical officers

to whom surgical duties were assigned, with recommendations for such changes

of assignment of duties and of location as were indicated.

4. Establishment of the surgical procedures that could suitably be undertaken at each echelon of medical care and by different medical installations

under varying tactical conditions.

5. Adaptation of evacuation procedures to the exigencies of surgical care,

so that military necessities would interfere as little as possible with the welfare

of all casualties.

053«81*
74 THORACIC SURGERY

6. Kecommenchitions for the deployment of surgical teams for routine and

special missions.

7. Recommendations for the organization and staffing of special centers for

the treatment of patients requiring specialized skills.

8. Introduction into the theater of new and approved methods developed

in other theaters and in the Zone of Interior.

9. Dissemination of information on medical and medieomilitary matters

to medical officers throughout the theater.

10. Preparation of circular letters and occasionally of command circulars.

11. Collection and interpretation of the overall experience in the theater

as well as the experiences in special types of wounds and injuries and with

special methods of treatment. Analysis of these experiences was perhaps the

best method of evaluating the results obtained and comparing them with the

results which might reasonably be expected under prevailing conditions.

These functions were discharged in various ways by the consultants in

surgery. Their methods included inspection of hospitals, direct examination

of patients, demonstrations of special techniques, formal and informal conferences with surgical staffs of the various medical installations, and planned

meetings for division, army, and base area surgeons as military necessities permitted. Special educational efforts were directed toward indoctrination and

orientation of surgeons accustomed to the practice of surgery in civilian life,

or in the less urgent circumstances of the Zone of Interior, in the light of the

different medieomilitary considerations that had to be taken into account in

oversea theaters.

Important improvements in surgical care emerged from the stimulation of

medical officers to collect and analyze their own results. Important sections

of this and other volumes of the history of the U.S. Army Medical Department in World War II emerged from these studies.

THORACIC SURGERY PERSONNEL

Numerical shortages of thoracic surgeons existed in all theaters. Beebe

and DeBakey (/), in their book on battle casualties published in 1952 and

based on official records, estimated that if each surgeon were to operate on 7

casualties per day, nine thoracic surgeons would be required to perform initial

suro-ery on each 1,000 wounded casualties. Even in the Mediterranean theater,

where there were, proportionately, more thoracic surgeons than in any other

theater, this ratio was never met.

Shortages of thoracic surgeons had to be made up in any manner possible.

This meant using the limited number of experienced and well-qualified medical

officers in this specialty to the best possible advantage, as described later in

the discussion of auxiliary surgical group teams (p. 93). The most efficient

solution of the problem was the proper assignment of the thoracic surgeons on

auxiliary surgical group teams (p. 92). It was not possible to put surgeons
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER (5

with training of only ?> or 4 months into positions of supervisory importance,

no matter how carefully their training had been conducted.

The efficient use of thoracic surgeons was hampered by certain administrative roadblocks. By October 1.SJ44, the prediction had been amply fulfilled that

special hospitals would be necessary for thoracic surgery and other surgical

specialties. Yet at that time, the table-of-organization provision for thoracic

surgeons was extremely limited. Constant difficulty was encountered in fitting

these specialists into the inflexible hospital tables of organization and in supplying the additional help necessary to run a thoracic surgical service efficiently.

The importance of this specialty, properly set up to function efficiently, was

great enough to justify adequate table-of-organization provision for it in all

echelons of medical care, yet neurosurgeons were provided for administratively

long before thoracic surgeons.

Ideally, the personnel of a thoracic section in a thoracic surgery center

consisted of a lieutenant colonel, who served as chief of section: a captain, who

served as anesthesiologist; two captains, who served as surgical assistants and

as ward officers; three surgical nurses; and three surgical technicians. Neither

in rank nor in numbers was this ideal ever fulfilled.

EVACUATION AND TRANSPORT

In North Africa, nontransportable casualties were cared for in clearing

stations (p. 216).

Development of Policies of Surgical Care

Sicily.—In Sicily, the first casualties on D-day were handled by the Navy,

in beach stations set up in each, of the six landing areas. They were then

evacuated to ships offshore. In the next phase of the operation, beginning in

the afternoon of D-day and continuing through the next 24 hours, Company C

of the 261st Medical Battalion was landed and was followed by other units.

After some difficulties because of the landing of equipment without personnel

or vice versa, evacuation of casualties to the beaches and thence to the boats

proceeded with remarkably little confusion. On D + 2, casualties began to

receive initial care in the clearing station of the 51st Medical Battalion, with

surgical teams attached, or in Company A of the 261st Medical Battalion. On

D + 3, two platoons of the 11th Field Hospital began to receive and hold

casualties.

These details are important:

This was the- first time in this or in any previous war that casualties had

been cared for in field hospitals adjacent to division clearing stations, with the

intrinsic personnel of the field hospital platoons augmented by teams from an

auxiliary surgical group. As a result of these arrangements, the nontransportable casualties of the augmented II Corps (now the Seventh U.S. Army)
7G THORACIC SURGERY

received initial wound surgery within from 8 to 12 miles of the front. This

plan, greatly expanded, was followed for the remainder of the war in the

Mediterranean theater and was employed throughout the lighting in the European theater.

Anzio.—For a variety of reasons, the most serious medicomilitary problems encountered in Italy were met on the Anzio beachhead (Operation

SHIXGLE). Shore-to-ship evacuation of casualties was predicated on the

orderly return of casualties to the beaches. In the initial landings, casualties

were less than 1 percent of the troops committed instead of the estimated 12

percent. After 48 hours, however, the tactical situation worsened, and the

medical situation along with it. The original locations of the hospitals that

had been landed became untenable at once, because of continuous bombing and

strafing of the beachhead area, punctuated by heavy enemy attacks at intervals.

The hospitals were therefore relocated in open terrain, as far as possible from

military objectives, but at the best, this was not very far. Since the beachhead

was only about T miles in depth, the usual functional distinctions between field

and evacuation hospitals could not be observed. Both were practically on the

frontline. Hospitals were seriously damaged by heavy shelling, and there

were also losses of medical personnel.

From the beginning of the Anzio operation, an attempt was made to care

for all casualties before they were evacuated by LCT's (landing craft, tank)

and boat ambulances to hospital ships. If recovery was expected within 14

days or less, the wounded, especially if they were experienced combat soldiers,

were kept in evacuation hospitals. Otherwise, they were evacuated to the

Naples area by boat. After 26 May 1944, they were frequently evacuated by

air. Occasionally, when the casualty load was unusually heavy, patients who

were transportable were evacuated to the base hospitals in the Naples area for

initial wound surgery, which they thus received earlier than they would have

if they had been kept at Anzio.

The Chain of Evacuation

Thoracic casualties, like all other casualties (fig. 3), were successively

evacuated from the frontline, through the division area and the army area to

the zone of communications. After the early fighting in Sicily, the chain of

evacuation was as follows:

1. Casualties were brought by company aidmen to a battalion aid station

(fig. 4), whence they were removed to a collecting company and then to a clearing station. Here, triage was carried out, and nontransportable casualties

were transferred to the adjacent platoon of a field hospital, where the necessary

surgery was performed.

2. Transportable casualties were transported from the clearing station to

a forward evacuation hospital, where the necessary initial wound sureery was

performed. The nontransportable casualties who had been cared for in the
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 11

^VCOMF&NY AID MAN

BATTALION AID STATION

FORWARDA

FIELD

AIRFIELD

COLLECTING COMPANY

CLEARING STATION (TRIAGE POINT)

-TRANSPORTABLE CASUALTIES

FORWARD EVACUATION

EVACUATION HOSPITAL

RAILROAD

GENERAL HOSPITAL

DESIGNATED AS CENTER

PORT OF EMBARKATION

TO ZONE OF INTERIOR

g

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5

o

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FIGURE 3.—Chain of evacuation in oversea theater to and from thoracic surgery center.

field hospital were later transferred to the evacuation hospital, after the appropriate period of convalescence.

o. Casualties in evacuation hospitals, after a longer or shorter stay, depending upon the nature of their wounds, the therapy necessary, and their

response to it, were transferred to general and station hospitals in the communications zone or to special treatment centers.
78

^llfilllBS

THORACIC SURGERY

i >1

FIGUUK 4.—Aidmen unloading womided at battalion aid station in Italy.

4. From these hospitals, they were transferred to convalescent hospitals

for rehabilitation before being returned to duty or were evacuated to the Zone

of Interior from a port of embarkation or an adjacent airfield.

Transportation.—Litter carries and ambulances furnished the principal

means of transportation from the frontline to battalion aid stations. Ambulances were used for transportation from the aid stations to the collecting

and clearing stations. In mountain warfare, however, ambulances were useless

in many areas, and the company aidmen bad to move casualties by long litter

carries, on muleback. and sometimes by cables strung between mountain peaks.

Ambulances were also used to more casualties from clearing stations or

held hospitals in the division area to evacuation hospitals in the army area.

The long ambulance hauls, over rough ground, that were often necessary in

Tunisia, contributed materially to the state of shock in which many casualties

were received in evacuation hospitals. Some died en route. In Tunisia, as

well as during the first weeks of the fighting in Italy, some ambulance hauls

were materially longer than they should have been because medical officers and

ambulance drivers had inaccurate information about the location of hospital

units nearest to the frontline.

Transportation difficulties were seldom serious in Sicily, and both evacuation and transportation were greatly improved in the Italian campaigns, particularly when hospital policies were clarified early in 1944. Hospital trains

were first employed in Italy in Xovember 1943.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 79

Air evacuation.—After the Tunisian campaign, a questionnaire was sent

to 38 medical officers working in evacuation, station, general, and convalescent

hospitals, requesting their comments on methods of evacuation. Without a

single exception, all of them recommended that air evacuation (fig. 5) be used

for long hauls. Thoracic casualties came to consider it the preferred mode of

evacuation.

Air evacuation was begun in Sicily about D + 5. It proved a safe and

expeditious way of removing casualties to hospitals in North Africa, It was

particularly useful in moving casualties from the Anzio beachhead to Naples

for reparative surgery and sometimes, as already mentioned, when the beachhead hospitals were crowded and the casualty load was heavy, for initial

wound surgery. During the fall and winter of 1944-45, many casualties were

transported by air from the .field or evacuation hospitals at which they had

received initial wound surgery to the 24th General Hospital in Florence, or the

70th General Hospital in Pistoia. Casualties with less serious injuries were

flown to base hospitals in Leghorn and Home. Most of these casualties were

transported by means of C-47 (civilian DC-3) planes.

Air evacuation of individual patients by L-5 planes was begun experimentally in Italy early in March 1945. Careful selection was necessary, for no

medical' care was possible en route. These small planes proved extremely

useful during mountain fighting and still later, when the Army broke out into

the Po Valley. At this time, medical services, depleted by withdrawals for the

Seventh U.S. Army, had to be spread over hundreds of miles.

Boutine evacuation of thoracic casualties by air was not possible, since a

high altitude flight in nonpressurized planes, with the consequent respiratory

strain, might prove harmful, or even fatal, to patients with any degree of

respiratory difficulty. With careful selection, however, most casualties tolerated

flights at from 4,000 to 5,000 feet remarkably well.

TRAINING

There was no formal training in thoracic surgery in the Mediterranean

theater, but a considerable amount of informal training was carried out.

Lectures on the surgical and other aspects of the management of casualties

were given by members of the surgical stall's of various hospitals to medical

officers, nurses, and enlisted men. Because of the unusually large number of

thoracic surgeons assigned to the 2d Auxiliary Surgical Group, these officers

were frequently called upon to lead discussions and to give lectures and demonstrations on thoracic surgery. Newly arrived medical officers were attached to

thoracic surgical teams for indoctrination and training, and other officers were

attached to thoracic surgery services in general hospitals and to thoracic surgery

centers for training in this specialty. A great deal of useful teaching was also

done in field hospitals.

In 1944, the standards of thoracic surgery were greatly improved m a

number of evacuation hospitals by the attachment to them, for from 1 to 3

months, of experienced thoracic surgical teams. During these periods, intensive
80 THORACIC SURGERI

n

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A fl •: V ' Zfl ..-

1 UM! BS& '

SS*6*

Pi

FIGUKE 5.—Air evacuation of wounded in Italy. A. Transfer of casualties from ambulances

to plane. I!. Plane loaded and ready for takeoff to general hospital in base.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 81

JSp-i

***;

*****

'>

/

Ic

»h

EiGUJiK 5.—Continued. C. Medien 1 care en route.

efforts were inside to teach the intrinsic surgical staff the refinements of management of thoracic and thoracoabdominal wounds. This was an extremely important and useful effort. All thoracic surgery on transportable casualties was

handled in evacuation hospitals, and casualties with thoracoabdominal wounds

sometimes reached evacuation hospitals from forward areas in which there

were no intervening field hospitals. The surgeons in evacuation hospitals

therefore bad a great deal of thoracic surgery to do and had to be equal to the

task.

All of these measures helped to alleviate, though they did not compensate

for, shortages in trained thoracic surgeons. Of them all, none was more effective than the training given in thoracic surgery centers. In fact, from the

long-range point of view, these centers were regarded as scarcely less important

as instructional vehicles for the dissemination of the principles and practices

of sound management of combat-incurred chest wounds than as specialized

hospitals for the care of thoracic casualties.

Observation in British hospitals.—Some of the U.S. surgeons attached

to hospitals which went into North Africa from the United Kingdom in

November 1942 had been able to observe the -work of British thoracic surgeons

and to see some combat casualties. When the 77th Evacuation Hospital arrived

in England in August 1912, Major Snyder, who was in charge of the thoracic

6530811'—fi2 K
82 THORACIC SURGERY

surgery section, requested permission for himself and the members of his section

to go to London, to observe the work of Mr. A. Tudor Edwards, who was head

of the thoracic surgical services of the British EMS (Emergency Medical

Service). The original plans for a comprehensive 8- to 9-week tour of duty

in British thoracic centers were delayed, and the invasion of North Africa was

imminent when they were finally concluded. The extensive tour planned

therefore had to be telescoped into 8 clays. In the interim, however, Major

Snyder had been able to work with Mr. Ronald Belsey, head of the thoracic

surgical service at the Kewstoke Emergency Hospital (EMS) at Weston Super

Mare, near Frencbay Park, where the 77th Evacuation Hospital was located.

During the official tour of chest surgery centers and clinics, the U.S.

surgeons watched their British confreres in the operating room; made rounds

with them; studied their preoperative and postoperative techniques; and

attended their conferences, at which cases were presented, roentgenograms

shown, and all phases of thoracic surgery covered. The information thus

obtained proved of great value when combat-incurred injuries of the chest

were encountered in North Africa a few weeks later.

CONFERENCES AND MEETINGS

Thoracic injuries were frequently discussed at the numerous conferences

held in medical installations in all echelons in the Mediterranean theater,

and several times the entire program was devoted to them. Colonel Churchill,

in his visits to various installations in the theater, held what lie called chautauqua meetings, to discuss various phases of military surgery. Because of

his interest in the subject, his discussions of thoracic wounds always attracted

considerable attention.

The first formal meeting in which thoracic surgery was discussed on the

European Continent was held at Fifth U.S. Army headquarters in the King's

Palace at Caserta on 11 November 1943.

In November 1913, Col. L. Holmes Ginn, Jr., MC. Maj. Floyd PI. Jergesen, MC. and Major Snyder. Fifth U.S. Army consultant in surgery, talked

to the medical staff of the 3d Division at a clearing station near Riardo. Their

presentation and the ensuing discussion covered, among other subjects, the

management of shock, the correct use of morphine, and the management of

sucking chest wounds. Early in December 1943, Major Snyder discussed

wounds of the chest before the surgical section of the 8th Evacuation Hospital. Later that month. Colonel Churchill, Consultant in Surgery, Mediterranean theater, addressed an all-day session at the loth Medical General

Laboratory, in Naples, on the general principles of wound management; a

major portion of his remarks concerned chest injuries.

In February 1944, a meeting at the 38th Evacuation Hospital was devoted

to this subject, with special reference to the management of wet lung, the use

of atropine and morphine, and intercostal and paravertebra! nerve block.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 83

On 25 March, at the 401st Evacuation Hospital (French), an animated

discussion was devoted (1) to hemorrhage, (2) to Pentothal sodium (thiopental sodium), which the French regarded as contraindicated in shock, and

(3) to abdominal, thoracic, and maxillofacial wounds. On 30 March, at Marcianise, Italy, Major Snyder talked to the entire 2d Auxiliary Surgical Group

on triage at the division clearing station, surgery in field hospitals, and chest

surgery in field and evacuation hospitals. On 31 March 1944, a discussion

at the 52d Station Hospital concerned surgery in forward hospitals and

wounds of the chest. On the same day, a special meeting was held with thoracic surgeons of the 2d Auxiliary Surgical Group on the indications for chest

surgery in forward hospitals (p. 200).

A special session of the Congress of the Central Mediterranean Force

Army Surgeons held in Bonie, 12-19 February 1945, was devoted to chest

surgery.

Fifth U.S. Army medical conferences.—Chest surgery was a frequent

subject at the Fifth U.S. Army medical conferences, which were held weekly,

with very occasional exceptions, from their institution in the Royal Palace at

Caserta on 11 November 1943 until just before the fall of Rome in June 1944.

The first of these meetings and the meeting on 24 February 1944 were

entirely devoted to wounds of the chest. The participants in the first conference were Maj. (later Lt, Col.) Lawrence M. Shefts, MC, Maj. Lyman A.

Brewer III, MC, Maj. (later Lt, Col.) Daniel A. Mulvihill, MC, and Maj.

(later Lt. Col.) Henry K. Beecher, MC, who spoke on anesthesia for thoracic

surgery. At the second conference, the participants were Maj. Benjamin Burbank, MC, Maj. Thomas II. Burford, MC, Lt. Col. Paul W. Sanger, MC. and

Capt, Arthur J. Adams, MC, who spoke on anesthesia for thoracic surgery.

The majority of the speakers at both of the conferences devoted entirely to

chest surgery were heads of thoracic surgical teams of the 2d Auxiliary

Surgical Group.

Other Fifth U.S. Army medical meetings devoted to such subjects as

shock, hemorrhage, and anesthesia were also extremely useful in the development of policies on chest surgery.

All of these meetings proved a valuable means of disseminating information on chest surgery, particularly during the first winter (1943-44) in. Italy,

when educational needs were greatest. At this time, the front was generally

stable, and Army medical installations were not too widely scattered. The

Fifth U.S. Army medical conferences could therefore be attended by medical

officers of all echelons in the Army area, as well as by many officers from station and general hospitals supporting the Fifth U.S. Army. The first meeting, as already mentioned, was held at Caserta. When headquarters moved

forward, the conferences were held in one or another of the evacuation hospitals in the Army area.
84 THORACIC SURGERY

EQUIPMENT

North Africa.—Equipment for thoracic surgery in the North African

theater was originally poor. When the 77th Evacuation Hospital landed in

England in August 1942, its equipment for this type of specialized surgery

consisted of rib shears, a right and left rib raspatory, and a No. 14 F. ascites

trocar. The explanation came later, in North Africa, when it was discovered

from the newspapers in which the instruments and equipment for this hospital

were wrapped, that the table of equipment was of World War I vintage, 1917

and 1918.

Observation at the British chest centers showed the type of equipment

necessary for the proper management of combat-incurred wounds of the chest.

It included long-handled instruments for work deep in the thoracic cavity,

endoscopic equipment, various anesthetic agents (including cyclopropane),

and the necessary equipment for the administration of these agents. The British also had cabinets to convert electrical current into high frequency current

for cutting and coagulating and for converting current into low-tension current for use with endoscopic and other lighted instruments. A suction machine was attached to this cabinet, which thus took the place in U.S. medical

equipment of (1) the Bovie apparatus for cutting and coagulation, (2) the

suction machine, and (3) the battery case or rheostat that provided lowtension current for lighted instruments. The British considered this cabinet

indispensable for chest surgery. Their mobile thoracic surgical teams in the

United Kingdom had all the equipment just listed, and also had portable X-ray machines. Many months had to pass before U.S. Army thoracic

surgical teams were as well equipped.

Medical officers of the 77th Evacuation Hospital personally purchased

some of the equipment lacking for thoracic surgery, including a suction machine and a bronchoscope. When this hospital was assigned to the II Corps,

for the invasion of North Africa, supply officers of the Corps, in spite of the

purchase of supplies from British sources and other efforts, could not provide

even the minimum equipment necessary for the competent performance of

thoracic surgery. This hospital, and others similarly assigned, therefore went

into North Africa in November 1942 with their equipment far inferior to that

available to British chest surgeons.

Sicily.—There was great improvement in Sicily in the equipment provided

for field hospitals, which were serving, for the first time, adjacent to clearing

stations, but there were still shortages, including a lack of anesthetic machines.

Major Snyder reported that Major Shefts, a member of a thoracic surgical

team of the 2d Auxiliary Surgical Group, did most of his surgery under Pentothal sodium and oxygen supplied by a Boothby-Lovelace-Bulbulian mask,

with extremely satisfactory results, though this variety of anesthesia is ordinarily regarded as contraindicated in chest surgery. Evacuation hospitals

were much better equipped.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 85

The portable liand-driven suction machines devised by Major Brewer and

constructed from U.S. Army ordnance materials (figs. 6 and 7) were first used

in forward hospitals in the Sicilian campaign. They proved very useful in

trachea! and bronchial aspiration when electric power failed or was not

available.

In Sicily, field hospitals had only a single X-ray machine for all three

platoons, although each platoon, including platoons temporarily functioning

^ Sterna. _K

J

f

EIUUKE (j.—Portable liana-driven suction machine, improvised from

salvaged ordnance material and used in the Sicilian campaign. This

machine, like the one illustrated in figure 7, was devised by Major

Brewer, with the assistance of Maj. William C. Brewer, Ordnance

Department, and 1st Lt. Earl R. Kverno, and Sgt. Eugene A. Novak,

Ordnance Department. A. Machine constructed from 3-gallon contaminating spray pump and used to produce negative pressure:

Handle (a), cutoff valve to regulate suction (b), 3-gallon tank (c),

piston (d), cylinder (e), valve reversed to produce negative pressure

(f), and angle iron (g). B. Detail of valve shown in position to produce positive pressure: Cylinder (a), and valve (b). In this position, the valve allows air to enter the tank and prevents its escape.

In the position shown in view A, the air in the tank can escape but

cannot reenter. Continued pumping of the piston exhausts the air

from the tank and produces a vacuum.
86 THORACIC SURGERY

as holding units, needed its own to function properly. In 1943, as already mentioned, films were in somewhat short supply, and restrictions were necessarily

placed upon their unlimited use. In 1944, these restrictions were removed, and

no chest casualty went to operation without adequate roentgenologic examination. Large dryers were also provided, so that dry processed films were ready

when the patient went to the operating room.

Italy.—In Italy, after the first 6 months of combat, all hospitals came into

the theater with modern, fully adequate equipment, and even the most forward

hospitals were excellently equipped. Surgical instruments for all varieties

of surgery, X-ray facilities, and anesthetic apparatus very closely approached

those found in the best civilian hospitals. With the equipment used, as it was,

FIGURE T.—Portable hand-driven suction machine improvised from

fuel tank of standard Army held gasoline stove, with vacuum brakebooster from 2%-ton truck used to exhaust air from tank. The parts

of the machine appear as follows: Support to fix pump (a), BendixWestinghouse air valves (b), cutoff valve (c), fuel tank from gasoline

field stove (d), vacuum brake-booster (e), piston rod (f), and gear

shift handle (g). This machine produced more suction than the

machine described in figure 6 and was more easily operated. Both,

in the absence of electrically driven suction machines, proved most

useful in both operating room and ward tents for evacuating the

tracheobronchial tree in chest and other injuries.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 87

by well-qualified personnel, there was never any excuse for slipshod surgery

in any field.

Shortages of equipment occasionally occurred till the end of the war, as

the result of transportation difficulties. In the race across the Po Valley, for

instance, in 1945, when supply depots and dumps were still back in Florence,

the transportation of medical supplies sometimes had to make way for more

critical needs, such as gasoline and ammunition.

Provision of the hospitals on the Anzio beachhead furnished special problems because of the local conditions. The supplies taken ashore in the original

landings were brought in without incident. Later, supply dumps had to be

abandoned because of losses caused by enemy shelling, and supplies had to be

widely distributed.

Nonstaiidard equipment needed for thoracic and other specialized surgery

in the Mediterranean theater was obtained on the authorization of the Fifth

U.S. Army consultant in surgery, who, by direction of the Army surgeon, made

his requests to the medical supply officer. Not all of the nonstaiidard equipment requested was supplied. Medical officers fresh from the civilian practice

of surgery soon learned how to make do with the excellent and generally adequate equipment provided from late 1943 on.

There is no doubt that some credit for the good results of thoracic and other

surgery in the Mediterranean theater must be attributed to good equipment.

When equipment was in short supply, thoracic and other surgeons managed as

best they could, making ingenious improvisations take care of deficiencies. At

the beginning of the fighting in North Africa, for instance, the only suture material available was No. 0 and No. 00 chromic catgut. It was totally unsuited

for pulmonary surgery, as well as for vascular and intestinal surgery. One

thoracic surgeon supplied himself by having his wife send him some spools of

cotton and silk thread from a 5- and 10-cent store. Later in the campaign, all

types of suture material were available, including the atraumatic suture material (No. 0000 and No. 00000) particularly necessary for vascular surgery.

Thoracic Surgical Teams

Equipment.—When Major Snyder was placed on temporary duty in

II Corps headquarters in March 1943, to report on the work of auxiliary surgical group teams in the Tunisian campaign, he made several recommendations

concerning equipment for these teams, which then were doing surgery in clearing stations improperly equipped for this function (2). Two of the most

important were for portable anesthetic machines and for more efficient apparatus for transfusions. He also recommended that teams be furnished with

individual transportation.

In June 1943, after observing the surgical work in the chain of evacuation

in North Africa and questioning many of the surgeons individually, Maj.

Francis M. Findlay, MC, and Capt, Marion E. Black, MC, from Team No. 6,

c
88 THORACIC SURGERY

FioriiE 8.—Jeep used with 1%-ton truck for transportation of personnel and equipment of

2d Auxiliary Surgical Group teams in Italy.

3d Auxiliary Surgical Group, reported to the Surgeon, II Corps, that the following equipment was essential for any surgical team to operate independently :

1. Adequate transportation assigned permanently to the team. The original system of depending upon other units for transportation "was -wasteful and

unsatisfactory. A iy2-ton truck plus a jeep (fig. 8) or a command car would

furnish complete transportation for personnel and all equipment, The enlisted

men on a surgical team should be licensed as drivers.

2. Candle power (200 watts) for each operating table. In Tunisia, bulbs

of this size had not been obtainable, and the most satisfactory substitute was a

string of several bulbs of lesser wattage, set up by the electrician available in

every hospital unit.

3. A portable oxygen apparatus, with a large cylinder reducing valve,

and a Boothby-Lovelace-Bulbulian mask. This complete, efficient outfit was

essential for all chest surgery. Army Air Corps medical officers already had

this equipment.

i. A simple transfusion set for giving whole blood by the citrate method.

The equipment should include large-gage (No. 15) needles as well as No.

13 needles. A very satisfactory transfusion set could be improvised, if these

needles were provided, from aluminum tubing from airplanes, empty vacuoliter

bottles, and tubing and filters from used plasma sets.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 89

5. A large autoclave for sterilizing towels, gowns, and sheets. The upright British autoclave had three times the capacity of the U.S. Army type

of pressure cooker being used for this purpose in some clearing stations.

6. Two covered metal sterilizers, each 18 inches long, for boiling instruments, gloves, and transfusion sets.

7. Two stoves for sterilizing. The Coleman stove, which burned leaded

gas, though small, was quite efficient for this purpose. A third stove in

reserve was a good asset, to heat water and to use in case one of the stoves

in use broke down. Without heat, surgery had to stop.

8. Three large, 30-gallon galvanized GI cans, to use for washing, waste,

and soaking dirty and bloody linen.

9. Linen, including 200 towels, 20 gowns, and 40 sheets. Drapes for the

surgical tent were also necessary, to keep out dirt and dust.

10. A positive pressure apparatus of either the foot- or the hand-bellows

type, or a portable anesthetic machine, which was useful even if anesthetic

gases were not available.

11. The basic surgical instruments supplied to all teams.

12. A wall or pyramidal tent to furnish living quarters for the surgical

team.

The necessity for making such a list points to the deficiencies in the original

supply and equipment of auxiliary surgical group surgical teams. By the

time the Italian campaign was well underway, all of these items, and many

times even more efficient items, were in full supply. Eventually, the equipment of a thoracic surgical team consisted of an Army basic instrument

set and a special thoracic surgical instrument and equipment set. The latter

included not only all necessary instruments for chest surgery but also a suction

machine (a portable suction machine had been a major deficiency originally),

a portable anesthetic machine, a bronchoscope, and full equipment for therapeutic bronchoscopic aspiration. This equipment, like all equipment used by

auxiliary surgical group teams, was severely tested in respect to both durability and serviceability by repeated sterilization and by the rapid moves

necessary over air and water routes and by motor routes over difficult terrain.

It stood up admirably.

Transportation.—Transportation for the teams of the 2d Auxiliaiy Surgical Group remained something of a problem to the end of the war. In the

Tunisian campaign, the teams attached to the II Corps were furnished transportation that was turned in when the special assignment was completed. The

same arrangements prevailed in. Sicily.

In Italy, a certain amount of transportation was authorized for the 2d

Auxiliary Surgical Group; it was maintained in a motor pool and assigned

as necessary when the individual teams were moved. A few teams had independent transportation, which was far more satisfactory when fighting was

heavy and rapid advances were necessary. When progress was slow, the need

for independent transportation was, of course, less urgent.
90 THORACIC SURGERY

The six by six truck was the most satisfactory vehicle, since all equipment and personnel could be transported in it. The jeep, in spite of its many

advantages, could not accomplish this. It gave rise to so many difficulties,

in fact, that surgeons of the 2d Auxiliary Surgical Group developed the habit

of referring to it as Hitler's secret weapon.

BLOOD SUPPLY

U.S. medical officers found, as soon as they began to care for casualties

in North Africa, how essential whole blood was for both freshly wounded

men and for those with older wounds (•>'). The situation was not at all

satisfactory. There were almost unlimited supplies of plasma, but the indications for its use were not nearly so extensive as had been anticipated.

Whole blood was required, and it had to be obtained from clearing station

and hospital personnel. Most units, furthermore, had come overseas with

limited equipment for transfusion or with none at all. In the critiques of

surgery in the Tunisian campaign, as already mentioned, attention was called

to the need for more convenient methods of transfusion, and Major Snyder

also pointed out that a source of blood other than noncombat personnel should

be provided (2).

During the Sicilian campaign, as in North Africa, blood donors were

secured from the personnel of hospital units or from neighboring service

units, which was highly undesirable. Even these sources were not unlimited,

for the frequency of malaria reduced the lists of available donors. Transfusion sets still had to be prepared, cleaned, and sterilized by hospital personnel, which took a great deal of time and was far from safe under field

conditions.

By the end of 1913, most hospital units in the Fifth U.S. Army in Italy

had provided their own small blood banks as a matter of necessity. Typespecific blood could be held in them for 24 hours, or, if necessary, a little

longer. In February 1944, a central blood bank was organized, designed to

supply whole blood to all Fifth U.S. Army units, and thereafter blood could

be used in as liberal quantities as was considered necessary. A similar bank

was set up in the Seventh U.S. Army before the invasion of southern France

in August 1944.

The use of blood in thoracic casualties expanded as the supply of blood

expanded, though it always had to be used with special precautions in these

wounds (p. 253).

HOSPITAL INSTALLATIONS

Field Hospitals

Evolution of mission.—The evolution of the mission of field hospitals in

World War II represents a major development in the care of combat-incurred

wounds. In North Africa, these hospitals provided only the station type of
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 91

medical care. Surgery on nontransportable battle casualties was performed

at the division clearing station.

In his report in April 194:} to Col. Richard T. Arnest, MC, Surgeon,

II Corps, on the use of surgical teams in the Tunisian campaign, Major

Snyder pointed out that the primary function of clearing stations was triage

and that to perform surgery in them interfered with this function and also

had elements of surgical risk (2). Furthermore, if triage was not correctly

performed, nontransportable casualties might be classified as transportable

and lose their lives as a result, while casualties who could be returned to

duty if kept forward were likely to be evacuated to the rear and become

lost for combat purposes.

Major Snyder recommended that thereafter platoons of clearing companies should be designated for surgical duties in an installation adjacent to

clearing stations rather than within them. This arrangement would make

it possible for seriously wounded casualties to be operated on without delay

and would, at the same time, leave the clearing stations free to perform their

basic function of triage.

Before the invasion of Sicily, this recommendation was advanced another

step. In his evaluation of the work of the teams (2d Auxiliary Surgical

Group) (2) which had been assigned to a British hospital in Algiers, Major

Snyder had been greatly impressed with the fine work of these teams and with

their potential usefulness in a combat zone. It was therefore planned that

teams from the 2d and 3d Auxiliary Surgical Groups should be assigned to the

11th Field Hospital, which was to support the invading forces. During the

latter part of the campaign, when the 10th Field Hospital also came under II

Corps control and a platoon went forward to care for nontransportable casualties, it was promptly evident that its organic personnel could not handle the

situation alone, and auxiliary surgical group teams were attached to it, as they

had been to the 11th Field Hospital. Thereafter, surgical teams were attached

to all field hospitals in the Mediterranean theater and were used in the same

manner after D-day in Europe.

Concept and functions of field hospitals.—Field hospitals were operated

on two concepts:

1. Some casualties, including those with thoracoahclominal wounds and

certain types of chest wounds, as well as all casualties in deep shock, must receive surgical care at this level if they were to survive.

2. Casualties who had undergone the surgery required by such wounds

must not be moved for a certain period of time, ranging from 8 to 14 days as a

rule, and generally averaging 10 days.

About 10 percent of all casualties reaching a clearing station were nontransportable and required surgery in a field hospital at this level. Depending upon conditions of evacuation forward of the clearing station, casualties

might be received within a few minutes after their evacuation from the battlefield; but as a rule, at least 1 or 2 hours had elapsed, and occasionally from 18

to 24 hours, or even longer, had passed since wounding.
92 THORACIC SURGERY

The patients treated in field hospitals were frequently in desperate condition. Shock was profound, and heroic measures were often required to resuscitate them. The terms of reference under which these hospitals operated

made it inevitable that the mortality rate should be high. Since the selection

of patients for surgery at this level depended upon the triage performed in the

adjacent clearing station, the importance of the function of the clearing station

is evident. Without field hospitals, however, the mortality rate would have

been still higher, and a surprising number of casualties operated on in them

were returned to duty. An overall mortality rate of 25 percent was not unusual, while a rate less than from 12 to 20 percent strongly suggested that

casualties who should have been operated on at this level had not been cared

for there. If a field hospital was not accepting first priority (nontransportable) casualties or if other than first priority casualties were being accepted, it

was not fulfilling the functions for which it was set up.

Field hospitals received patients, usually by litter carry, from the adjacent

clearing station as soon as triage in them had been accomplished. The fundamental requirements for the performance of good surgery in them were:

1. Expei-ienced surgeons, anesthesiologists, and operating personnel.

2. Good nursing.

?>. Reasonable accommodation under shelter.

i. Adequate lighting and water supply.

5. Adequate equipment, including simple facilities for roentgenologic examination. One of Major Snyders recommendations in his report to the

Surgeon, II Corps, in April 194.3 had been that clearing platoons designated

to do major surgery should be better equipped than they had been In the

Tunisian campaign (2). This recommendation was acted upon, and the field

hospitals that handled forward surgery in the Sicilian campaign were far better equipped than the clearing stations that had performed the same mission in

Xort.h Africa.

6. Facilities to retain patients for an average of 10 days after operation.

Physical setup.—The physical setup of a field hospital was fairly well

standardized after its functions were standardized. The hospital was set up

in ward tents, so erected that they formed a cross, the center of which was a

pyramidal tent. The receiving and shock ward was located at the main entrance, with the postoperative ward directly opposite. The X-ray and laboratory equipment was in another ward tent, with the operating room directly

opposite it. This compact arrangement reduced the movement of patients,

concentrated supplies, made heating more efficient during the winter, permitted

a complete blackout, and simplified nursing care.

Staffing.—The organic personnel of a field hospital, as already indicated,

was not constituted, either numerically, frequently, or by training or experience, to do the sort of surgery assigned to these hospitals after the iSTorth

African campaign and throughout the remainder of the war in the Mediterranean theater and in the European theater. The solution of the problem was
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 93

the attachment of teams from an auxiliary surgical group to field hospitals.

As a rule, the intrinsic hospital personnel performed all administrative duties,

and the attached teams performed most of the heavy major surgery required

in medical installations located so far forward.

Each field hospital consisted of three platoons, each of which was staffed

and equipped to care for from 40 to 50 newly wounded casualties, providing

for them all services from resuscitation through postoperative care. While

the number of teams attached was flexible, an active platoon required, as a rule,

four general surgical teams, one thoracic surgical team, and one shock team.

When their intrinsic staff was thus augmented, the number of surgeons and

nurses provided in field hospitals was proportionately greater than in evacuation hospitals. This meant that seriously wounded patients could receive

better individual attention and postoperative care than less seriously wounded

casualties cared for in evacuation hospitals.

The establishment of field hospitals at the level of the clearing station

proved highly advantageous for the morale of troops. Every man in a division

thus supported knew that if he were seriously wounded, he would receive highly

competent care and would receive it without delay.

At this level of medical care, segregation of injuries was not possible, if

only because so many of them were multiple. Thoracic surgeons attached to

held hospitals therefore had to have special qualifications. A thoracic surgeon

must also be able to perform competent abdominal surgery; if no thoracic

injuries required his attention, he had to undertake the care of casualties with

abdominal and other injuries. In addition, a large percentage of thoracic

wounds also involved the abdomen by continuity.

In view of the shortages of thoracic surgeons, it was often expedient, instead of attaching a surgical team to a field hospital, to attach a single thoracic

surgeon. He performed the most serious operations himself, supervised other

operations, supervised preoperative and postoperative care, and taught general

surgeons the indications for, and the techniques of, thoracic surgical procedures. Many young general surgeons thus learned to do excellent thoracic

surgery of the sort necessary in a field hospital. An experienced thoracic

surgeon could also do much to elevate the standards of anesthesia for chest

surgery in both field and evacuation hospitals.

Another possibility was to attach a senior thoracic surgeon to a field hospital and place two teams under his direction.

By whatever means the necessary personnel was provided, the proximity

to the frontline of experienced thoracic surgeons (and other specialists) made

it unnecessary for medical officers in clearing companies to indulge in heroic

surgery for which their installations were not designed and for which they

themselves were not trained.

A single thoracic surgeon could not usually handle all of the thoracic and

thoracoabdominal surgery in a field hospital, even after indications for forward

surgery were standardized. It was agreed that certain types of penetrating

and perforating wounds which had earlier been considered first priority (non-
9i THORACIC SURGERY

transportable) problems could quite as well be handled in evacuation hospitals

(p. 199). Even then, the number of thoracic injuries which required forward

surgery was still large. In one unselected series of cases encountered during a

7-week period in a platoon of a held hospital in the Mediterranean theater, 92

patients had intrathoracic wounds that made them noutransportable (22

thoracoabdominal wounds, IG wounds requiring formal thoracotomy, and 50

other perforating or penetrating wounds). During the same period, the

thoracic surgical team that cared for these patients also cared for 44 patients

with abdominal wounds.

Postoperative function.—At the beginning of the lighting in Xortli

Africa, the tendency had been to place the chief emphasis upon the operative

act and to regard most patients as transportable almost immediately after

operation. It was promptly evident that casualties who were moved too soon

after major surgery might be in worse status than if surgery had been postponed until an evacuation hospital was reached. In short, it was learned in

military surgery, at bitter cost, just as it had been learned in civilian surgery,

that complete postoperative care is quite as important in the surgical result as

is the operation itself. The hospital on wheels was an alluring concept but

totally impractical. Surgery was not practical beyond the point at which

facilities for aftercare could be provided.

Holding patients after operation was reasonably simple in both field and

evacuation hospitals when the hospital was located behind a stable front or a

slowly advancing front. In these tactical circumstances, one held hospital

could serve two divisions in the line by using two of its three platoons at two

division clearing stations. The third platoon held patients at a fixed location

until they were all evacuated, then leapfrogged over one platoon or the other

to set up beside the clearing station that had moved forward.

"When the front was moving rapidly, the postoperative situation was difficult and much more complicated. Every division then usually required the

support of an entire Held hospital, the platoons of which were set up in depth

behind the front. Only the most forward platoon, adjacent to the division

clearing station, received casualties. The other two platoons held patients

in various stages of postoperative recovery until they could be evacuated and

the platoons could move forward. When the forward platoon was closed to

admissions, as it was when the clearing station adjacent to it moved forward

the rearmost platoon, whose patients had been operated on before those in the

middle platoon, leapfrogged over the middle platoon to take its place alongside

the clearing station in its new forward position. The platoon which had closed

its admissions cared for its patients until they could be evacuated and it, in

turn, could leapfrog forward and again receive patients.

In the beginning, only a skeleton staff was left with the platoon holding

patients after operation. It Mas soon found that this was not adequate, for

it made no provision for the management of complications and emero-encies.

The plan was then developed of leaving a surgical team with this platoon. It
ADMINISTRATIVE CONSIDERATIONS IX MEDITERRANEAN THEATER 95

was also found necessary to leave facilities for roentgenologic examination and

for surgery, which meant a complete operating room setup.

When field hospitals were urgently needed during active campaigns, an

evacuation hospital sometimes moved to the site occupied by the holding platoon and took over its postoperative duties in addition to its own responsibilities for initial wound surgery. The holding platoon could then move forward

and again receive casualties.

Evacuation Hospitals

Mission.—Evacuation hospitals (fig. 9) were located from 3 to 15 miles

behind field hospitals in Italy. In Tunisia, the distances had frequently been

considerably greater. After it had been established that thoracic casualties

withstood transportation well, the majority were treated in evacuation hospitals. Most of them came directly from clearing stations, but a small number

were received from field hospitals, in which resuscitation had been instituted in

the shock wards.

Evacuation hospitals were of two types, 400-bed and 750-bed. The larger

capacity was often an advantage, but 400-bed hospitals, if reinforced by the

appropriate number of teams from auxiliary surgical groups, were capable of

-i^^feif' ; -.

•*--

FIGURE 0.—Tents used for officers' quarters at Ilth Evacuation Hospital, Auzio, Italy,

in May 1044, dug in for protection from shellfire. On this beachhead, evacuation hospitals

were so far forward that they served as field hospitals and frequently came under heavy

fire.
90 THORACIC SURGERY

handling about the same number of casualties as 750-bed hospitals not thus

reinforced. The smaller hospital, with extra bed capacity provided in the

form of an adequately equipped clearing- platoon, was far more efficient in a

fluid tactical situation than a larger hospital. A 400-bed semimobile evacuation hospital, because it could be rapidly moved to a new location, proved a

particularly practical unit in Sicily, where frequent changes of position were

required.

The clearing platoons were left as holding hospitals when the parent

hospitals moved forward. It was quite as important to hold patients after

major abdominal and thoracic surgery in an evacuation hospital as after surgery in a field hospital.

When the load on field hospitals increased, evacuation hospitals received

more seriously wounded casualties than in nonpeak periods, which meant that

they received more thoracic casualties. The general policy, whenever it Mas

practical, was to send the most seriously wounded patients to the most forward

evacuation hospitals. It was not a desirable plan to send patients to evacuation

hospitals who should have, been treated in field hospitals, but it was sometimes

an operational necessity, as during the Anzio phase or during the pursuit of

the Germans north of Rome after that city fell. Very careful selection of

patients was obviously necessary when this policy was employed.

The extent to which other than urgent intrathoracic surgery was done in

evacuation hospitals depended upon the tactical situation as well as upon the

distance between them and the fixed hospitals in (he communications zone.

Transportation facilities also had to be taken into account.

It was fundamental policy that evacuation hospitals must not engage in

the performance of semielective surgery when there was any chance at all that

their bed capacity would be required for battle casualties. In quiet periods at

the front, however, and sometimes when evacuation facilities to the rear were

slow and uncertain, certain surgical procedures usually reserved for base section

hospitals were undertaken in (hem. These procedures included the removal of

intrapulmonary foreign bodies and, very occasionally, pulmonary decortication

for organizing hemothorax. One justification for this type of' surgery in an

evacuation hospital was that the patient might be returned to duty'from it.

This policy was chiefly used in North Africa, when hospital policies were

not yet stabilized, and to a lesser extent in Sicily. During the Italian campaign,

after the establishment of general hospitals, these surgical procedures were

almost always reserved for these hospitals or for thoracic surgical centers.

Staffing.—When triage in the clearing station was efficient, evacuation

hospitals received almost no abdominal or thoracoabdominal wounds, but they

did receive the larger number of penetrating and perforating wounds of the

chest, which frequently were associated with wounds of the extremities.

At this echelon of medical care, segregation of casualties for specialized

management was entirely practical. Thoracic surgical teams proved particularly useful both in supplementing the thoracic surgical section of the

hospital and in furnishing qualified personnel if there were no experienced
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 97

thoracic surgeons on the intrinsic staff. During peak periods, it was desirable

to have two thoracic teams functioning in an evacuation hospital and devoting

their chief, if not their entire, attention to the treatment of wounded whose

major injuries involved the thorax. Preoperative and postoperative care of

these patients was the responsibility of the thoracic surgeons, and they also

supervised the care of the thoracic wounds in patients on other wards who had

multiple wounds, some of which took precedence over the chest wounds.

Fixed Hospitals

Mission.—General and station hospitals in the base area received thoracic

casualties as soon as they could be transported to the rear from evacuation

hospitals. The time of the transfer depended on the nature of the wound and

the surgery that had been necessary for it in the forward hospital.

The policies that governed the management of thoracic and other casualties

in fixed hospitals in the base were worked out at the base section in Bizerte in

the North African theater during 1948. The mission of these general hospitals

in respect to thoracic casualties was threefold:

1. To perform the final reparative surgery on wounded casualties who could

be promptly returned to duty. From the military standpoint, the most important function in the base was the energetic treatment of this group of

patients, most of whom had wounds limited to the chest wall or wounds without severe intrapleural involvement. Sometimes patients with clotted hemothorax fell into this category. The principal operations performed were delayed

primary wound closure; thoracentesis, if hemothorax still persisted; and decortication. Later in the war, decortication was practically always performed in

chest centers.

Whenever a choice had to be made from the standpoint of time, available

surgical personnel, or facilities, the final care and rehabilitation of patients in

this group had the highest priority unless, of course, other patients would have

suffered from a delay in their treatment. It was a matter of great importance

that soldiers whose return to duty seemed probable should receive treatment as

far forward, and as promptly, as possible. The farther from the front a

casualty was moved and the longer his return to it was delayed, the less inclined

he was to return to active combat.

2. To improve the morbid state of more severely wounded patients, to make

them transportable to the Zone of Interior. Since these soldiers were no longer

useful in the theater, the sooner they could be prepared for evacuation to the

United States, the less was the drain on theater resources.

Casualties from Sicily were evacuated to North Africa before being sent

to the Zone of Interior, and the same routine was followed in the early days of

the fighting in Italy, before Italian ports were open. Seventh U.S. Army

casualties, even after the Army passed into control of the European theater,

were evacuated to the 21st General Hospital in Mirecourt, then to a general

hospital in Dijon, and finally to Marseilles.
98 THORACIC SURGERY

3. To preserve thoracic function and prevent chronicity and deformity.

The preservation of physiologic function was the major objective in all casualties treated in the base, just as it was in the forward area. The institution of

correct therapeutic measures prevented ultimate deformity of the lungs, heart,

chest wall, diaphragm, and shoulder girdle. As a result of these measures, plus

the absence of intrinsic (postpneumonic) infection, the number of so-called

thoracic cripples after World War II was very small as compared with

the very huge number, absolutely and proportionately, after World War I

(vol. II, ckXI).

The management of thoracic casualties in the base areas permitted the

continuity of treatment essential to avoid infection. The mission of hospitals

in the base area was fundamentally to minimize the incidence and gravity of

this and other complications. If a delaying or expectant policy was followed,

the immediate mortality rate perhaps did not vary greatly from the rate associated with active therapy, but the degree and frequency of permanent disability was inevitably higher. A hemothorax, for instance, not completely

evacuated in the forward hospital, was not likely to develop into hemothoracic

empyema if it was treated promptly in the base hospital. Decortication could

be done with minimal risk and a high expectation of good results. If the removal of foreign bodies was indicated, it could be undertaken before infection

developed or pulmonary function was permanently reduced.

While the functions of base hospitals were generally as described, the tactical situation sometimes required that they assume other missions. These

hospitals were occasionally far enough forward to receive freshly wounded

patients, while during the first few days after a landing or other operation,

particularly when air evacuation was possible, casualties also occasionally received initial wound surgery in them.

Thoracic Surgery Centers

Establishment.—Their early experience with thoracic casualties in Xovth

Africa, convinced Major Burford and Maj. (later Lt. Col.) Paul C. Samson,

MC. that the only really efficient way to handle these patients would be in

thoracic surgery centers (fig. 10) equipped for this type, of surgery and staffed

by thoracic surgeons. Major Burford's first specific assignment in North

Africa had been at the -21st General Hospital, then at Bou Hanifia, which had

been receiving heavily infected thoracic casualties, consisting of both U.S.

Army wounded .personnel and German prisoners of war. It was here, incidentally, that he did the first decortication and established the precedent for

the. management of clotted and infected hemothorax and hemothoracic empyema in World War II (p. 27).

His own observations convinced Colonel Churchill of the soundness of

Major Burford's and Major Samsoirs position, and the management, of tho-
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 99

^pp3

U^>3i'!§fS&~=~W-- ;_J

fc_/ «f

Mü^

FiGuia: 10.—Thoracic: surgery Center, 300th General Hospital, Mediterranean theater.

A. Main operating' room. B. Typical ward.
100 THOKACIO SURGERY

racic casualties in chest centers became standard policy in the Mediterranean

theater throughout the war.

The first such chest center was set up on 7 July 1943 in the 53d Station

Hospital at Bizerte (4), where the 53d and other hospitals, commonly referred

to as "hospital row," were already in operation. At the request of the surgeons

who made up the thoracic surgical staff of this center (Major Burford, Major

Samson, and Captain Brewer), an internist, Major Burbank, was also attached

to the service. This center received casualties from evacuation hospitals and

from general hospitals in North Africa. After the invasion of Sicily, in July

1943, some freshly wounded casualties were flown directly to it.

There was almost no overlapping of the operation of chest centers in

the Mediterranean theater, the policy being that not more than one should

function at any one time. When the center at the 53d Station Hospital was

closed at the end of October 1943. the 28 patients then hospitalized were transferred to the 24th General Hospital, also at Bizerte. The Salerno landings

had been made in September, and casualties were then being received from

Italy. This center was closed on 31 January 1944, just after the Anzio invasion, and the next center was established in Italy, at the 17th General Hospital

located near Naples.

"When the center at the 17th General Hospital was closed in March 1944.

its functions were assumed by the 300th. General Hospital at Naples. The last

center to be established during the war was opened in March 1945, at the 70th

General Hospital, located at Pistoia, just before the drive on Bologna. The

hospital was at first so close to the frontline that during the first few days of

the drive, it functioned, for all practical purposes, as a field hospital, and

thoracic casualties were received shortly after they had been wounded.

The first chest center in the Mediterranean theater was established at a

station hospital, but it promptly became evident that the limited bed capacity

and the lack of certain essentials for the proper care of thoracic casualties

made hospitals of this type unsuited to serve as thoracic surgery centers. All

centers subsequently established were therefore at general hospitals. The influx of casualties to the centers proved the wisdom of this change of policy.

The facilities of general hospitals were required to meet the variegated problems of a large specialty service dealing with difficulties of the magnitude

encountered in combat-incurred chest injuries.

When the policy of chest centers was instituted, it was necessary to change

the lines of evacuation (fig. 3) so that thoracic casualties would be evacuated

from evacuation hospitals to the centers, without the delay and wasted motion

involved in their going first to genera] hospitals. There was no selection of

cases. Casualties sent to the chest centers represented an overall distribution.

As a result, the observations made in the centers in the Mediterranean theater

have a validity that was not possible when centers were used only as the las!

resort for patients with complicated and intractable wounds.

The system of staffing and operation evolved in the thoracic surgery centers and other centers for specialized treatment established in the Mediter-
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 101

raiiean theater served as a pattern for the similar centers later established in

the European theater, both in the United Kingdom Base and on the Continent.

Advantages.—The establishment of centers in base section hospitals for

the study and treatment of specialized surgical problems had the same farreaching influence on thoracic surgery that this policy had on other specialties.

There were a number of obvious advantages:

1. The concentration of casualties with thoracic wounds under one roof

meant that the thoracic surgeons, who were in such short supply, could be

assigned to these centers and could use their talent and experience with the

greatest economy and most effectively. This was a serious consideration. At

the end of 1943, aside from the thoracic surgeons in auxiliary surgical groups,

there were, at the most, six surgeons in the 17 hospitals in the Mediterranean

theater who were qualified by training and experience to handle complicated

thoracic wounds.

2. The concentration of thoracic casualties under trained personnel in a

hospital with specialized equipment provided better opportunities for their

observation and care than was possible when they were scattered through the

general hospitals in the theater.

•3. The opportunity of studying large numbers of casualties permitted

an objective evaluation of the efficiency of previous treatment. It was then

possible to alter therapeutic policies when they were not proving effective. The

constructive criticisms that emerged as the result of these evaluations were disseminated to other installations by Colonel Churchill and others designated

by him for this duty. They were also disseminated by means of circular letters. Numerous new techniques, of which decortication is an outstanding

example, were thus introduced and standardized.

4. The establishment of special centers made possible the best timing for

the reparative phase of the management of thoracic wounds. Xumerous soldiers were returned to duty in the theater because their wounds were closed

at the optimum time and, when indicated, retained foreign bodies were removed, Xumerous empyemas were prevented because decortication was carried out at the optimum time in massive organizing hemothoraces. Many operations for which the optimum time had arrived before transportation to the

Zone of Interior was available were also carried out in these centers.

5. As a result of these various policies, treatment was expedited as well as

made more effective. The incidence of infection in thoracic casualties received

in general hospitals and managed in them by surgeons without experience in

chest surgery provided additional proof of the wisdom of, and necessity for,

the policy of establishing chest centers. Manpower losses were diminished.

Disposition of patients was accelerated, and the number of soldiers who could

be returned to active duty in the theater was greatly increased. Finally, the

crippling sequelae of chest injuries, which had been a continuing problem after

World War I, furnished only minimal problems in World War II.

6. Not the least advantage, of the thoracic surgery centers was the means

they afforded for training younger officers with general surgical experience in
102 THORACIC SURGERY

chest surgery and in preoperative and postoperative management of thoracic

casualties. These officers, as already pointed out, received concentrated experience, under supervision, which they could not possibly have obtained if

they had had to take the entire responsibility for the small share of chest

injuries that would have come under their observation if the casualties had been

scattered diffusely through the general and station hospitals of the theater.

Special experiences.—The thoracic surgery centers in the Mediterranean

theater cared for a total of 1,538 intrathoracic wounds during World War II.

The first centers established, the 53d Station Hospital and the 24th General

Hospital, together treated 390 thoracic casualties, with the aid of Thoracic

Surgical Teams Kos. 2 and 3 and Miscellaneous Team Ko. I from the 2d

Auxiliary Surgical Group. These figures include 20 cases of thoracic disease,

of which 22 were spontaneous idiopathie pneumothorax. In the remaining

304 cases, the wounds were limited to the chest wall in 185. There were 83

fractured ribs; 188 instances of traumatic hemothorax, pneumothorax,

or hemopneumothorax; and 10 instances of blast lung (the figures are

overlapping).

There were 3 deaths among the 300 patients. Of the survivors, 100 were

returned to duty or to convalescent hospitals with the expectation that they

would be returned to duty; 104 were evacuated to the rear and were probably

later evacuated to the Zone of Interior; and 124 were transferred to other

services or to other hospitals for active therapy. When the center at the 24th

General Hospital was discontinued on 31 January 1044, 5!) patients were still

hospitalized, not all of whom were hospitalized because of their thoracic

wounds. It should be remembered that even in a thoracic surgery center, the

presence of other wounds frequently made certain modifications, sometimes not

altogether desirable, necessary in the management of chest injuries.

AUXILIARY SURGICAL GROUPS

Early Concepts

In 1943, while the 2d Auxiliary Surgical Group was still at Lawson

General Hospital, Atlanta, Ga., its commanding officer, Maj. (later Col.) James

H. Forsee, MC, prepared an article on the management of thoracic combatincurred injuries with two of the group thoracic surgeons (Major Shefts and

Major Burford) ; an internist (Major Burbank) ; and an anesthesiologist

(Maj. Leo J. Fitzpatrick. MC) (5).

The statements in this article about administrative considerations in chest

injuries were to prove prophetic:

1. The single factor which can reduce the high mortality of chest injuries

as recorded in previous wars is earlier definitive treatment by trained thoracic

surgeons.

2. To effect this in the mobile type of war now occurring, it is necessary

to have an equally mobile system of evacuation and management, which is
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 103

flexible enough and mobile enough to handle casualties soon after their injuries

are incurred.

3. To accomplish these results requires the special training of surgeons and

their assistants in the care of chest wounds. It also requires an organization

whereby such personnel are available on short notice to function in properly

equipped medical installations at the point of maximum casualties close to the

battlefront.

4. Since there are too few specialists in thoracic surgery of field age to

staff all hospitals, the deficiency must be remedied by the training of general

surgeons in the fundamentals of thoracic physiology, preferably in hospitals

in which chest cases are concentrated. Centers of this sort would also permit

training in bronchoscopy and provide training for anesthesiologists in the

techniques of endotracheal and positive pressure anesthesia, both essential for

safe thoracic surgery.

5. Keduction of the timelag after wounding, which is also concerned with

distance, resolves itself into (1) having the surgeon immediately available

behind the frontline, even if it is a rapidly moving line, or (2) evacuating the

wounded to him by ambulance or airplane.

Such a program of early definitive treatment by trained personnel, the

authors concluded, would reduce the mortality of thoracic injuries, decrease

their morbidity, reduce the hospital stay days, and eliminate a large proportion

of the patients with chronic empyema who linger on long after a war is over.

These so-called thoracic cripples are the obvious result of treatment applied

late and frequently applied incorrectly. The elimination of this group of

patients, who would require hospital care for many years, would have the

additional advantage of accomplishing enormous monetary savings.

Implementation of Concepts

This statement of principles for the most part was translated into action

in World War II (6). Never before in history had battle casualties received

such, prompt surgical care by such highly skilled specialists. This was made

possible by two policies. The first was the provision of medical service in the

combat zone in such locations that the period between wounding and competent

surgical care was decreased. The second was the availability of young, formally

trained medical officers, who were not only well qualified technically to perform

good thoracic surgery but who, even more important, were schooled and

grounded in the fundamental principles upon which good surgical practice is

based.

The availability of these highly trained surgeons was a reflection of the

carefully nurtured system of postgraduate medical education in the United

States. Their superior performance was a measure of the progress made in

this special field. The brilliant results that they achieved were accomplished

because they were properly utilized and correctly fitted into the organi-
104 THORACIC SURGERY

zation of medical service in the forward area. The keynote of the plan of

medical care in advanced battle zones was that the sooner a wounded man

received adequate first aid and subsequent surgical care, the better would be

the outcome of his injuries. For this concept, much credit is due Colonel

Churchill, theater consultant in surgery.

In short, everything that the surgeons of the 2d Auxiliary Surgical

Group wrote in 1943 came to pass in the ensuing years of the war. The case

fatality rate of chest wounds was sharply decreased, their postwar morbidity was even more sharply reduced, and thoracic cripples ceased to be seen.

Organization and Utilization of Auxiliary Surgical Group Teams

Although some specialty teams had been used during World War I (7),

thoracic surgery did not then exist as a specialty and was therefore not

represented among them. All of the teams operated independently and not

as a group. The unit known as an auxiliary surgical group and utilized

as surgical needs arose was employed for the first time in the U.S. Army

in World War II.

Teams from the 3d Auxiliary Surgical Group supported the II Corps

in North Africa and Sicily before the group was put under the control of

the European theater. Some teams of the 5th Auxiliary Surgical Group also

supported the Fifth U.S. Army. In November 1944, teams from the 1st

Auxiliary Surgical Group attached to the Seventh U.S. Army included eight

general surgical teams; two orthopedic surgical teams; two shock teams; and

teams representing, respectively, thoracic surgery, neurosurgery, maxillofacial

surgery, radiology, and dental prosthetic surgery. Later, other teams were

added, including four general surgical teams: two thoracic surgical teams;

and teams representing, respectively, orthopedic surgery, neurosurgery, and

radiology.

Teams of the 2d Auxiliary Surgical Group served with the II Corps in

North Africa and in Sicily, with the Fifth U.S. Army in Italy, and with

the Seventh U.S. Army for the invasion of southern France and until the

end of the war in Europe. In preparation for the invasion of southern France,

half of the teams of this group, including two thoracic surgical teams, were

attached to this Army and remained with it even after control of the Army

passed to the European theater in December 1944. When this change was

effected, fiffhtinsr had slowed down considerably, and the loss of the teams

was not immediately felt. When the character of combat changed from the

battle of pursuit in July and August to the bitter fighting that characterized

the North Apennines campaign in the fall and winter of 1944-45. the changed

tactical situation produced the longest sustained combat load in the history

of the Fifth U.S. Army. Surgical teams made up from base hospitals, valuable as they were, did not prove a substitute for the experienced teams that

had been withdrawn.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 105

The teams of the 2d Auxiliary Surgical Group cared for a total of 22,000

casualties during their service in the Mediterranean theater, of whom 1,364

had thoracic injuries and 903 thoracoabdominal injuries.1-

2

Early policies.—While some auxiliary surgical group teams were used in

the North African campaign in 1942-43, thoracic surgical teams were not

among them. Chest surgery was done entirely by the staffs of the forward

hospitals and the general surgical teams, though some thoracic casualties from

this campaign were later treated in the first thoracic surgery center established

at Bizerte in July 1943.

There were a number of reasons for failure to use the chest teams at

all, and to use the other teams properly, in this campaign. For one thing,

the fighting was in eastern Algeria and later in Tunisia, while the headquarters of the 2d Auxiliary Surgical Group was in Rabat, Morocco. There

was no clear concept in the minds of hospital staffs or in the headquarters

of the theater surgeon of either the availability or the usefulness of these

teams. The number of troops committed was small, at least as compared

to the number committed in later campaigns, and the mobility of the front

and the tenuous lines of communication furnished difficult problems of logistics.

Major Snyder's first special mission in North Africa, before he was

appointed professional services officer to the Surgeon, II Corps, and later

consultant in surgery to the Surgeon, Fifth U.S. Army, was to evaluate

the work of the teams from the 2d Auxiliary Surgical Group that had been

assigned to a British hospital in Algiers (2). He was immediately impressed with the potentialities and great usefulness of these teams in a combat

zone, and it was on his recommendation, as already noted, that they were

attached to field hospitals. They were used in this capacity in Sicily and

throughout the remainder of the war. They were also attached to evacuation hospitals and, in some instances, worked in general hospitals and in

general hospitals that served as chest centers.

Administrative considerations.—An auxiliary surgical group was composed of a headquarters and of a varying number of teams, including general surgical, thoracic surgical (thoracosuigical), orthopedic, maxillofacial,

neurosurgical, and shock teams.

The coordination of functions and the employment of the teams of the

2d Auxiliary Surgical Group were effected through Group headquarters. The

need for the use of the teams in special installations was worked out between

the theater surgeon and Colonel Churchill, who, as consultant in surgery

to the theater surgeon, participated in medical planning and was at all times

fully aware of the tactical situation. When it was determined which field

1 The work of the 2d Auxiliary Surgical Group is referred to frequently and in great detail

throughout this volume for the reason that its records, which were carefully planned in advance,

provide data on thoracic injuries not available from any other source.—F. B. B.

- To round out the picture, it might be mentioned that the 9th Evacuation Hospital, which was

supporting the Seventh U.S. Army and was stationed in Naples from January to August 1044, was

loaned to the French Army in the winter of 1944. It remained under the control of Maj. Gen.

Morrison C. Stayer, Surgeon, Mediterranean theater.—F. B. B.

053GS1V—02 9
106 THORACIC SURGERY

hospitals and which evacuation hospitals would be employed in a given operation. Colonel Churchill decided upon the number and kinds of teams to be

employed, and the commanding officer of the group, Colonel Forsee, arranged

for them to be properly deployed. In other words, these particular hospitals

were augmented by surgical, thoracic surgical, and other specialty teams in

anticipation of heavy casualty rates.

The number of teams attached to forward hospitals was flexible. During

a slack period, two teams could handle all the work, but at least six surgical

teams and two shock teams were required during an offensive, and the assignment of eight teams was not unusual. The hospitals that participated in

amphibious landings required the assistance of teams fi'om the group, and

numerous teams were used during the Anzio operation, in which the Army

had major forces in two areas separated by intervening territory held by

the enemy.

Originally, auxiliary surgical group teams were not used to their full

capacity. In Sicily and later in Italy, for instance, between 10 July 1913

and 1 February 1941, a thoracic surgical team cared for 100 casualties, of

whom only 6 had penetrating wounds of the chest and of whom only 5

had thoracoabdominal wounds. This was a serious waste of trained personnel.

Another of the earlier policies which resulted in similar waste was the

keeping of teams attached to field and evacuation hospitals with those installations even after their mission had been completed. In North Africa, in Sicily,

and in the first months of the fighting in Italy, they were moved only when

they were needed elsewhere. When the headquarters of the 2d Auxiliary Surgical Group was moved to Italy in 1914, these wasteful practices were discontinued, and thereafter, when the teams finished their special missions, they

were recalled to headquarters at once for a period of rest and preparation for

the next assignment.

All teams were kept on the alert, and were prepared to move to any assignment on very short notice. The Sicilian experience proved that attachment

of these teams to field and evacuation hospitals resulted in a much higher grade

of care for wounded casualties than the previous policy of surgery in clearing

stations; the ability to shift the teams rapidly had much to do with the

improvement.

Components of a thoracic surgical team.—All thoracic surgical teams

were so constituted as to be complete operating units. Each team consisted of

a thoracic surgeon (major), an assistant surgeon (captain), an anesthesiologist

(first lieutenant), a surgical nurse, and two enlisted technicians. Each possessed special qualifications:

1. The thoracic surgeon was expected to have a precise knowledge of the

surgical physiology of the chest, technical skill in thoracic surgery, and sound

sui'O'ical judgment. It was also necessary that he have had a thorough training

in general surgery as the basis for his training in thoracic surgery.

The latter requirement, which is highly desirable in civilian practice,

proved essential in military surgery, when the exigencies of the military situa-
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 107

tion often made it necessary for the thoracic surgeon to -work in the abdomen,

and sometimes elsewhere in the body. The majority of patients admitted to

field hospitals had multiple wounds because they had been injured by high

explosive missiles, such as artillery shells, mortars, mines, and antipersonnel

bombs. The general surgical training possessed by the thoracic surgeon (and

the assistant surgeon) of a well-constituted thoracic surgical team fitted them

for the assumption of responsibilities outside of their special field and greatly

limited their usefulness if they could not assume them.

The thoracic surgeon was also responsible for preoperative preparation,

determination of the optimum time for operation, postoperative care, and the

designation of the time of evacuation for thoracic casualties.

It was always desirable to have a senior team chief act as senior officer for

the teams in a hospital, and if the thoracic surgeon was senior to the other team

chiefs, he had this responsibility also.

2. The assistant surgeon ideally had had a minimum of 2 years of surgical

training and had devoted several months, at least, to the study of the medical

aspects of thoracic diseases.

3. Since good anesthesia plays an important role in all chest surgery, the

severity of the thoracic injuries sustained in World War II simply compounded

this necessity. The anesthesiologist had to be capable of administering endotracheal and positive pressure anesthesia; of clearing the tracheobronchial tree

of secretions by catheter suction or, if that was ineffective, by bronchoscopy ;

of recognizing and correcting disturbed cardiorespiratory physiology; and of

directing the management of the shocked casualty. In addition to administering anesthetics, he had to share with the surgeon, the assistant surgeon, and

the ward officer the responsibility for the preparation of casualties for operation and for their postoperative care.

4. The surgical nurse on a thoracic surgical team began by being a good

surgical nurse. In addition, she had to have a detailed knowledge of the technical features of this specialty. She had to possess the temperament and

adaptability to endure frequent operative ordeals during long periods of sustained tension. She also had to be an able instructor in operating room technique, capable of teaching the principles of asepsis and other techniques to

corpsmen without previous medical experience.

5. The surgical technicians had to be good, well-disciplined soldiers, with

a capacity and willingness for long, hard work. They were necessarily youru>\

and they had to be in sound physical condition. They preferably possessed

inquisitiveness concerning the accomplishments and potentialities of modern

surgery. They had to be thoroughly reliable and responsible, since their duties

included the preparation and sterilization of surgical supplies. They also had

to be gentle and careful enough to serve as good assistants at the operating table.

6. All of the members of the team had to have sufficient physical stamina

to endure long hours of taxing work at the operating table and also had to have

a capacity for quick, decisive action.
108 THORACIC SURGERY

Hospital Responsibilities

Field and evacuation hospitals.—In the field hospitals of the Fifth and

Seventh U.S. Armies, auxiliary surgical group teams carried the chief responsibility of the professional service, while the organic personnel were chiefly

responsible for administration. In evacuation and general hospitals, teams

from the group augmented the regularly assigned surgical staff. No other

arrangements would have been practical in these particular field hospitals, in

which the assigned personnel were practically always numerically insufficient

to handle both administrative and professional responsibilities.

In the early days of the war in North Africa, the teams were not always

welcome. Organic personnel of both field and evacuation hospitals resented

their presence and took the attitude that they could take care of their own responsibilities without outside help. Proper indoctrination of commanding

officers of hospital installations and chiefs of service, and the careful placing

of auxiliary surgical group teams in positions in which casualties were heavy

and the need for help obvious, solved part of the difficulty. Quite as important

was the performance of the teams themselves. Only second to their professional requirements was their ability to adapt themselves to varied and changing situations. Their own attitude and tact determined the reception they got

from organic hospital staffs. Unless a spirit of cooperation existed on both

sides, casualties suffered. Fortunately, when the usefulness of these teams

was realized, cooperation was invariably excellent, and the original, quite natural, resentment over their assignment and assumption of responsibility quickly

disappeared.

General hospitals.—Over a 2y2-jear period in the Mediterranean theater,

three thoracic surgeons of the 2d Auxiliary Surgical Group (Major Burford.

Major Brewer, and Major Samson) supervised eight major thoracic services in

base section hospitals, five of which were at various times officially designated

as chest centers.3The personnel of such a service might be permanent or might

consist of a thoracic surgical team on temporary duty. The limited availability

of thoracic surgeons and the need for their services in forward hospitals made if

impossible to spare more than one team at a time to work in a general hospital,

whether or not it served as a thoracic surgery center.

Records

The maintenance of accurate individual case records was a requirement

for all teams. Enforcement of this policy made it possible for the 2d Auxiliary

Surgical Group to compile the statistical and clinical data that serve as a point

of departure for this history of thoracic surgery in World War II. Similar

3 Major Samson later supervised the thoracic surgery service for 2 months at the Oth Evacuation

Hospital in eastern France.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 109

basic data (3,154 abdominal injuries) form the background for the extensive

section on that subject in the second general surgery volume in this series (7).

Conclusions

The following comments were made in Februaiy 1945 by Colonel Forsee,

commanding officer of the 2d Auxiliary Surgical Group, which was the first

such group to function in World War II and which also had a longer experience

than any other surgical group. His conclusions concern the thoracic surgical

teams of the group, but for the most part, they are applicable to all teams :

1. The function of thoracic surgical teams, like that of all other surgical

teams, is to augment the staff of hospitals throughout a theater when the requirements for surgery exceed the capacity of the regular staff. Teams of the

2d Auxiliary Surgical Group functioned in installations as far forward as

divisional clearing stations, which was not an efficient mission, for these installations lack the facilities necessary for the proper care of first priority cases.

They also functioned as far to the rear as general hospitals in the communications zone. They functioned in all varieties of hospitals in the Fifth and

Seventh U.S. Armies and in the II Corps, in many hospitals in four different

base sections, in British casualty clearing stations, and in British general

hospitals. Teams of the group also supported the assault forces in amphibious

operations.

2. A team assigned to a hospital should become an integral part of the staff

during its temporary stay and should take its turn on the operating schedule

with the intrinsic surgical staff.

3. The chief of the team should be responsible for preoperative and postoperative care, determination of when to operate, and designation of patients

for evacuation when he considers them ready for transportation.

4. Teams should be relieved and returned to their own group headquarters

as soon as the flow of casualties has so decreased that the organic hospital staff

can care for them.

5. It is highly desirable that all teams function in as many types of hospitals as possible, so that they may be able to function efficiently on short notice

in any of them.

6. During inactive or quiet periods at the front, surgeons should be attached

individually to duty in base hospitals, to augment their experience.

7. The World War II policy of assigning to thoracic surgical teams the

responsibility for the professional service in a chest center in a fixed hospital has

proved highly successful. This plan permitted continuity of treatment of many

patients who had received their initial wound surgery from other surgeons of

the same auxiliary surgical group. A detailed followup of many problems of

traumatic thoracic surgery was thus possible and permitted significant advances

in this field.

8. The maintenance of accurate individual case records is a function of all

teams.
110 THORACIC SURGERY

DISPOSITION

Appraisal of the duty status of casualties recovered from chest woundss

gained in accuracy with accrued experience. Clinical evaluation and psychologic estimates proved more valuable criteria in this appraisal than laboratory

tests such as spirometry. Definite progress Avas made toward retaining more

men for duty in the theater as the war progressed. Early in the war, almost

every patient who underwent thoracotomy was evacuated to the United States,

as was almost every patient with empyema. Later, it was possible to return

significant numbers in both categories, especially the former, to duty in the

theater. Furthermore, a great many of the patients who were returned to the

Zone of Interior—some estimates were three of every four—were surgically

well when they reached the United States. The principal reason for returning

them was to evaluate their potential for military duty; this was necessary

because of lack of previous experience with fully recovered patients with such

severe injuries.

A large number of patients sent to the Zone of Interior were also evacuated

because of associated wounds and not because of their thoracic status. Thus in

870 thoracic injuries analyzed by Major Burford and Maj. Edward F. Parker,

MC, 370 of the patients were returned to the Zone of Interior, but only 86 (9.9

percent) of the number studied were evacuated because of their chest injuries

and disability resulting from them.

Beyond these generalities, it is difficult to go. It was impossible to obtain

adequate followup studies overseas. It is thought that perhaps from 10 to 15

percent of all patients with thoracic injuries could be kept on duty in the theater

following hospitalization, but how many were later admitted to other hospitals

because of symptoms and disability and how many of these were sent to the

Zone of Interior remains unknown. It is unfortunate that prolonged observation was not possible during the war on a sufficiently large group of patients to

warrant conclusions concerning the sequelae of intrathoracic wounds. It was

these sequelae, actual or potential, which influenced ultimate disposition.

There were not many deaths in general hospitals and chest centers. Those

which occurred were chiefly due to the complications for which the patients

were under treatment.

The figures reported by Maj. (later Lt. Col.) William M. Tuttle, MC, and

his associates from the thoracic surgery service at the With General Hospital,

showed 2 deaths in 320 cases. Of the surviving 318 patients, 20 percent were

returned to full duty and ?>?> percent to limited duty in the theater. The remainder were evacuated to the Zone of Interior. These statistics are typical of

immediate results at other general hospitals and chest centers. That all of the

soldiers who were returned to full or limited duty were able to maintain a duty

status is in the highest degree doubtful.
ADMINISTRATIVE CONSIDERATIONS IN MEDITERRANEAN THEATER 111

References

1. Beebe, Gilbert W., and DeBakey, Michael E.: Battle Casualties: Incidence, Mortality, and Logistic Considerations. Springfield: Charles C Thomas, 1052.

2. Snyder, Howard E.: Fifth U.S. Army. In Medical Department, United States

Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington : U.S. Government Printing Office, 19G2, pp. 333^164.

3. Kendriek, Douglas B., Jr.: The Blood Program. In Medical Department, United

States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I.

Washington : U.S. Government Printing Office, 1962, pp. 121-163.

4. Medical Memorandum No. 3, Office of the Surgeon, Headquarters, Eastern Base Section, 7 July 1943, subject: Surgical Policies for Bizerte-Ferryville-Mateur Area of EBS,

Effective July 1943.

5. Eorsee, J. H., Shefts, L. M., Burbank, B., Eitzpatrick, L. J., and Burford, T. H. :

The Management of Thoracic War Injuries. J. Lab. & Clin. Med. 28: 418-440, January

1943.

0. Carter. B. N., and DeBakey, M. E.: Current Observations on War Wounds of the

Chest. J. Thoracic Surg. 13 : 271-293, August 1944.

7. Medical Department, United States Army. Surgery in World War II. General

Surgerv. Volume II. Washington: U.S. Government Printing Office, 1955.
CHAPTER IV

Administrative and Basic Clinical Considerations

in the European Theater of Operations

Dwight E. Harken, M.D.

Section I. Administrative Considerations

THE CONSULTANT SYSTEM

General Functions of Consultants

In the summer of 1942, a Professional Services Division was set up in the

Office of the Chief Surgeon, Headquarters, ETOUSA (European Theater of

Operations, U.S. Army), composed of senior consultants in most of the major

medical and surgical specialties.3It is probably indicative of the still uncertain

status of thoracic surgery at this time that a theater consultant in this specialty

was not included in the list, although a consultant was appointed for such a

specialty as plastic surgery, for instance, which was concerned with injuries

that were far less potentially lethal.

After their appointment, these consultants originated all policies pertaining to specialized care and settled all problems referred to them concerning

their specialties. Administratively, the activities of the senior consultants were

limited to hospitals in the communications zone and the advanced section zone.

Practically, their services were also fully utilized by surgeons of the armies.

As a result, during the active campaign, there were seldom any difficulties in

coordinating the professional services of hospitals in the rear and in the forward

echelons.

In May 1943, 36 regional consultants were appointed in general surgery

and the various specialties, and a number of additional medical officers were

appointed to this position before a regional consultant in thoracic surgery was

appointed in May 1944. In February 1944, base section consultants were appointed in general surgery and in medicine. Still later, regional consultants

1

This has been a difficult chapter to prepare. There "was no official consultant in thoracic surgery in the European theater. Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in

Surgery, ETOUSA, handled thoracic surgery himself during the organizational period, and his death

soon after the war ended has made it impossible to supply numerous important details. We are

grateful to Dr. (formerly Lt. Col.) Dwight E. Harken, who served as unofficial theater consultant,

and later as regional consultant, in this specialty for collaborating in the preparation of this chapter

and for supplying a large portion of the material for it.—F. B. B.

113

cr.fiosD
114 THORACIC SURGERY

in the various specialties were appointed on the Continent, though thoracic

surgery was not included in the list,

Regional consultants who were appointed to centers for specialized care in

appropriate hospital centers retained their own services in the hospitals to which

they were attached. Tables of organization did not provide for these regional

consultants, but by D-day, and in a number of instances long before, general

hospitals had thoracic surgery sections. Difficulties arose in connection with

rank. In the table of organization, i& the chief of the thoracic surcery section

was a major. The problem was, when he served as regional consultant in his

specialty, to make him a lieutenant colonel -without taking the rank away from

the head of some other section. Eventually, this was worked out, and when it

was, it was routine for regional consultants to have the rank of lieutenant

colonel.

The smoothness of operation and the brilliant success of the entire senior

consultant and regional consultant system made it even more unfortunate that

a consultant in thoracic surgery was not appointed when the system was set

up in the Ollice of the Chief Surgeon, Headquarters, ETOUSA, and that none

was appointed during the war.

Consultant Activities in Thoracic Surgery

During World War II, the responsibility for thoracic surgery, at least

nominally, rested with Col. (later Brig. Gen.') Elliott C. Cutler, MC, Chief

Consultant in Surgery to the Chief Surgeon, ETOUSA, Brig. Gen. (later

Maj. Gen.) Paul E, Hawley. Colonel Cutler had always had a great interest

in chest surgery though he was not a thoracic surgeon at heart in the modern

sense of the term. In fact, when the Professional Services Division was first

set up in General Hawley's Office, Colonel Cutler was convinced that thoracic

surgery was not a true surgical specialty.

As time passed, his idea of supervising thoracic surgery himself seemed

less practical. His associations with British surgeons who had had a wide

experience in it, and his own observations on these injuries, gradually modified

his point of view, and, by the end of the war, both he and General Hawley were

prepared to accept thoracic surgery as an important surgical specialty.

In December 1943, in a comment in his official diary on his recent visit to

Italy, Colonel Cutler listed the admirable management of thoracic and thoracoabdominal wounds that he had observed in the hospitals of the North African

(later Mediterranean) theater as the chief surgical advance in the theater. He

noted several points of importance: the fact that the chest wall rather than the

lung was the most frequent source of hemorrhage in thoracic wounds; the consequent emphasis on adequate debridement of the parietal wound, with effective hemostasis; the minimal need for pulmonary surgery; the prevention of

empyema by early, repeated thoracentesis; the importance of roentgenologic

control in all thoracic injuries; and the frequency and seriousness of thoracoabdominal injuries.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 115

On 24 January 1944, Colonel Cutler wrote to Col. James C. Kimbrough,

MC, Chief, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, that for some time he had been having considerable difficulty in his assumption of personal responsibility for the proper care of

thoracic surgery in the theater. He had done a great deal of the supervisory

work himself, particularly in the training of medical officers in this specialty;

the training was necessary because very few surgeons had come to the theater

qualified to do chest surgery. The caseload had now become so large that it

demanded the attention of a properly qualified consultant who could assist him

in controlling the work and in standardizing procedures and routines. The

work, of course, could be expected to become very much heavier after the invasion of the Continent.

Colonel Cutler did not ask that the consultant whom he was requesting be

on the table of organization at the theater chief surgeon's headquarters. In

fact, he believed that it would be more efficient for him to carry on his work

from a general hospital.

Colonel Cutler's recommendation for consultant in thoracic surgery was

Maj. H. Brodie Stephens, MC, who was then attached to the 30th General

Hospital, near Mansfield, Nottinghamshire. He regarded Major Stephens as

fully qualified for the position, and he believed that his seniority and other

qualifications would make him generally acceptable to other surgeons who would

work under him.

On 4 February, Colonel Cutler wrote to Major Stephens to tell him that

he had made the official request that he be appointed senior consultant in

thoracic surgery in the European theater but that General Hawley did not wish

to make any more official appointments in the consultant group. He was quite

willing, however, that Colonel Cutler should use Major Stephens unofficially.

In the meantime, Capt, (later Lt. Col.) Dwight E. Harken, MC, had arrived in the theater, in the fall of 1943, with the 1st Auxiliary Surgical Group.

His interest in thoracic surgery, plus the fact that he had done work with the

British group of thoracic surgeons and had served as resident under Mr. A.

Tudor Edwards, F.B.C.S. (fig. 11), at the Brompton Hospital in London, admirably fitted him to act as liaison officer with the British and as Colonel Cutler's

representative in thoracic surgery. In particular, he did the active work in

the courses on thoracic surgery given in British hospitals under Mr. Tudor

Edwards' supervision. In May 1944, when the 160th General Hospital was

established as a thoracic surgery center in the 15th Hospital Center, Cirencester, Gloucestershire, Major Harken was appointed chief of the thoracic surgery section and regional consultant in thoracic surgery. Also, although he

was never officially appointed to the position, he served as theater consultant in

thoracic surgery under Colonel Cutler.

In fulfillment of his consultant functions, Captain Harken:

1. Did the active teaching in the courses in thoracic surgery for selected

U.S. medical officers at British hospitals (p. 120).
116 THORACIC SURGERY

FIGUEE 11.—Mr. A. Tudor Edwards, 1941-45. civilian consultant in thoracic surgery

for the British Emergency Medical Service, British Army, and Royal Air Corps; Surgeonin-Charge, Department of Thoracic Surgery, London Hospital; Surgeon, Brompton Hospital

for Diseases of the Chest; Consultant Advisor to Minister of Health for Chest Casualties;

and Consulting Surgeon, King Edward VII Sanatorium, Midhurst.

2. Reviewed the experience of the principal British thoracic centers in

their care of chest injuries from a vast number of air-raid casualties. The surgical policies and practices set up for U.S. Army thoracic surgeons were derived

from the aggregate of the British experience,

3. Wrote a huge part of the original draft of the thoracic surgery section

in the "Manual of Therapy, European Theater of Operations" (p. 141).

-4. Wrote the original draft, of the standing operating procedure that governed policies in thoracic surgery in the European theater after D-day (p. 138).

5. Briefed all U.S. hospitals in the United Kingdom before D-day on the

management of chest injuries.

When Colonel Cutler wrote to Major Stephens to tell him that he had been

unable to secure General Hawley's permission for his appointment as consultant in thoracic surgery but had his permission to use him unofficially, he

explained Captain Ilarken's activities and said that, under these new circum-
ADMINISTRATIVE CONSIDERATIONS IN EUROrEAN THEATER llf

stances, they would be improper without Major Stephens' sanction. He therefore directed Major Stephens to get in touch with Captain Harken, so that

together they could set up general principles and policies in the held of thoracic

surgery. On 9 March, Major Stephens wrote Colonel Cutler that Captain

Harken had visited the 30th General Hospital the preceding week, where he

had made an excellent talk on thoracic injuries. Captain Harken had also

provided him with slides for use in the talk he himself was scheduled to make

on the same subject at the Eastern Base Section meeting on 24 March.

Major Stephens expressed himself as anxious to have a conference with

Colonel Cutler, to obtain his general views on thoracic surgery, so that he

could incorporate them in this talk and in other instructions. So far as is

known, nothing further came of Major Stephens' proposed activities as

consultant.

Recommendations for the U.S. Army of Occupation

From time to time after the war ended, Colonel Cutler, in response to

requests from the theater chief surgeon's office, made recommendations for the

organization of professional services in the U.S. Army of Occupation. A system of hospital centers was planned for the administration of the farflung

network of hospitals that would be required for the occupation forces. The

prevailing system of regional consultants was to be continued; that is, qualified medical officers were to be appointed to serve in this role for their own

hospitals and the surrounding hospitals. The system developed in the European theater of appointing medical officers as surgical coordinators, to coordinate all surgical activities within the various hospital centers, was also to be

continued.

All of these concepts were agreed to in principle. The consultant system

put into effect in. July 1945 did not, however, include a consultant in thoracic

surgery in the Paris hospitals, for which consultants in other specialties were

appointed at once. Nor was a consultant in thoracic surgery appointed in the

Office of the Chief Surgeon, Communications Zone, Headquarters, ETOUSA,

which was to move later to Headquarters, USFET (U.S. Forces, European

Theater) in Frankfurt. In other words, in spite of the importance of this

specialty, no theater consultant in thoracic surgery ever served officially in the

European theater in World War II.

PERSONNEL

Thoracic Surgery

The number of trained thoracic surgeons in the European theater was

always small. In September 1943, there were only 12 surgeons in the United

Kingdom Base considered capable of handling thoracic surgery in a general

hospital and only 8 considered capable of handling it in a station hospital.
118 THORACIC SCKGERY

These shortages had to be made up in the best fashion possible. which was

to assign the small number of qualified and experienced surgeons to head chest

centers and thoracic surgery sections. The shortages could not be overcome

by the use of surgeons who had had 3 or 4 months' training in thoracic surgery

after they had entered the Army. These officers proved extremely useful on

thoracic surgery services, but they were not qualified to assume full responsibilities for them.

The situation was made more difficult than it should have been by administrative obstacles. By October 1944, it had been realized that special hospitals for thoracic surgery and other specialties would be necessary. There

was still, however, no provision for a single thoracic (or plastic) surgeon in

any medical installation in the communications zone. Constant difficulty was

therefore encountered in fitting thoracic surgeons into the inflexible tables of

organization for general and station hospitals and in providing the additional

assistance necessary to run a thoracic service efficiently. It was just as important that thoracic sections operate efficiently as it was that neurosurgical services should, yet neurosurgeons were provided for in tables of organization for

general and station hospitals long before either thoracic or plastic surgeons

were provided.

Because of table-of-organization difficulties, it was frequently necessary to

assign thoracic surgeons to such positions as chief of the surgical' service, chief

of aseptic surgery, or even ward officer. These were not satisfactory circumventions, and they had the added disadvantage that, once such an assignment

was made, it was very difficult to change it. Colonel Cutler commented in his

official diary that emergency changes of assignment could sometimes be handled

quickly, but that routine changes often occupied weeks and were sometimes

not accomplished at all.

In the meantime, the list of thoracic surgeons in the theater was sent to

Colonel Cutler by Captain Harken, and he sent the names, in turn, to Colonel

Kimbrough and General Hawley for action. Personnel difficulties continued

until the end of the war, but in October 1944, after a round of visits of inspection to hospitals in the United Kingdom Base, Colonel Cutler expressed the

opinion that this section had four "superlatively good" thoracic surgeons: Lt.

Col. (later Col.) Laurence Miscall, MC, at the 137th General Hospital, located

near Ellesmere, Shropshire; Lt. Col. George N. J. Sommers, Jr., MC, at the

140th General Hospital, near Blandford Forum, Dorsetshire; Lt. Col. (later

Col.) Arthur S. W. Touroff, MC, at the 155th General Hospital, Malvern

"Wells; and Major Harken at the 160th General Hospital. In Colonel Cutler's

opinion, this base section was now adequately covered from the point of view

of thoracic surgery, in which he said that more advances had been made

during the war than in any other surgical specialty.

It was the general opinion that, in the future, the personnel of a thoracic

section should be made up of a team composed of a lieutenant colonel as chief

of section ; a captain as anesthesiologist; two captains to serve as surgical assistants and also as ward officers; three surgical nurses, one of whom would be a
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 119

first lieutenant; and three surgical technicians, grade 4. These groups should

either be sent overseas from the Zone of Interior as table-of-organization

cellular units or should be assigned by the Professional Services Division,

Office of The Surgeon General. Obviously, personnel for such groups must be

selected with great care.

Anesthesia

Anesthesia for chest surgery was never a problem in the European theater.

Expert anesthesiologists were available all the way from field hospitals near

the frontlines to general hospitals in the base area. They had at their disposal

a wide variety of anesthetic agents and could use intravenous, inhalation, or

regional techniques according to the requirements of the individual patient.

When differential pressure was needed for intratlioracic surgery, endotracheal

anesthesia was always used, with safety for the patient and satisfaction for the

surgeon.

At a meeting of the theater consultants in December 1914, Lt. Col. (later

Col.) Ralph M. Tovell, MC, presented an analysis which he had prepared for

the theater chief surgeon on the use, according to medical echelon, of inhalation, regional, and local anesthesia. At the conclusion of the presentation,

General Hawley paid tribute to the quality of the work done by anesthesiologists in the theater, under Colonel Tovelhs supervision. "The fine surgical

results that have been gained in this theater," he said, "are in no small way the

responsibility of Colonel Tovell for the fine service that he has brought here,"

In a conference with Third U.S. Army surgeons, also in December 1944,

Colonel Cutler noted in his official diary that he found very gratifying the

remarks made by Col. Joseph A. Crisler, Jr., MC, Consultant in Surgery, First

U.S. Army, that "one of the greatest boons to surgeons in medical facilities of

the field army were the anesthetists supplied by Colonel Tovell * * *. This

may be taken as almost a personal triumph for Colonel Tovell, who has worked

indefatigably in his special field and now is reaping a rich and well-deserved

harvest."

TRAINING

Training in British Hospitals

Late in 1942, Mr. Tudor Edwards, who was then serving as civilian consultant in thoracic surgery for the British Emergency Medical Service (p. 115)

o-ave a course in thoracic surgery, which consisted of lectures and demonstrations in a number of hospitals, for U.S. Army medical officers. It was a most

valuable introduction to combat surgery.

When Mr. Tudor Edwards was asked to repeat the course in 1943, he felt

obliged to decline. This Avas entirely reasonable, for his own work as consultant for the Emergency Medical Service, as well as for the British Army

and the Royal Air Corps, constituted an incredible burden for a man who had

already had several coronary thromboses.
120 THORACIC SURGERY

Mr. Tudor Edwards' course had been so valuable, however, that Colonel

Cutler could not accept his refusal as final. He therefore suggested to him

that he might find it possible to lend his name and general supervision to the

course if U.S. Army medical officers carried the bulk of the burden. Mr. Tudor

Edwards replied that this was not practical: American medical officers, he said,

would not be permitted to move freely about British hospitals, nor did they

know the British hospitals and British ways well enough to make the proposed

arrangement workable. In his opinion, friction would be inevitable.

As an afterthought, Mr. Tudor Edwards asked Colonel Cutler what American officer he had had in mind to supervise the courses. Colonel Cutler replied

that he was considering Captain Harken. Mr. Tudor Edwards said that this

appointment would be entirely acceptable to him, and he then withdrew all of

his objections to the courses in British hospitals, but, he said, "Harken is not

your man, he's mine. He was my resident at the Brompton Hospital before

the war, and he knows us well enough to do the job."

Circular Letter No. 174-, issued on 28 November 1948 (1), called attention in

paragraph 4g to the 2-week courses in thoracic surgery to be conducted at

several British thoracic surgery centers in the London area under Mr. Tudor

Edwards. It was intended for thoracic surgeons or for medical officers with

some previous training in thoracic surgery.

There were seven of these 2-week sessions. Each consisted of lectures and

demonstrations by the most eminent thoracic surgeons in England. Between

8 and 10 U.S. medical officers participated actively in each course, and visitors

who attended the sessions but did not actively participate brought the number

in each course to about 15. Major Harken served as director and coordinator

of all of the courses. The slides used in the lectures and demonstrations represented probably the most complete collection of roentgenograms of chest trauma

ever collected.

The formal courses just described had three objects:

1. To permit the officers in attendance to learn as much as possible about

the thoracic surgery of combat-incurred wounds, including both principles and

practices.

2. To give medical officers interested in thoracic surgery an opportunity to

become acquainted with the best British chest surgeons and internists. This

was an unparalleled opportunity, for all of these British physicians and surgeons were highly skilled men, with broad visions and horizons.

3. To provide useful occupation for men bored to death with inactivity in

tents and nissen huts and physically uncomfortable in the frightful British

winter weather. These courses provided a brief respite for them in warm, dry,

metropolitan surroundings and a little exposure to the more pleasant life in

London.

In addition to the formal courses just described, selected Medical Corps

officers were able to observe the work of British chest surgeons in chest centers

in the areas in which their units were stationed.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 121

Other Training

In addition to the specialized training- in British hospitals just described,

the following training was given to medical units in the United Kingdom Base:

1. Medical Corps officers who went to North Africa in November 1942

received special, instruction at Tidworth Barracks, 16-18 September. Colonel

Cutler's lectures on surgical subjects included the management of sucking

wounds and other thoracic injuries.

2. The Medical Field Service School was established at Shrivenham Barracks, Swindon, England, by Circular No. 22, on 23 February 1943 {2). The

first courses were given on 8 March 1943, with Capt, (later Lt. Col.) Bernard

J. Pisani, MC, as director. There were some initial difficulties, including the

appointment of instructors without consultation with, and approval by, the

Professional Services Division, Office of the Chief Surgeon, Headquarters,

ETOUSA. In a short time, however, this school became a highly efficient functional unit. The lectures and conferences on problems in combat surgery and

acute medical and neuropsychiatric conditions did not include special instruction in thoracic surgery, though chest wounds, of course, were discussed in the

surgical lectures.

3. All medical units which reached the United Kingdom before D-day received a minimum of 3 hours of lectures on thoracic injuries. The content of

these briefings, most of which were given by Captain Harken, was decided upon

in a conference with Colonel Cutler on 27 October 1943. The policies and

practices recommended were based on the experience in the North African

theater to date and on an analysis of 300 British air-raid casualties in the

London area. All medical and surgical problems that conceivably might arise

in chest injuries were thoroughly discussed.

4. Professional training of officer personnel also included lectures by both

military and civilian authorities whenever units were so situated that this was

practical. These lectures were supplemented by weekly grand teaching rounds,

at which problems of disposition as well as medical care were discussed.

5. Nurses received continuous training in compliance with section II,

Training Memorandum No. 3, issued on 15 February 1943 (-5). Thoracic

surgery and penicillin therapy were covered in the training.

6. The availability of basic and current medical literature formed an important background for practical training, and Colonel Cutler therefore maintained a constant interest in hospital libraries. Originally, the medical texts

and journals sent from the Zone of Interior had simply been held in supply

depots and not distributed. He ended this situation promptly and also ended

the foolish mutilation of U.S. medical journals by censors in the Zone of Interior before they were shipped to England.

Anesthesia

After some initial resistance to all formal training overseas, special courses

in anesthesia were given in a number of hospitals to medical officers, with spe-
122 THORACIC' SURGERY

cial emphasis on endotracheal anesthesia and positive pressure techniques for

thoracic surgery.

Special courses for nurses were also given in some hospitals. As soon as

the lGOth General Hospital arrived in England in April 1944, daily lectures

on anesthesia were given to 12 nurses, all volunteers for the course. Four were

selected for further specialized training. This course was concluded on 3 June

1944, and on 12 June, the hospital received its first battle casualties.

In March 1944, a 3-month course of instruction in the fundamentals of

general anesthesia was given at the 15th General Hospital, Ellesmere, Shropshire, to two medical officers and four nurses. It consisted of didactic lectures, demonstrations, and practical training. A small group of technicians

were also trained in anesthesia and used as a reserve when casualties were

heavy.

In the spring of 1944, two courses in anesthesia, each lasting a month, were

given to four officers and seven nurses from the 12th Field Hospital and the

122d, 123d, 124th, and 134th Evacuation Hospitals. Mimeographed outlines,

training films, and practical instruction were employed. The practical instruction included intravenous, inhalation, and endotracheal techniques.

By special arrangement with the Office of the Chief Surgeon, Headquarters, ETOUSA, a 4-day course in anesthesia, for medical officers and nurses

was conducted at the 10th Station Hospital in the Manchester area. This

course was designed to precede a 30-clay period of temporary duty in this

specialty at station and general hospitals.

DISSEMINATION OF INFORMATION

Medicomilitary medicine requires a degree of uniformity in both policies

and practices that is not necessary in civilian practice (p. 187). Without such

uniformity, with so many medical officers of such varied training and experience working in medical installations in many different military echelons,

chaos could have resulted.

In the European theater, uniformity in thoracic surgical practices was

more difficult to achieve, in the absence of a theater consultant in this specialty,

than it might have been otherwise. It was accomplished in the followinc way's :

1. Approved procedures in all types of wounds, based on the results of

research, civilian experience, and experience in the Mediterranean theater,

were set forth in circular letters and other directives issued by the Office of the

Chief Surgeon, Headquarters, ETOUSA. These letters were later altered

as necessary in the light of the post-D-day experience in the European theater.

2. A medical bulletin, containing similar material, was issued monthly.

3. Shortly before D-day, a manual of therapy was published and distributed to every medical officer in the theater (p. 141). This manual outlined

official procedures in combat-incurred wounds in forward installations. The

manual was authoritative, since it had been compiled by the senior consultants
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 123

in surgery and the surgical specialties in the Office of the Chief Surgeon,

Headquarters, ETOUSA. Later, it was modified and supplemented as necessary in the light of combat experience in the theater. The material on thoracic

injuries was a somewhat oversimplified outline of material prepared by Major

Harken.

4. The senior consultant group in the Office of the Chief Surgeon, Headquarters, ETOUSA, met frequently with the regional consultants in the specialties and also with their British, French, and other colleagues to discuss

their joint experiences. From the overall picture, they were able to evaluate

the results of treatment and suggest improvements in methods. These improvements were incorporated in circular letters, which were so widely distributed that all medical officers in the theater could keep in touch with the

latest and best techniques of military practice. The letters, Colonel Cutler

noted in his official diary, make up a story which might well be entitled "Surgery in the European Theater in World War II."

A great deal of information on thoracic surgery was disseminated b_v

Colonel Cutler himself as he moved about the theater. Pie made it his business

to keep himself informed on thoracic surgery by frequent conferences and

conversations with the chest surgeons in the hospitals he visited. He was an

inspiring man and was able to get the best out of all who worked with him.

The information thus secured he synthesized into useful policies. He was not,

as already mentioned, a chest surgeon in the modern sense of the term, but

he was a vastly experienced general surgeon, with good common sense, who

was Milling to ask for advice and to take it. After he himself had had what

seemed to him a good idea, he would often write to the thoracic surgeons in

the theater and ask for their comments before issuing it as a directive. He

leaned heavily for advice on Mr. Tudor Edwards, whom he always referred

to as "the great man."

These policies of Colonel Cutler's proved particularly useful after Dday. He made it his business to gather professional comment from the surgical specialists who had cared for the casualties in the first clays of the invasion

of the Continent, and this information, based on combat experience, often under fire, was incorporated in Circular Letter No. 101 issued from the Office

of the Chief Surgeon on 30 July 1944 (4).

5. In addition to the informal conferences just described, a number of

formal professional meetings were held.

Circular Letters

Circular letters issued from the Office of the Chief Surgeon contained

the following information pertinent to chest wounds :

1. Circular Letter No. 71, 15 May 1944 (o), concerned the general management of battle casualties. Casualties with chest wounds who were to be

considered nontransportable and cared for in field hospitals were listed as
124 THORACIC SURGERY

those with thoracoabclominal wounds, thoracic wounds that were serious either

because they were large and sucking or because they were associated with intrathoracic hemorrhage, and thoracic wounds of any type associated with

shock that did not respond to appropriate therapy. The difficulty of diagnosing thoracoabclominal wounds was noted, and medical officers were reminded

that a missile that entered via the buttocks might lodge in the thorax, while

a missile that entered by way of the shoulder might produce a thoracoabclominal wound. Eoentgenologic examination would clarify the situation, but

if facilities for it were not available, the medical officer must be certain to

examine the body cavity opposite from the point of wounding.

Many of the general directions in this circular letter were applicable

to chest wounds as to all other wounds. Thus it was pointed out that infection

arising from contamination caused by repeated inspections and changes of

dressing might delay or prevent delayed primary wound closure after the

casualty had arrived at a third echelon unit. It was also noted that one of

the best safeguards a patient could have was an adequate and legible record,

which would make it possible for a receiving officer farther to the rear to

refer to the record rather than look at the wound.

2. Circular Letter No. 80, issued on 10 June 194-4 (G), also included a

general discussion of battle casualties. It mentioned hospitals for the care

of special types of wounds, including thoracic surgery, and recommended that

in these hospitals separate sections be maintained for each specialty and that

the heads of these sections be used as regional consultants.

8. Circular Letter No. 101, issued on 30 July 1944 (4), supplemented the

"Manual of Therapy, European Theater of Operations," issued on 5 May 1944

(?'), and the circular letters already issued. Its contents, as already mentioned, were based on the experience acquired during the first 5 weeks of active

operation after D-day.

4. Circular Letter No. 23, issued on 17 March 1945 (8), contained a section devoted to thoracic wounds, including resuscitation, sucking wounds,

hemothorax, empyema, intercostal nerve block, thoracotomy, and thoracoabclominal wounds.

Professional Meetings

Inter-Allied Conferences on War Medicine.—On 27 October 1942 Colonel Cutler met, for the first time, at the Eoyal Society of Medicine, with representatives of the medical services of all the Allied countries to plan what

came to be the Inter-Allied Conferences on War Medicine. The first monthly

meeting was held on 7 December 1942. The presentations made at these meetings were published at the end of the war (9) ; there was a continuous improvement in them as the war progressed.

The subject of thoracic surgery occupied many of the meetings. In

November 1943, the conference met with Captain Harken, then with the 1st

Auxiliary Surgical Group. At the conference held in January 1945, Mr. Tudor
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 125

Edwards, in his role of honorary consulting thoracic surgeon to the British

Army, presented an extensive discussion of thoracic surgery in the field and at

the base, with particular attention to surgery at the base. His remarks were

based on 1,683 thoracic casualties admitted to chest centers in the United Kingdom between D-day and 30 September 1944.

At the same meeting Mr. T. Holmes Sellors, Regional Adviser in Thoracic

Surgery. British Emergency Medical Service, also discussed chest surgery at the

base. Lt. Col. Charles S. Welch, MC, presented an analysis of 380 thoracic

injuries observed during the first G months of fighting on the Continent.

Army Medical Society, European Theater of Operations.—On 14 May

1943, the organizational meeting of the Army Medical Society, ETOUSA, was

held with Maj. (later Col.) Robert M. Zollinger, MC, in charge. The first

formal meeting was held on 23 June 1943, at the 298th General Hospital, Bristol. Monthly meetings were held thereafter at different hospitals until the

pressure of combat activities brought an end to them in August 1944.

Other professional meetings.—On 14 and 15 April 1943. Colonel Cutler

attended the meeting of the Association of Thoracic Surgeons of Great Britain

and Ireland, of which Mr. Tudor Edwards was president.

The first discussion at the Inter-Allied Consultants Conference in Brussels

on 10 October 1944 concerned chest injuries. Maj. J. Leigh Collis, RAMC,

stated that infection was of major importance in them. This observation came

as a surprise to Colonel Cutler, since Major Harken had recently reported to

him from the 160th General Hospital thoracic surgery center that empyema

was not a major problem in these injuries. Col. G. A. G. Mitchell, RAMC,

who opened the discussion on penicillin, stated that the British considered that

a satisfactory bacteriostatic level could be maintained by the intramuscular

injection of 100,000 units in physiologic salt solution each 24 hours. Major

Collis thought penicillin of little value unless it was instilled in the pleura!

space.

At the third Anglo-American Consultants Conference held in Paris on

25-26 May 4945, the vigorous discussions conducted on thoracic surgery included anesthesia for chest operations. There was active participation by both

British and U.S. medical officers.

Colonel Cutler seized the opportunity offered by the Trench Foot Conference held in Paris in January 1945 to work over the current circular letters

dealing with the treatment of battle casualties. Chest surgery was extensively

discussed.

The information gained at all of these meetings was transmitted by Colonel

Cutler and other consultants to all medical officers in the theater by the various

channels already described.

The experience of Major Harken and his associates at the 160th General

Hospitalthoracic surgery center was presented to the Royal Society of Medicine

and the Royal College of Surgeons in January and April 1945, respectively.
126 THORACIC STKGERY

SUPPLY AND EQUIPMENT

Early Deficiencies

Hospitals which reached the United Kingdom jn 1942 and some of those

which supported the North African invasion "in November of that year were

poorly equipped from the standpoint of thoracic surgery (p. 84). The chest

surgeons, in fact, looked with envy upon the ample equipment of excellent

quality possessed by their British counterparts.

"When Colonel Cutler inspected the thoracic surgery equipment in November 1942, he described it as completely outmoded and of "20-years-past" vintage.

He thought most of what was on hand was close to useless. The medical chests

to be used under battle conditions were totally inadequate. So were the instrument kits. There were no morphine syrettes for forward work. There was

no sulfonamide powder for wounds (at this time, local chemotherapy was still

advocated). There was no provision for local or intravenous anesthesia. The

necessary needles and silkworm gut sutures for emergency closure of sucking

chest wounds were not on hand, though this was a simple, I'ifesaving procedure',

which almost anyone could carry out.

It was possible to supply most of these deficiencies from British sources,

and Colonel Cutler took immediate steps to see that this was done. Meantime'

when equipment was in short supply or totally lacking, ingenious improvisations were employed.

As in the Mediterranean theater, X-ray films were in somewhat limited

supply in 1942 and early 1943, and some restrictions upon their use were

necessary.

Later Provision

By the time of the invasion of the Continent, all of these initial shortages

and deficiences had long since been overcome. All equipment was now in full

supply and of the best quality. Temporary shortages, of course, still occasionally occurred, chiefly because of transportation difficulties. This usually

happened when fighting was intense and the situation critical, as in the area

of the Battle of the Bulge.

Xonstandard equipment was procurable as necessary, but not all that was

requested was supplied because not all of what was requested was considered

necessary. As in the Mediterranean theater, chest surgeons, like all other

medical officers fresh from civilian life, soon learned to do excellent surgery

with no more than the generally excellent equipment provided in tables of

equipment.

The following experience indicates how rapidly special equipment that was

really needed could be supplied: On 22 March 1944, Major Harken wrote

Colonel Cutler that the U.S. experience to date, as well as the British combat

experience, had proved conclusively that the essential treatment of hemothorax
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 127

was complete and early aspiration; and that the mortality, morbidity, possible

deformity, and future pulmonary function were all favorably influenced when

this technique was used. At this time, the proper equipment for its employment was not available to U.S. medical officers in the United Kingdom.

Major Harken therefore requested that immediate steps be taken to provide

all medical units with standard record syringes equipped with 2-way stopcocks

and 15-gage aspirating needles. There was no acceptable substitute for this

item. In view of the importance of the correct treatment of hemothorax,

Major Harken suggested that a sufficiently large order be placed to permit

automatic distribution of four of these syringes to each hospital in the theater.

The clay this request was received, Colonel Cutler forwarded it, with his

approval to the Supply Division, Office of the Chief Surgeon, Headquarters,

ETOUSA. He not only recommended that the syringes, in the quantity requested, be distributed to all hospitals in the European theater, both Army and

SOS (Services of Supply), but also recommended that they be added to the

tables of equipment of all hospitals arriving in the theater. The recommendation was promptly implemented.

Some equipment was considerably improved as time passed. Thus the

mounting of the field type of anesthetic machine upon a wheeled cart that also

carried the large gas tanks resulted in both increased mobility of the apparatus

and increased economy of operation.

Auxiliary Surgical Group Teams

Equipment for auxiliary surgical group thoracic surgical teams was always

excellent. Some teams in the European theater carried accessory surgical

equipment in special surgical trucks or personnel carriers, but most teams had

only a single basic instrument set, which was adequate for two major thoracic

procedures, and an anesthetic machine.

It was the general policy to pool the tentage and transportation for all

teams, to assure economy in their use. Personal equipment for the medical

officers on the teams consisted of standard Army field equipment, including

a sleeping bag and an air mattress.

Thoracic Surgery Centers

Thoracic surgery centers often required specialized equipment, If it

was available from Army medical depots or from British sources, usually

civilian sources, it was supplied at once. The officer with ingenuity and aggressiveness was always able to get it if it existed in the European theater.

When the equipment had to be brought into the theater from the Zone of

Interior, supply lines were remarkably efficient.
128 THORACIC SURGERY

The basic equipment of chest centers was both excellent and abundant.

It was recognized that the chest surgeons working in them were performing

special procedures, some of which, such as decortication, were new operations. Every attempt, therefore, was made to supply such nonstandard equipment as these chest surgeons needed for their purposes.

Supplies of Penicillin and Blood

The first shipment of penicillin to the United Kingdom, consisting of

180 boxes, was received in the theater on 5 May 1943. Each box contained

10 ampules, and each ampule contained 10,000 Florey units. This first shipment thus consisted of 18,000,000 units. The initial use of penicillin was necessarily restricted, but long before the invasion of the Continent, full supplies

were available, and antibiotic therapy was possible whenever it was indicated.

The story of the supply of blood for the invasion of the Continent

and the later supply of this agent is told in full in the volume in this series

of histories that deals with the blood program in World War II (10). After

the first shortages on the Continent after D-day, when, for a time, blood had

to be rationed and used only for casualties whose need for it was critical,

it was in ample supply because of the daily airlift from the Zone of Interior.

When possible, however, especially for casualties who required multiple transfusions, thoracic surgeons preferred to use blood from the blood bank in

the United Kingdom. This was because blood flown from the United States

was preserved in Alsevers solution and the excess of fluid was undesirable

in casualties with chest injuries. They were highly susceptible to pulmonary

edema, and the policy was to limit replacement therapy to as small quantities

of fluid (electrolytes) as were adequate (p. 253).

THORACIC SURGICAL TEAMS

The concept of the specialty surgical team was in Colonel Cutler's mind

as early as the invasion of North Africa. On 6 January 1943, he recommended

to the theater chief surgeon that surgical teams in various specialties, including

thoracic surgery, should be appointed to serve in forward elements of the

division, in order to make observations on special types of wounds from the

battlefield to the evacuation hospital. The investigation of even 50 cases

of each type of wound, he thought, would open a new outlook on their management and prognosis. If such teams were appointed, he wrote General Ilawley,

Col. Johan C. Hoist, consultant in surgery to the Norwegian Forces in the

United Kingdom, who was an experienced thoracic surgeon, had expressed

the desire to accompany the thoracic surgical group.

A number of special studies of chest injuries were made in the European

theater but none under the precise circumstances envisaged by Colonel Cutler.

His concept of surgical teams in the various specialties was implemented in

the teams of the auxiliary surgical groups that had just been organized.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 129

Auxiliary Surgical Groups

There is general agreement that the reason that thoracic and thoracoabdominal injuries carried a much lower mortality in "World War II than in

World War I was clue in large part, at least in the Mediterranean and European theaters, to the effective work of the thoracic surgical teams of auxiliary

surgical groups.

In the European theater, as in the Mediterranean (p. 105), these teams

worked chiefly in field and evacuation hospitals. In the European theater,

however, the groups were assigned to the Army surgeon, in contrast to the

Mediterranean policy, by which the teams were controlled at theater level.

In the European theater, as in the Mediterranean, the effectiveness of all group

teams depended to a considerable degree upon how they were received and

utilized in the installations to which they were assigned. After the first—

quite natural—surprise, not unmixed with resentment, at the presence of these

teams in field and evacuation hospitals and at the heavy responsibilities assigned

to them, their potentialities were realized, and they were fully utilized by the

desire and cooperation of most commanding officers.

In addition to the care of chest casualties, the teams served usefully in

the indoctrination of other members of the medical staff, as well as of the

nursing staff and technicians, in the principles of management of chest injuries.

In all pre-D-day discussions, Colonel Cutler emphasized that the experience of the Mediterranean theater showed that thoracic surgical teams must

be able, whenever necessary, to handle other injuries, particularly abdominal

injuries. Thoracic surgical teams capable of doing only thoracic surgery

would be useful in base areas, where complete segregation of injuries was

possible. In the circumstances that prevailed in forward areas, team surgeons

must be able to handle other wounds also, and this consideration was always

borne in mind when assignments were made.

Special Experiences

The following data on the experiences of the four auxiliary surgical groups

that supported U.S. Armies in the European theater give some indication

of the enormous number of thoracic and thoracoabdominal injuries that the

teams handled:

1st Auxiliary Surgical Group.—The 1st Auxiliary Surgical Group supplied teams to the 3d Auxiliary Surgical Group after D-day; these teams

remained under the control of the latter group during most of the campaigns

in Europe. Other teams from this auxiliary surgical group served witli the

Seventh U.S. Army, in November 1914; with the XVIII Corps (Airborne),

during Operation MARKET; and with the 17th Airborne Division, during the

cross-Rhine operation. The group came under the control of the Fifteenth

U.S. Army on 18 April 1915.
130 THORACIC SURGERY

Its work for 1944 was not tabulated. In 1945, its teams handled 701

thoracic injuries and 332 thoracoabdominal injuries.

2d Auxiliary Surgical Group.—The 2d Auxiliary Surgical Group, which

had the longest experience of any of these groups, served in North Africa

and Sicily with the II Corps: with the Fifth U.S. Army in Italy; and with

the Seventh U.S. Army in southern France and during the remainder of the

lighting in Europe, after the Seventh U.S. Army passed from Mediterranean

to European theater control in December 1944.

The teams of this group handled approximately 22,000 casualties. During

1944 and 1945, they cared for 1,364 thoracic wounds and 903 thoracoabdominal

wounds. These data are discussed in detail elsewhere (vol. II, appendix).

3d Auxiliary Surgical Group.—Teams from the 3d Auxiliary Surgical

Group supported the II Corps in North Africa and Sicily and the First U.S.

Army in France, Belgium, and Germany.

Its detailed data are not complete, but it is estimated that its personnel

cared for a total of 25,000 casualties in both theaters. Complete information

is available on 18,885 injuries handled in the European theater, including 2,018

thoracic wounds and 824 thoracoabdominal wounds. It was also estimated

by the team surgeons that combined thoracic, thoracoabdominal, and abdominal

wounds accounted for 61 percent of the work in field hospitals; 18 percent

of the work in modified field hospitals; 30 percent of the work in beach

clearing stations; and 10 percent of the work in evacuation hospitals.

4th Auxiliary Surgical Group.—Teams of the 4th Auxiliary Surgical

Group served in France and Germany with the Third U.S. Army, which

became operational on 1 August 1944. Some of its teams, however, had gone

ashore on Omaha and Utah Beaches on D + 2. Two of its teams were flown to

Bastogne on 26 December 1944, during the Battle of the Bulge, and were

landed by glider not far from the German lines the same day that the 4th U.S.

Armored Division broke through to relieve the city. Two teams, which were

also landed by glider, were attached to the 17th Airborne Division for the

cross-Bhine operation in March 1944.

The teams of the 4th Auxiliary Surgical Group cared for 27,516 casualties,

of whom 1,040 are known to have had thoracic wounds. The 17,222 abdominal

injuries for which it cared are not broken down into abdominal and thoracoabdominal categories.

5th Auxiliary Surgical Group.—The 5th Auxiliary Surgical Group was

assigned to the Ninth U.S. Army after the middle of September 1944. Previously, some of its teams had served with the Fifth U.S. Army in Italy and,

for a short period, with the Third U.S. Army in France.

The records are not complete, but it is estimated that the teams of this

group cared for almost 16,000 casualties, of whom 1,063 had thoracic injuries

and 300 thoracoabdominal injuries. The report points out, as had other reports,

that the keeping of detailed personal case records was a luxury that had to be
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 131

sacrificed in periods of duress and heavy work, during which the great majority

of these casualties were treated.

The teams of the 5th Auxiliary Surgical Group spent 80 percent of their

time in field hospitals, in which operations were usually long and difficult and

averaged 2y2 hours each. The 7,829 casualties treated in these hospitals therefore required vastly more time and effort than the 8,069 casualties treated in

evacuation hospitals. As in all other auxiliary surgical groups, the high case

fatality rate during the first 24-hour period after operation implied the policy

of operating on all casualties who had even a remote chance of survival. Xo

accurate statistics are available concerning the number of patients admitted to

forward hospitals who died before they could be operated on, or who were not

operated on because their state was considered hopeless, but it is doubtful that

they accounted for 2 percent of the casualties admitted to field hospitals.

Data on the thoracic surgical experience of this group appear in detail

elsewhere (vol. II, appendix).

THORACIC SURGERY CENTERS

Establishment

On 6 December 1943, Colonel Cutler noted in his official diary that the

theater chief surgeon did not wish specialized hospitals set up in the European

theater. On further consideration, however, General Hawley reversed himself,

and by D-day, a variety of hospitals for special treatment had been established.

Thoracic surgery centers were included, although, as already noted, a thoracic

surgery consultant had not then been appointed for the theater and none was

ever appointed.

United Kingdom Base.—Circular Letter No. 81, issued on 10 June 1944

(11), designated centers for specialized treatment in thoracic surgery at:

1. The 15th Hospital Center. The chest center located at the 160th General

Hospital was directed by Major Harken.

2. The 12th Hospital Center, Malvern Wells, Worcestershire. The chesr

center was directed by Colonel Touroff, at first at the 90th General Hospital

and after 1 August 1944, at the 155th General Hospital.

3. The 6810th (U.S.) Hospital Center (Provisional), Whitclmrch, Shropshire. This center, later the 804th Hospital Center, had active thoracic surgical

services in several of its hospitals, and Colonel Miscall, chief of the Thoracic

Section, Surgical Service, 137th General Hospital, served as coordinator for

thoracic surgery. This installation, however, did not function as an active

thoracic center in the sense that the thoracic centers at the 160th and 155th

General Hospitals functioned.

Continent.—Shortly after D-day, the necessity for special centers on the

Continent became evident. The first center for chest surgery was established in

Paris, at the 48th General Hospital located at the 814th Hospital Center, on
132 THORACIC SURGERY

6 November 1944, to serve the hospitals of the Seine Base Section. Its mission

was to care for the thoracic casualties coming through the Paris area whose

condition did not warrant their transfer to centers in the United Kingdom.

It had an evacuation policy of 30 days, which meant that most patients had to

be evacuated as soon as they reached the convalescent stage.

There were 348 admissions to the center at the 48th General Hospital

during November and December 1944, upon whom the following chest surgery

was performed, in addition to 9 bronchoscopies:

21 closures of wounds of the chest wall.

6 removals of foreign bodies from the chest wall.

3 debridements of the chest wall.

11 removals of foreign bodies from the lun<r.

15 drainage operations for empyema.

2 drainage operations for lung abscess.

1 drainage operation for mediastinal infection.

30 decortications.

1 ligation of the axillary artery.

1 repair of a congenital diaphragmatic hernia. An occasional operation

of this kind was permitted in chest centers if the preexistent condition was

giving rise to symptoms and if it was thought, as in this instance, that surgery

could make the man fit for duty within a short time.

The plan for thoracic surgery and other specialized centers on the Continent was the outcome of discussions among the consultants at their meetings

on 27 October and on IT November 1944. The plan was to set up these centers

at the largest concentrations of activities in the communications zone; that is,

Paris, Liege, and Nancy. A circular letter that Colonel Cutler prepared after

the November meeting (Circular Letter No. 32, Office of the Chief Surgeon,

Headquarters, ETOUSA (12)) did not appear until 6 April 1945. It listed

the following hospitals for specialized care:

15th General Hospital, 818th Hospital Center, Liege.

50th General Hospital, 819th Hospital Center, Commercy.

5th General Hospital, 820th Hospital Center, Toul.

23d General Hospital, Vittel.

43d General Hospital, St. Pons, Delta Base Section, SOLOC (Southern

Line of Communications).

Ironically, by the time the circular letter designating these centers had

appeared, the field armies had moved forward so rapidly that the general

hospitals in the forward sections of the communications zone had been left far

behind. As a result, casualties were reaching hospitals in the Paris area, and

even hospitals in the United Kingdom Base, by air (fig. 12) more rapidly than

they could be evacuated by land transportation to the intervening hospitals

where specialized treatment facilities had been established. The war ended

about a month after the circular letter designating these centers appeared.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER iO:>

3£^ *» *

M

m

feiVsSwfeS i

:.#

£»&ä « -.«il

FIGUKE 12.—Air evacuation from Continent to United Kingdom

Base. C-47 transports ready to take off.

Facilities

Thoracic surgery and other specialized centers in the United Kingdom were

established in U.S. Army hospital plants obtained by lend-lease (figs. 13 and

14). Some of the buildings were of temporary type construction, of brick and

tile. Nissen huts and tents Avere also used, winterized for year-round occupancy.

Some centers had as many as 200 buildings, 40 of AA'hich seized as AA-ards. "When

the patient load exceeded the current capacity, expansion into tents, equipped

with stoves and lighting facilities, took care of the excess.

The grouping of several general hospitals, usually about 10, into hospital

centers proved an extremely sound plan. Administrative problems Avere

simplified, and more efficient use of professional and other personnel was

possible. The tAvo most active thoracic surgery centers that functioned in the

United Kingdom Base operated under this plan.

Assignment of Casualties

Chest centers in the United Kingdom Avere originally not used to their full

capacity because there Avas considerable confusion over IIOAV transfers to them

were to be handled. Casualties Avith chest injuries are not mentioned in Administrative Memorandum No. 62, issued on 3 May 1944 (.75). It Avas not understood, at first, Avhether transfers to the special centers Avere permissive or

mandatory. Difficulties Avere ended as soon as it became clear that the individual
134 THORACIC SURGERY

'HI- fit

BBSS**'!!!*!

' ' < .-•'•*:

r c

mm '" iV

i I r »"

;: ■■: ' '

rW it- V.'

FicL-iiE U'!.—RjOth General Hospital, site of thoracic surgery center.

A. Headquarters building. B. Ward buildings.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 135

FIGTJKK 14.—Thoracic surgery center at 155th General Hospital.

commanding officer or his chief of surgery would be responsible for their

unsatisfactory course if patients who required specialized care were not transferred to a center for it. The thoracic centers, like the other centers, maintained

good public relations and rendered good service. Good relations with the

sources of their population were therefore soon established. Once this happened, the mechanics of transfer of patients furnished no further trouble. The

entire relationship worked well not because of the rules but because of the

fundamental sameness of objectives in all echelons of medical care.

The October 1944 meeting of the consultants in the Office of the Chief

Surgeon, Headquarters, ETOUSA, was devoted in large part to improvement

of evacuation practices, particularly a better classification of transportable

and nontransportable patients and better care of patients in transit hospitals.

At this meeting, General Hawley stressed that the care of patients in transit

was just as important as their care in hospitals. At the November meeting of

the consultants, it was agreed that the airlift should continue to be used, whenever it was practical, to evacuate casualties to the United Kingdom within 4

days after wounding. The situation improved, but in January 1945. when

Colonel Cutler seized the opportunity offered by the Trench Foot Conference

in Paris to discuss other matters, he found that personnel at thoracic surgery

centers were still complaining that casualties were unduly long in reaching these

installations. They were sometimes received as late as 30 days after wounding.

These delavs sometimes nullified the advantages of the special treatment facil-
136 THORACIC SURGERY

ities and were responsible for patients being- received in poor condition and unfit

for prompt definitive treatment.

By no means were all casualties with chest injuries who were returned to

base sections in the European theater evacuated to the chest centers in the

United Kingdom Base. The policy was to admit these patients to general hospitals and then, if they did not show improvement under standard treatment

within a short period of time, to transfer them to a chest center. It was estimated that not more than 5 percent of the casualties returned to the United

Kingdom Base had chest injuries and that not more than 20 percent of these

required treatment at thoracic surgery centers.

As a result of selection, the population of chest centers in the United

Kingdom consisted of casualties who needed treatment more radical than

delayed primary wound closure, evacuation of a hemothorax, or management

of simple complications. In general, the distribution of injuries and complications that required treatment in chest centers, based on the experience of the

160th General Hospital chest center, was as follows:

Hemothorax, 70 percent; unclotted, 60 percent (infected, 3 percent);

clotted, 10 percent (infected, 4 percent).

Retained foreign bodies, 15 percent of which about 8 percent required

surgical removal.

Thoracoabdominal wounds, 8 percent,

Hematomas, 4 percent.

Injuries of the heart and pericardium, chiefly retained foreign bodies, 3

percent.

Obviously, in the light of these, facts, the definitive treatment necessary in

thoracic surgery centers consisted chiefly of:

1. The management of hemothorax and its complications, including such

complications as clotting and organization.

2. The management of posttraumatic (hemothoracic) empyema, by drainage or pulmonary decortication.

3. The localization of intrathoracic and other retained foreign bodies,

critical evaluation of the indications for their removal, and their removal as

indicated.

4. The management of other complications, chiefly those associated with

thoracoabdominal wounds.

Evacuation and holding policies.^A 120-day evacuation policy for the

entire European theater was established in the middle of October 1944. In

Xovember, the same evacuation policy was established for the Seventh U.S.

Army, which, had just been brought under complete ETO control. Patients -who

required more than 30 days of hospitalization, but not more than 120 days, were

to be evacuated to the United Kingdom Base or to SOLOC, the base section for

the Seventh U.S. Army.

When the chest centers on the Continent were in the planning stage, it was

Colonel Cutler's idea that strict specifications be set up for the duration of

hospitalization in them. He believed that there should be a limit of 14 (lavs.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 137

Because of the delay in opening the planned centers, except for the center at

the 48th General Hospital in Paris, and because of the success of air evacuation

to the United Kingdom Base, this policy was never put into effect.

Holding limits in all the centers were loosely interpreted, and properly so,

until V-E Day. As a result, many thoracic casualties were returned to duty

in the theater who, by a stricter interpretation, would have been evacuated to

the Zone of Interior and permanently lost to the theater manpower.

Advantages of Thoracic Surgery Centers

The thoracic surgery centers set up in the European theater were conducted,

in genera], by the policies that had proved so successful during the evolution

and establishment of similar centers in the Mediterranean theater. As in that

theater, the centers in the European theater had three chief advantages:

1. They permitted the concentration of casualties with chest injuries in

hospitals especially equipped and staffed for their care.

2. They permitted the most efficient and economical use of the limited number of thoracic surgeons available in the theater.

3. As a result of the cumulative experience in these centers, it was possible

to discard some policies that had proved ineffectual; alter others; and adopt

new policies that had proved, by clinical trial, to be effective.

The establishment of thoracic surgery centers in the European theater had

the same far-reaching effects as in the Mediterranean theater. Treatment was

expedited. The definitive surgery necessary could be carried out with the most

advantageous timing. Manpower losses were reduced. The crippling sequelae

of chest wounds that had furnished a continuing problem after World War I

were largely eliminated. The opportunity to study large numbers of patients

permitted the adoption of new techniques with assurance of their advantages

and disadvantages. Finally, younger officers who already had some experience

in chest surgery could receive further training in these centers. This trainingwas one of their most useful functions.

PRISONERS OF WAR

From the beginning of the fighting in the European theater, wounded and

sick prisoners of war were cared for according to the provisions of the Geneva

Convention.

Circular Letter No. 39, issued on 5 May 1945 (14-), furnished instructions

for hospitals utilizing the medical services of protected prisoner personnel in

the care of prisoners of war. Commanding officers of the affected hospitals

were to instruct these personnel in standard therapeutic procedures. The basis

of the instruction was to be the "Manual of Therapy, European Theater of

Operations" (7), and Circular Letters, all from the Office of the Chief Surgeon,

No. 71,15 May 1944 (5) ; No. 101. 30 July 1944 U) ; No. 131, 8 November 1944

653681T—G2 11
138 THORACIC SURGERY

(15) ; and No. 23, 17 March 1945 (8). German medical officers were furnished

with copies of the manual and these circular letters, which, together, contained

all the basic policies for the management of the wounded.

If protected prisoner personnel were not capable of performing thoracic

surgery, neurosurgery, or complicated plastic surgery, prisoners of war who

needed such care were to be transferred to appropriate specialized centers. The

experience in the European theater paralleled that in the Mediterranean t heater,

that captured German medical personnel were, for the most part, ill trained

and inexperienced and that their surgical standards were remarkably low

(p.35).

According to the Geneva Convention, wounded prisoners of war had to be

treated exactly as U.S. Army casualties were treated. After Major Harken

made an investigation of complaints that some chest casualties being cared for

by protected prisoner-of-war personnel were receiving unsatisfactory care,

chest services were set up for them and were affiliated with the U.S. Army

chest centers in the United Kingdom Base and on the Continent.

Section II. Basic Clinical Considerations

EVOLUTION OF CLINICAL POLICIES

General Policies

In the European theater, in spite of the efforts to disseminate the knowledge gained from the experience in the Mediterranean theater, the management

of chest injuries progressed through a cycle, much as in that theater. In the

beginning, before surgeons had much actual experience with combat wounds,

the general tendency was to be radical, and there were few casualties with

chest injuries who did not undergo thoracotomy. When casualty loads became

heavier, however, and there was a large backlog of patients with abdominal

and thoracoabdominal wounds with high priority for surgery, thoracotomies

were necessarily fewer. It was thus learned that patients with thoracic injuries could be handled with better results by delayed surgery and by less

radical surgery.

Eventually, the indications for thoracotomy were stabilized about as

follows:

1. Hemothorax caused by active bleeding which rapidly refilled the chest

cavity after aspiration. Patients in this category were frequently in severe

shock on admission and did not respond well to resuscitation. The source of

bleeding was usually an intercostal or internal mammary artery, the lung itself,

or, less often, the heart or some other mediastinal structure.

2. Massive clotted hemothorax that did not lend itself to aspiration.

Patients in this group often presented dyspnea, cyanosis, and mediastinal shift.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 139

Evacuation of the clotted blood and control of bleeding were readily effected

through an open thoracotomy and made this operation the procedure of choice.

3. The presence of foreign bodies 2 cm. or larger in the pulmonary

parenchyma or pleural cavity. The principal indication for their removal was

the risk of infected hemothorax and lung abscess, but other indications were

possible further damage to the lung or laceration of some blood vessel.

4. The presence of shattered rib fragments in the lung or pleural cavity

or of large fragments that had not perforated the pleura. These required

removal either by thoracotomy or by extrapleural rib resection. Many surgeons in the European theater came to agree with surgeons in the Mediterranean

theater that bone fragments in the lung were potentially more serious than

metallic foreign bodies. They were apt to be long and sharp with irregular

edges, so that they could penetrate the tissues and forge ahead in them. After

a time, these detached bone fragments became necrotic, and an abscess or an

infected hemothorax was a likely consequence. Laceration of a blood vessel

was always far more likely from contact with bone fragments than with

metallic foreign bodies.

5. Sucking wounds. This type of wound always demanded definitive treatment. If simple debridement and wound closure were not adequate, and if

it was known that there was intrathoracic damage of consequence, thoracotomy

was indicated.

6. Tension pneumothorax due to an ail' leak, as in bronchopleural fistulas.

After these indications had become established, the treatment of thoracic

casualties in the European theater became more conservative. There were still

many departures from official policy, however, usually attributable to (1) the

desire of surgeons to follow their personal preferences and (2) the difficulty

of teaching them that, in wartime, policies must be standardized and that the

procedure proved by group experience to be safest must be employed rather

than the policy which the individual surgeon happened to consider best.

The material in the "Manual of Therapy, European Theater of Operations," issued on 5 May 1944, provided the basic principles for all surgical

procedures in the theater, including wounds of the chest. Circular letters

(p. 123) were issued later, to elaborate or modify various procedures in the

light of experience, as well as to reemphasize certain policies that were not

being followed.

The chief surgical error was the omission of adequate debridement. Next

came the closure of wounds under tension, by pulling the edges together, instead

of employing techniques of closure such as undermining incisions or splitthickness skin grafts. Dumping of sulfonamide powder or crystals into

wounds simply made subsequent closure more difficult.

Originally, many casualties were evacuated to base hospitals with large

collections of fluid in their chests. Special attention was directed to this

error, but often it was not considered feasible to carry out routine roentgenologic examination or aspiration of the chest before evacuation.
140 THORACIC SURGERY

Special Policies

Wound closure.—The first procedure in most patients received in a. base

hospital was prompt closure of wounds that had been left open at initial

wound surgery. The early experience in the Mediterranean theater had shown

the disastrous consequences of primary suture, and the later experience had

shown the excellent results of delayed primary wound closure, which was therefore the general policy in the European theater.

Principles and practices were the same as in wounds of other parts of the

body. The routine culture of w

Tounds was found to be unnecessary and to be

wasteful of both time and material. As in the Mediterranean theater, only a

brief experience was necessary to show that the clinical appearance of the

wound was sufficient criterion for its closure or nonclosure. Cultures were

made only when there was clinical evidence of infection and the information

would be useful for subsequent clinical management.

In judging the suitability of a wound for closure, it was the practice at

a number of hospitals in the theater to elevate only the outer dressing, leaving

the fine-mesh gauze directly over the wound still in place. The gauze directly

over the wound was not removed until the patient was in the operating room.

If no sign of infection was evident through the gauze, the patient w

Tas scheduled for delayed primary wound closure. This was a practical method of

determining the feasibility of closure. It reduced the risk of infection, and

it saved time in the operating room.

If the wound was not clean, as indicated by induration or exudation,

continuous compresses were used for from 24 to 48 hours. If devitalized tissue

was present, redebridement was performed before closure, which was delayed

for another 3 or 4 days.

In large soft-tissue defects, in which undermining procedures did not permit closure without tension, the prompt use of split-thickness skin grafts saved

weeks of slow healing. This plan was also better than too radical undermining,

in an attempt to secure satisfactory flaps for closure.

Associated wounds.—Even if the casualty had associated head injuries

or compound fractures of greater seriousness than the chest wound, it was the

best policy to care for the chest wound first, in order to restore cardiorespiratory balance. Thoracoabdominal wounds always took precedence over

other wounds. If the patient's condition at the conclusion of the thoracic or

thoracoabdominal procedure was poor, operation for associated injuries was

deferred for from 24 to 72 hours. The risk of development of infection in

these wounds was less than the risk of subjecting a thoracic casualty who was

in shock or had just been brought out of shock to additional trauma and blood

loss without an interval for further resuscitation and stabilization.

Fractures of the humerus and shoulder girdle, which were often associated

with wounds of the chest, introduced problems if postoperative aspiration

of the chest was necessary. In some cases, a plaster Velpeau dressing was
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 141

applied und a window cut in the chest portion for this purpose or, if drainage

had been instituted, to permit the exit of the catheter. In many case", temporary dressings of elastic or adhesive bandages were applied in Velpeau

fashion for the immediate postoperative period. They were replaced later

by a plaster Velpeau or by a thoracobrachial cast for transportation. Hanging

casts were very effective in base hospitals. Some patients with fractures of the

supracondylar portion of the shaft of the humerus were put up temporarily in

full arm casts, and suitable transportation casts were substituted before

evacuation.

Adjunct therapy.—The policies of replacement therapy set up in the

Mediterranean theater on the basis of its early experience were generally

followed in the European theater. The lessons of the inadequacy of plasma

had been well learned in the Mediterranean theater, and the errors originally

made there were not repeated in Western Europe. Shortages of supply

imposed some limitations upon the use of blood in the first weeks after D-day,

but when once blood began to be flown to Europe from the Zone of Interior,

all restrictions were removed, and every casualty received as much as he needed.

At the beginning of the campaign in Europe, it was still the practice to

sprinkle all wounds in body cavities with sulfanilamide crystals or with a

mixture of dry penicillin and sulfanilamide. Later, local therapy was omitted

because systemic therapy was found to be adequate. Instillations of penicillin Avere used in the chest cavity (p. 296). Otherwise, only systemic therapy

Avas used, by the policies established in the Mediterranean theater. Since

penicillin was administered in all cases in which it was believed to be indicated,

no control series was run, and it is therefore impossible to determine the effects

of antibiotic therapy on the end results. There Avas no doubt, however, that

the basic reason for the good results secured was good surgery, Avith the sulfonamides and penicillin playing a A'ery significant part, if comparison Avith

comparable Avounds in World War I had validity.

MANUAL OF THERAPY, EUROPEAN THEATER

General guidance for the management of Avounds of the chest Avas contained in the Manual of Therapy, published in the European theater in May

1944 and distributed to all medical officers.

Wounds Avere divided into three types:

1. Wounds limited to the chest Avail, which Avere managed as any other

soft-tissue Avound.

2. Wounds that perforated or penetrated the pleural caAuty or lung without

resulting cardiorespiratoiy embarrassment. These Avounds required no specific

treatment in forward areas beyond proper treatment of the external Avound and

priority evacuation, to permit prompt treatment of any complications that

might develop.
142 THORACIC SURGERY

3. "Wounds associated with cardiorespiratory embarrassment. The recognition of these wounds and the associated pathologic processes was essential

because management was lifesaving and often had to be instituted in forward

areas.

The manual listed the important points of diagnosis in open pneumothorax,

tension (pressure) pneumothorax, crushing injuries (stove-in chest), hemorrhage, subcutaneous emphysema, and blast injuries. In penetrating wounds of

the chest in which the missile was not seen in the roentgenograms, additional

roentgenograms should be made of the abdomen.

The following instructions were given for the emergency and definitive

management of chest injuries:

Emergency Measures

1. In open pneumothorax, the primary consideration is closure of the opening in the chest wall, which is best done by the application of a large, sterile,

petrolatum-impregnated gauze pad, supported by a bulky gauze dressing held

firmly with adhesive tape. To avoid the danger of tension pneumothorax. the

dressing should be almost, but not absolutely, airtight. If the wound is large

and gaping, it may be necessary to suture the gauze pad in place, to prevent its

loss into the pleural cavity. In an emergency, anything can be used to occlude

the opening, even a sterile pad held over the wound by the hand, which will

save life until more adequate measures can be instituted. The patient should

lie on the affected side.

2. In pressure pneumothorax, a needle is introduced through the second

interspace anteriorly on the involved side to allow the trapped air to escape.

As a precaution against recurrence, and always if air continues to escape, the

needle should be reinserted through a cork strapped in place and covered with

a condom or finger cot, so that a valve is produced.2In place of the needle, a

small catheter may be introduced through an incision in the thoracic wall and

attached to a closed drainage system.

3. In crush injuries, pain is relieved by intercostal nerve block. In extensive bilateral injuries, an attempt may be made to stabilize the chest wall by

circular adhesive strapping. Paradoxical movements of the chest wall are

controlled by strapping the injured side only.

4. Marked cyanosis indicates possible bronchial obstruction. Nerve block

should be performed, and the patient encouraged to cough vigorously. These

measures, with the head-down position,3 may clear the bronchial tract. The

patient must not be left alone in this position, for fear of respiratory

embarrassment.

- So far as is known, this method was not used in the European theater. It is a traditional

technique, but it is not always either practical or effective.

-* Experience showed that the head-down position was a very bad position for a thoracic casualty

and that catheter aspiration or bronchoscopy was the correct way to clear the tracheobronchial tubes.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 143

5. In external bleeding, the wound should be inspected, to determine

obvious bleeding points. If the site of the -wound suggests possible injury to

the internal mammary or intercostal vessels, an attempt is made to secure the

ends of the severed vessels with hemostats and then ligate them. If the attempt

fails, the wound is enlarged sufficiently to permit temporary digital control

by compression of the bleeding point against the chest wall, after which deep

transfixing sutures are used. If no bleeding point is found, firm packing is

employed. The patient is treated for shock.

6. Subcutaneous emphysema usually needs no treatment. If it has developed after airtight closure of an open sucking wound, the associated tension

pneumothorax must be treated.

7. In blast injuries, absolute rest is more important than immediate evacuation to the rear. Oxygen is of great value, but neither plasma nor blood affects

the associated collapse.

Thoracoabdominal wounds are not discussed as such under emergency

measures beyond the statement that any projectile that enters the chest must

be regarded as a possible cause of abdominal injury.

Definitive Treatment

General measures.—The folio-wing general measures were employed:

1. The patient should be kept on the injured side or sitting up and should

be disturbed as little as possible during examination.

2. Largo doses of morphine should not be given, as they abolish the cough

reflex. Intractable pain is better controlled by intercostal nerve block.

3. Open pneumothorax and rapidly progressive pressure pneumothorax

are grave emergencies, but once they have been controlled, there is no need for

further emergency procedures, and there can be deliberate consideration of

what comes next.

4. Associated thoracic injuries should be suspected in all wounds of the

upper arm, cervical region, and abdomen. Roentgenologic examination is

essential for diagnosis.

5. Hemorrhage requires adequate blood replacement, as in other injuries.

6. Acute gastric dilatation is a common accompaniment of chest injuries

and often accounts for disproportionately great dyspnea. The complication is

potentially lethal but responds readily to decompression by the Levin tube.

It should be specifically sought for in all roentgenologic examinations of the

chest. It is easily recognized.

7. Untreated effusions of serum and blood are the commonest avoidable

causes of complications. The pleural space must be kept empty.

8. Bronchoscopy is of inestimable value whenever the bronchi and trachea

are obstructed by mucus or other excessive secretions. It is often a lifesaving

measure both before and after operation.
144 THORACIC SURGERY

9. Local analgesia is suitable for injuries of the chest Avail. For intrathoracic surgery, positive pressure anesthesia is essential, preferably through

an enclotracheal tube. Intravenous Pentothal sodium (thiopental sodium)

should bo avoided in the presence of respiratory embarrassment.

10. Drainage tubes should be securely anchored to the chest wall. Their

loss in the pleural cavity during evacuation is an avoidable cause of late

complications.

11. Postoperative measures include precautions against, and prompt diagnosis of, acute gastric dilatation: oxygen therapy; repeated aspirations of the

pleural space if effusion occurs; bronchial aspiration in the management of

atelectasis; and early, active breathing exercises, to shorten convalescence and

avoid deformities of the chest wall.

Special injuries and complications.—Certain injuries and complications

furnished special problems, as follows:

1. Open pneumothorax.—In open pneumothorax, the dressings are not disturbed until the patient is prepared for operation. Debridement is performed,

with such intrathoracic surgery as is indicated, followed by airtight closure

of the chest wall and reinflation of the collapsed lung. A large defect may be

repaired by the combined use of the diaphragm and a large muscle of the chest

wall, such as the latissimus dorsi or pectoralis major. Occasionally, it is necessary to suture the lung to the margin of the wound. Intercostal closed catheter

drainage is instituted through a separate incision, in a dependent position, if it

is required because of contamination of the pleural cavity and the risk of sepsis.

If drainage is omitted, the patient must be watched carefully for subcutaneous

emphysema or pressure pneumothorax.

2. Tension pneumothorax.—Tension is relieved hy aspiration of air from

the involved side through the second interspace anteriorly. A flutter valve is

inserted, or closed drainage is instituted as a precaution against recurrence,

3. Hemorrhage.—Bleeding from the lung usually ceases spontaneously,

but a pulmonary wound close to the root of a lobe may be the source of major

bleeding that must be controlled by suture, or by partial resection and suture,

of damaged pulmonary tissues. Bleeding from the intercostal and internal

mammary vessels, the most frequent sources, can be suspected from the location

of the wound. It is readily controlled under suitable operating conditions.

Wounds involving the great vessels at the hilus are usually rapidly fatal, but

early intervention and heroic surgery may occasionally be lifesaving. It

should be remembered that a casualty can bleed to death into the pleural cavity

without any mechanical embarrassment to the cardiorespiratory system.

4. TIemothorax.—A hemothorax should be evacuated within 48 hours, in

order to reduce the chances of infection, prevent loss of pulmonary function by

the development of fused chest, prevent deformity, and shorten convalescence.

If the blood has not clotted, simple aspiration is sufficient, without introduction of air. If the blood has clotted but is uninfected, the clots are broken up

and removed through a cannula. If this is impossible, it may be necessary to
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 145

make an intercostal incision to evacuate them. The chest is then closed and

air aspirated from it. If infection has occurred, as shown by characteristic

roentgenograms, the treatment is that employed for empyema. An attempt is

made to remove the clot without risking contamination of adjacent walled-off

uninfected pleural space.

5. Foreign bodies.—A conservative attitude is best. Foreign bodies should

be assumed to be in the subcutaneous tissues or the parietes until they are proved

unequivocally to be in the lung. Precise localization by roentgenogram is

necessary before a plan of management is determined. Smooth foreign bodies,

less than 2.5 cm. in diameter, seldom require urgent removal. Large, irregular

objects should be removed as soon as possible because of the high incidence of

serious infection arising from them. They are usually present in wounds that

require debridement down to the pleural cavity. A shattered rib on the side of

entry, regardless of the status of the external wound or the characteristics of

an associated retained missile, requires thorough exploration of the wound of

entrance and the pleural space. Explosive costal injuries are often associated

with extensive damage to the lung, and rib fragments prove to be troublesome

foreign bodies.

6. Crushing injuries.—The treatment already described (p. 143) is continued. In most bilateral injuries, and in some unilateral injuries, the thoracic

wall should be stabilized and elevated by perichondrial wire sutures or towel

clips; they are attached to the mobile sections of the fractured ribs and then

used to provide traction. The sutures or clips are left in place until the chest

is stable, a minimum of 3 weeks.

7. Blast injuries.—The most important phases of treatment, as already

described, are oxygen and absolute rest. Chemotherapy is used to prevent infection. If surgery is imperative for other injuries, inhalation anesthesia is

avoided.

8. Thoracoabdominal injuries.—A thoracic approach is employed only

when injuries of the thorax require urgent surgery to save life. If it is used,

the diaphragmatic wound may be radically enlarged and the abdomen explored

through it. Wounds of the stomach and spleen may be readily handled by this

route. If exploration through the diaphragm is unsatisfactory, a secondary

abdominal incision should be used after the chest surgery is completed. The

diaphragm is closed by overlapping the lacerated margins with nonabsorbable

sutures. Low phrenic crushing is done to keep it at rest. Eepair of lungdamage with closed intercostal drainage may be indicated. If the liver is

lacerated, the subdiaphragmatic space is packed and drained posteriorly below

the diaphragm. The patient should be observed for empyema and intra-abdominal complications, especially subphrenic abscess.4

4 As their experience accumulated, many surgeons came to prefer the transthoracic approach to

thoracoabdominal wounds, employing it on the indications and contraindications established in the

Mediterranean theater (vol. II, ch. III). Packing in hepatic wounds was also discontinued in favor of

simple drainage, though this never became official theater policy.

053GS1V—02 12
146 THORACIC SURGERY

REPORTS OF CHEST CENTERS IN THE UNITED KINGDOM BASE

A composite summary of the reports of the chest centers at the 160th General Hospital and the 155th General Hospital is appended, to show the workload and activities of these installations.

160th General Hospital

The 160th General Hospital reached the United Kingdom on 27 April

1944.3 On 10 June 1944, it was designated a thoracic surgery center (the first

to be set up in the European theater) for the 15th Hospital Center. Major

Harken, who had previously been working in General Hawley's office in

Grosvenor Square, was sent to the center as director on General Hawley's personal orders. The assignment was entirely to his liking, for, as he had told

Colonel Cutler and General Hawley many times, he personally believed that

thoracic surgery should be recognized as an independent surgical specialty. In

all of his contacts with U.S. chest surgeons, Mr. Tudor Edwards expressed the

same opinion and pointed to the results being achieved in British chest centers

by implementation of this concept.

Personnel.—The personnel of the center varied considerably during the

lo months of its operation. Major Harken, the chief anesthesiologist, Capt.

(later Maj.) Charles L. Burstein, MC, the senior ward nurse, and two of the

surgical nurses served throughout this period. Captain Burstein was a highly

competent anesthesiologist and a productive investigator. 1st Lt. (later Capt.)

Margaret Evans, ANC, the senior ward nurse, was a woman of great capacity,

both as a bedside nurse and as a teacher. She exercised remarkable disciplinary

control over her patients, who did what she expected of them because of their

affection and respect for her.

Later, two excellent additional surgeons were assigned to Major Harken

at the thoracic surgery center, Capt. Joseph P. Lynch, MC, and Capt. Ashbel

C. Williams, MC. Their assistance made it possible to teach and train a number of surgeons who were attached to the center on temporary duty at various

times.

This nucleus of officers and nurses was augmented, at different times, by

other medical officers and other personnel, and by extremely competent thoracic

surgical teams from the 1st Auxiliary Surgical Group.

Enlisted men and convalescent patients were used for rehabilitation instruction and demonstration. It was possible, by standardizing all procedures,

including preoperative and postoperative care, to perform a maximum amount

of work with minimum help as soon as sufficient experience had been accumulated to determine the best policies and practices.

Training.—When the 160th General Hospital was activated as a thoracic

surgery center, the professional activities of the entire hospital were minimal.

5

These data are derived from the semiannual reports of the 160th General Hospital chest center

for July-December 1944 and January-June 1045 and from a supplementary report made by Major

Harken to Colonel Cutler on 9 November 1944.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 147

In the few weeks before D-day, it was therefore possible to select and train

ward and operating personnel, as well as nurses, with special interest in chest

surgery and in anesthesia (p. 122).

Reports and records.—The surgical staff found time, amid their professional activities, to prepare several articles for publication. They made frequent presentations at meetings and conferences. They prepared specimens for

the Army Medical Museum and also took motion pictures not only of unusual

cases but to demonstrate the techniques most frequently used in such an

installation.

In his first report to Colonel Cutler, in November 1944, Major Harken

reminded him that he (Colonel Cutler) had pointed out that an important

aspect of the mission of a chest center was to share its experiences with others.

This was difficult because of the lack of secretarial help. The stall' had to

maintain its own records, and such information as could be salvaged, beyond

the required official records, was produced by the efforts of a badly overworked

staff, who frequently felt that they were fighting a losing battle.

Population.—The first patient received in the thoracic surgery center, a

few days after it had been activated, was an Army Air Force sergeant who

had been injured over Germany. He had been treated in a succession of hospitals for an infected hemothorax that had long since become a chronic

empyema. The rib-resection drainage performed successfully at the 160th

General Hospital was the first operation in a chest center in the European

theater. This same technique was used in all extensive empyemas treated by

rib-resection drainage in this center (fig. 15).

Casualties from the Continent began to be received on D + 4, and by the

time the center was deactivated, it had received 1,859 casualties by direct admission. Additional patients received by transfer from other sections of the

hospital center brought the total number treated in the chest center to more

than 2,000. The expansion of the center was so rapid that 500 patients were

sometimes under treatment at the same time.

These figures do not include a certain number of chest casualties who were

treated in other hospitals in the United Kingdom Base because they were too

ill to be moved. On these occasions, Major Harken several times took a team,

including one or two assistant surgeons, an anesthesiologist, and one or two

surgical nurses, to the hospitals in question. They traveled at night, by

ambulance, and operated during the clay.

Because of the limited bed capacity and personnel at the center, every

effort was made to limit admissions to the 160th General Hospital chest center

to real surgical problems. Other patients were treated in the referring hospitals, by standard policies, and were moved to the thoracic surgery center only

if their progress was not satisfactory. If this plan had not been followed, the

census would have run well past 3,000.

A great many of the casualties received at the 160th General Hospital

arrived by air. This was a satisfactory means of transport if pneumothorax

was not present. A nearby airport made transport to this center easier and
148 THORACIC SCRCKRY

FIGURE !•">.—Technique of drainage of empyema employed at 160th

(General Hospital thoracic surgery center in United Kingdom Base. A.

Rubber drainage tube. B. Adhesive used to stabilize drainage tube.

C. Site of frequently used posterolateral drainage of posterior empyema

pocket. Note.—Surgeons in the Mediterranean theater (q.v.) preferred

another technique, which they considered simpler and more adequate.—•

F.B.B.

faster than to some geographically nearer installations. Casualties from the

Ehine were often on the operating table at this hospital the same day they were

wounded.

Case fatality rates.—During the operation of this center, 1,065 major

operations were performed on 951 patients. When two procedures were necessary, they were usually performed at the same sitting. Over the same period,

249 minor operations were performed on 248 patients.

The case fatality rates were a source of great satisfaction. There were

only 12 deaths in the 951 surgical patients (1.4 percent), 2 in 493 foreign body

removals, 1 in 203 decortications, and 9 in 170 rib resections for empyema.

While young, vigorous U.S. soldiers proved generally excellent surgical

risks, many patients were received in poor condition because of the nature of

their wounds; the nature and degree of associated physiologic dysfunction; and,

in a certain number of cases, previous inadequate or unwise treatment. The

number of patients in the latter category decreased as time passed.

Six other deaths occurred among patients with thoracic injuries who were

not admitted to the center but whose thoracic component was being supervised

on the wards on which they were being treated for associated conditions. Two

patients had empyema and lung abscesses, which had not responded to previous

drainage. One of these died of a suppurative thrombophlebitis and the other
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 149

of a high cord lesion, with a spinal fluid fistula into the pleura. Another

patient had a fatal transfusion reaction, and still another died of exsanguination before surgical intervention was possible. At autopsy, the source was

found to be an area of erosion from the aorta into the esophagus. The foreign

body was in the stomach.

Numerous factors might be adduced to explain the good results obtained

at this center. Among them were:

1. Very careful preoperative preparation.

2. Excellent anesthesia.

3. The increasing experience of the chest surgeons and their assistants,

gained from the observation of such a large concentration of chest casualties.

4. An excellent system of rehabilitation, based on remedial breathing exercises. The personnel of this center preferred to handle personally as much of

the rehabilitation of their patients as was practical. They regarded rehabilitation as part of therapy and believed that when it was segmentalized, it lost

a major degree of its effectiveness. The special exercises employed are described in detail elsewhere in this volume (p. 314).

Anesthesia.—Anesthesiologists at the center individualized theiv patients

and used the types of anesthesia for them most suited for their special problems.

Their objects were to protect the patient from untoward reflex changes, assure

ample oxygenation, provide adequate ventilation for elimination of carbon

dioxide, reduce annoying motion of the intrathoracic viscera to a minimum,

and produce as little disturbance as possible of normal physiologic function.

The following technique was devised, or, more correctly, evolved, to achieve

these objectives:

1. Rapid induction with a relatively large dose of Pentothal sodium

except in patients who had suffered recent hemorrhage or were poor risks for

other reasons. Then the amount of the drug was greatly reduced.

2. Intubation with a large-bore Magill enclotracheal tube with an inflatable

cuff.

3. Maintenance of anesthesia with nitrous oxide, oxygen, and ether, with

the use of compensated respiration (continuous manual reinforcement of the

automatic respiratory effort). A constant flow of from 5 to 7 liters of oxygen

per minute was maintained.

4. The use of whatever procedure was necessary to prevent untoward

cardiocirculatory reflexes and peripheral circulatory depression.

This technique proved both safe for the patient and satisfactory for the

surgeon. Many anesthesiologists who employed it had had relatively little

general training in anesthesia, but all had had special training in this method

and all worked under the continuous supervision of experienced and highly

trained anesthesiologists, who themselves usually cared for bad-risk patients

or those likely to present special difficulties.
150 THORACIC SURGERY

From the Standpoint, of anesthesia, thoracic operations fell into two

groups:

1. Thoracotomy for intrathoracic exploration required endotracheal intubation, so that pulmonary ventilation could be controlled. Induction was

performed with intravenous Pentothal sodium alone or combined with nitrous

oxide, so that the electrical Bovie unit could be used at the beginning of the

operation. The larynx was cocainized with 4 percent cocaine before intubation if the glottis and vocal cords seemed hyperactive. Ether anesthesia was

begun when the chest was opened and there was no further need for the Bovie

unit. Cardiovascular reflexes due to stimulation of branches of the vagus

in the hilus of the lung or in the mediastinal structures were watched for, and

controlled by local injection of 1 percent procaine hydrochloride. The surface of the heart was kept moistened with a solution of procaine hydrochloride when cardiac manipulations were necessary. The involved intercostal

nerves were injected with from 3 to 5 cc. of procaine hydrochloride (l1/?

percent in oil) to prevent the shock that might follow spreading of the ribs

during thoracotomy, as well as to decrease postoperative pain.

2. Rib resections for drainage of empyema were usually performed under

light anesthesia secured by intravenous Pentothal sodium supplemented by

nitrous oxide with oxygen in liberal amounts. This technique was considered

superior to local analgesia, since it reduced the time required for operation

and provided good oxygenation for a patient tying on his intact side during

the procedure. Several patients who were extremely toxic from putrid empyema required unusually high concentrations of oxygen, and cyclopropane was

used for them.

Retained foreign bodies.—The fascinating experience of the 160th General Hospital thoracic surgery center with retained foreign bodies in the heart,

pericardium, and great vessels is described in detail elsewhere (vol. II, ch.

VIII). The experience with the removal of retained foreign bodies in the lungwas similarly favorable. Several studies showed that it was possible to operate

on a patient and transfer him to a reconditioning center for return to duty in

the theater more rapidly than he could be handled by a disposition board and

returned to the Zone of Interior.

Hemothorax.—As the Avar progressed, clotting of uninfected hemothorax

was observed less frequently, and fewer patients in this group required surgery, probably because of the increasing efficiency of treatment in forward

hospitals. The majority of the patients received with hemothoraces could

be treated by a combination of complete aspiration and breathing exercises.

Decortication was employed when the hemothorax had clotted or had become

infected.

For reasons that are not clear, the number of patients admitted with

grossly infected hemothoraces was larger in 1945 than in 1944. These patients, like those with clotted hemothoraces, were treated bv decortication.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 151

Empyema.—A small number of patients with basilar empyema, whose

cavities did not exceed 500 cc. in volume, were treated by open drainage. This

policy was based on four major premises:

1. Early, adequate drainage. The site, always dependent, was selected

after routine roentgenologic examination, mapping of the lesion after the

instillation of Lipiodol, and aspiration.

2. Maintenance of the wall of the empyema cavity in an acute inflammatory state, so that obliterative pleuritis would proceed rapidly. The frequent

application of irritating packs tended to maintain the desired acute pleuritis.

3. Maintenance of the nutritional state by appropriate diet, accessory vitamin therapy, and replacement therapy as indicated.

4. General and specific remedial exercises (p. 314).

A small number of patients who were in poor or critical condition when

they were received in the center were treated by open drainage, in preparation

for later decortication. As a rule, they were ready for the more radical operation in from 7 to 14 clays. Open drainage was also used for the small localized

residual empyemas sometimes observed after decortication.

Rib-resection drainage (fig. 15) was performed in 170 cases in which the

empyema was too extensive to be managed by open drainage.

Decortication.—Decortication was used with increasing frequency, and

with improving results, as the war progressed. The approach, however, was

always conservative. The indications were as follows:

1. Clotted hemopneumothorax associated with acute cardiorespiratory

embarrassment, overwhelming sepsis, or both. In such cases, the extensive

loculation and clotting made both aspiration and rib-resection drainage unsatisfactory.

2. Any hemothorax in which the accumulation of clotted, infected blood

was estimated to be more than 700 cc. Smaller accumulations could usually

be handled satisfactorily by more conservative measures.

3. Obscuration of at least half of the involved lung field, with no evidence of clearing under attempts at aspiration and the institution of active

breathing exercises, as determined by weekly fluoroscopic and roentgenologic

examinations. When the obscuration was greater than half the lung field and

remained stationary for more than 2 weeks, decortication was usually resorted

to without further delay. With proper roentgenologic techniques, it was possible to outline the extent of the hemothorax and the encompassing membrane

fairly clearly.

The technique used was, in general, that employed in the Mediterranean

theater, where the operation was first introduced for organizing hemothorax

and hemothoracic empyema (p. 27). If a foreign body was retained in the

lung, it was removed atthe same operation.

A primary cure was obtained in possibly 75 percent or more of all cases.

If infection persisted, the empyema was usually small and localized, and open

drainage rapidly effected a cure. In some cases, the cause of failure was found
152 THORACIC SURGERY

\ /

-^n

,-*. i m

FIGUKE 10.—Technique of ligation of lacerated thoracic duct. A. Posterolateral incision. B. Bed of fifth rib, which has been resected. C. Isolation of duct above aorta

and behind left subclavian artery. D. Double ligation of duct. Decortication was also

performed. Recovery was uneventful (ICOtli General Hospital thoracic surgery center).

to be a persistent bronchopleural fistula, which prevented complete reexpansion of the lung. These patients were treated without delay by continuous

high negative pressure. They were placed on suction drainage applied from

a suction line set up in one of the wards, the lung thus being held in expansion

until the fistula closed.

Chylothorax.—Two patients were observed at the center with chylothorax

following perforating chest wounds. One, who had a moderately large cystic

area in the upper left lung field, was treated by repeated aspiration of chyle

from it. Convalescence was prolonged, but the response was favorable, and

no further treatment was required.

The second patient had a massive effusion through which large quantities

of chyle were repeatedly aspirated. When no signs of improvement were

evident, the thoracic duct was ligated (fig. 16), and decortication was performed. The result was excellent.

Diaphragmatic hernia.—It was the policy at the center to repair all

hernias of the diaphragm that were diagnosed, no matter how small the per-
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 153

foration might be, on the ground that otherwise the opening would inevitably

increase in size and permit herniation of abdominal organs. Operations for

herniations that had already occurred, particularly herniations of the stomach,

were often technically difficult.

Lobectomy.—The 951 operations performed at the 160th General Hospital

chest center included 15 lobectomies. This operation was used only when the

lobe, or part of the lobe, was damaged beyond repair. Sometimes the tissue

was found to have been actually blasted away. Whenever possible, the BladesKent technique of individual ligation, which had been described shortly before

the war, was used in these cases.

Thoracoabdominal wounds.—Fifty-six patients with suppurative complications of thoracoabdominal wounds were treated at the chest center at the

160th General Hospital. The data are as follows:

As was usual, the initial location of the wound greatly influenced both the

number and the seriousness of the complications. There were 46 complications on the right side, against only 10 on the left, They were classified as

follows:

1. Of the 15 instances of subphrenic infection without pleural involvement,

14 were on the right side, including 7 subphrenic abscesses, 6 hepatic abscesses,

and 1 combined subphrenic-hepatic abscess. The single infection on the left

side in this group was a subphrenic abscess. All 15 infections were successfully treated by conventional subphrenic drainage.

2. Of the 42 instances of subphrenic infection with pleural involvement,

32 were on the right side. They included 30 infected hemothoraces, 2 with

subphrenic and 28 with hepatic abscesses, and 2 uninfected hemothoraces, 1 with

a subphrenic and 1 with a hepatic abscess. The 10 infections on the left side

included 2 uninfected hemothoraces, both with subphrenic abscesses, and 7 infected hemothoraces. In this group there were two herniations of the stomach

and two gastropleural fistulas.

In the infections with pleural involvement, management depended upon

whether or not the diaphragmatic perforation was sealed off. If it was, the

pleural and subphrenic lesions were treated independently, by standard techniques. If the perforation was still open, the treatment depended upon the

size of the thoracic component:

1. If an empyema with an associated liver abscess was shown by roentgenograms to be small, it was opened widely by rib resection, and the hepatic abscess

was deroofed by removal of the overlying diaphragm and was drained into the

empyema cavity (fig. 17). Sloughing tissue was removed, and the abscess was

packed with gauze impregnated with zinc peroxide. Drainage was maintained

by the use of multiple tubes.

Among the first patients received at this center were a number with serious

liver abscesses associated with severe bleeding. One patient died. The open

method of treatment gave excellent exposure and permitted hemostatic packing

of the abscess under direct vision. This technique was lifesaving when bleed-
154 THORACIC SURGERY

•*»&

FIGUHE 17.—Combined drainage of chronic empyema and liver abscess following thoracoabdominal wound. A. Site of incision. B. Transplirenic derooflng of liver abscess with

drainage of liver abscess and localized chronic empyema through same wound: Empyema

pocket (a), divided diaphragm (b), and deroofed liver abscess (c). (Performed at 160th

General Hospital thoracic surgery center.)

ing was severe, but the duration of healing was intolerably long, and the more

definitive procedure was resorted to.

2. If the thoracic component was large, decortication was performed, with

repair of the diaphragm and immediate reexpansion of the lung. The hepatic

abscess was drained subdiaphragmatically to the point nearest to it on the chest

wall.

This technique was first used as a staged procedure in two patients who

were acutely ill on admission to the center, with total empyema and large liver

abscesses. Both were treated by immediate drainage of the empyema, with

deroofing of the liver abscess, followed by subphrenic drainage. Later, when

the patients' conditions had improved, decortication was carried out, with closure of the diaphragm. In both cases, convalescence was materially shortened,

and the end results were excellent. The procedure was thereafter used routinely, as a one-stage operation.

In one case in which this technique was used, the patient had a liver abscess

of 600-cc. volume, a laceration of the diaphragm to which a lacerated lung was

adherent, and an 80-percent mixed empyema containing bile. Bile and pus

were draining through an 8-inch sucking wound in the third anterior interspace,

and over a liter of fluid was being evacuated daily. Wide-open thoracotomy

was performed, with decortication of the empyema, repair of the lacerated lung,

and lateral drainage of the liver abscess through a liberal rib resection. Drainage of the liver abscess w-as effected by splitting the dome of the diaphragm

wide open to the area of the lateral rib resection. This technique seemed miphysiologic to some observers, who were concerned about the future of the
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 155

collapsed lung. The patient, however, was well on the way to recovery when

he was evacuated. He was typical of others who responded favorably to

similar treatment.

155th General Hospital

Administrative considerations.^The chest center at the 12th Hospital

Center was first established at the 90th General Hospital (Hospital Plant

No. 4173) on 18 May 1944. On 1 August 1944, the 90th General Hospital was

replaced by the 155th General Hospital, which operated as a chest center until

it was deactivated on 8 June 1945. Colonel Touroff served as director of the

chest center throughoutthe period of operation. In addition to serving as chief

of the thoracic surgery service at the 155th General Hospital, he was responsible for the care of all thoracic casualties in the various medical installations

which made up the chest center.6

During the 2 weeks between the establishment of the thoracic surgery center

and D-day^ Colonel Touroff visited all of the hospitals in his hospital center

and outlined a plan of treatment for thoracic casualties to the chiefs of the

surgical services, who were encouraged to request consultation on all special

problems. The policy of referring all elective thoracic surgery to the thoracic

center was also inaugurated.

When the center was fully operational and carrying its heaviest load, in

the first months of 1945, the personnel, in addition to the director, consisted of

three ward officers, six nurses, and five corpsmen. As the ward officers gained

in experience, they were able to assume most of the ward work and to relieve

the director of many of the routine duties he had originally had to assume himself. Since they had had little surgical training, all major surgical procedures

had to be performed by the chief of the center. As the operating load was

continuously large, many patients who required extensive secondary closure of

superficial wounds or operating procedures confined to the chest wall were

transferred to the general surgical section.

Population.—During the operation of the center, 1,388 patients were admitted, of whom 1,252 were referred from other hospitals in the hospital center.

In addition, 128 patients were treated in the medical or surgical wards of the

155th General Hospital under the direction of the staff of the thoracic surgery

center but were not transferred to it. The director saw 609 patients in consultation in the hospitals of the hospital center and performed 552 major operations. A few of the 836 patients treated by nonsurgical measures required

minor surgical procedures, such as secondary closure of small wounds or nerve

block.

The greatest patient and surgical load came in February 1945. In spite

of the sharp falling off of casualties around V-E Day, admissions to the thoracic

6 These data are derived from the semiannual reports of the 155th General Hospital for .TulyDeeember' 104-1 and .Tanuary-.Tune 1945, and from a special report on the activities of the chest center

by Colonel Touroff on 22 June 1945.
15C THORACIC SURGERY

center did not begin to slacken off until the latter part of May, and surgical

activity continued into June.

Facilities.—By early November 1944, casualties with chest wounds had

become so numerous that they had to be housed in widely separated wards,

wherever beds were available. On 11 November, the center was moved into a

separate group of three buildings originally designed by the British as a venereal disease section. It continued to function here until the hospital was closed.

By the utilization of the services of convalescent casualties, as will be pointed

out shortly, the buildings were kept in an excellent state of repair. In the

same manner, the grounds were landscaped, rehabilitation facilities were maintained, special equipment and furniture were constructed, and all nonmedical

activities of the center were supported.

The thoracic surgery center functioned as a self-contained unit within the

1.35th General Hospital. Complete facilities were available except for the performance of major surgery, for which the general hospital operating rooms

were used. Physical features included accommodations for 165 patients, an

operating room for minor surgical procedures and dressings, a recovery ward

for postoperative patients, a messhall, a dayroom, a central linen supply room,

and adequate office space. Ample grounds surrounding the building were

available for rehabilitation activities.

Plan of operation.—The compactness of the unit, an efficient arrangement of facilities, and extensive use of patient labor not only resulted in better

care of patients but also effected a great economy in operating personnel.

Patients who required maximal medical and nursing care, including bedridden

patients and those who needed special medication, were placed in rooms and

wards close to the offices for the medical staff and nurses. Here they were

always under close supervision. As soon as they became ambulatory or were

no longer in need of special attention, they were placed in convalescent wards

in which the atmosphere was more that of a military barracks than of a

hospital. Noncommissioned officer patients maintained discipline and order.

Patients made their own beds and were entirely responsible for the cleanliness

and policing of the wards. Convalescence under these circumstances prepared

them for subsequent return to duty rather than for prolonged invalidism.

Early mobilization of patients was the rule. As soon as a man became

ambulatory, he walked to the operating room for dressings and other treatment.

He took his meals in the messhall at the center until he was able to walk to the

main messhall in the hospital. These activities not only expedited the return

of the patient's strength but also resulted in considerable saving of time and

effort on the part of the professional staff and maintenance personnel.

Furthermore, the utilization of patient labor made it possible to use the services

of medical corpsmen exclusively for medical care.

As part of their program of rehabilitation, patients operated the messhall

and linen supply room. They served as clerks, messengers, hretenders, carpenters, painters, and gardeners. Convalescent patients with a special interest

in medical work were trained to assist corpsmen on the vrards and to help in
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 157

the operating room. Others served food to the bedridden patients and to those

who took their meals in the messhall of the center.

Equipment.—Equipment at the center was adequate, and every attempt

was made to avoid the use of unnecessarily elaborate instruments and accessories. Improvisation was necessary only twice:

1. A new and simple type of bottle stand, for use in closed drainage, was

devised, and six were constructed by one of the patients.

2. Extra-long probes, necessary for the packing technique used in certain

pleural infections, were also designed at the center and constructed by a patient.

Foreign bodies.—The foreign bodies removed from 318 casualties in the

155th General Hospital chest center are discussed under that heading (vol II,

cli. VIII). Included in the discussion is the technique devised at this center

for removing certain intrathoracic objects without entering the free pleural

cavity.

Suppurative processes.—In 124 cases, the major pathologic process was

suppurative, as follows:

1. The infection was intrapleural in 99 cases, 81 of which were managed

by open drainage, 13 by decortication, and 2 by closed drainage.

The open-drainage technique included a liberal incision, rib resection,

thorough visualization of the interior of the cavity with illuminated retractors,

opening of all recesses and loculations, and light packing of the cavity with

plain gauze. If the pulmonary surface was rigid and it was thought that

reexpansion might be slow, decortication of the lung was carried out within

the limits of the visceroparietal adhesions. In none of the 48 cases in which

this technique was employed was further revision of the empyema necessary.

The 13 patients selected for primary pulmonary decortication all presented

collapse of the pulmonary apex, which was so bound down that a prolonged

convalescence seemed inevitable if, indeed, the lung reexpanded at all. In

10 of the 13 operations, healing was by primary union, and the period of postoperative convalescence was greatly reduced. In the three other cases, subsequent open drainage was necessary before cure was accomplished.

The two cases treated by simple closed drainage needed no special comment.

Bacteriologic studies indicated that the type of organism responsible for

the pleural infection did not influence the success or failure of decortication.

In the two cases in which a culture of pure Clostridium weJchii was obtained,

the course was essentially as benign as in the ordinary pyogenic infection.

2. All four patients with abscess of the lung were treated by a single-stage

drainao-e operation. A small, accurately positioned incision was made directly

over the abscess, which was entered through the zone of visceroparietal adhesions invariably present.

In six other cases, pulmonary suppuration was treated by partial

lobectomy. In five cases, the lesion was an infected, necrotic hematoma, the

result of trauma by high explosive shell fragments. In the remaining case,

in which the indication for surgery was continued hemoptysis, the infection,

which was caused by Friedländer's bacillus was primary.
158 THORACIC SURGERY

3. In each of the three mediastinal abscesses, infection was the result of

injury to the esophagus by high explosive shell fragments. In each instance,

the suppurative lesion was in the superior mediastinum, above the level of the

aortic arch. All three operations were performed in a single stage, through an

anterior cervical incision.

4. In five of the eight cases in which empyema and subphrenic abscess

were present in combination, drainage was performed through two separate

incisions. In the three remaining cases, a single incision was used, the subphrenic abscess being drained by enlargement of the preexistent perforation

of the diaphragm.

5. In three of the four subphrenic abscesses, transdiaphragmatic-transpleural drainage was accomplished as a single procedure by the following

technique: immediate marsupialization of the diaphragm, by suture, after

the pleural cavity had been entered; incision of the diaphragm; evacuation of

the subphrenic abscess by suction before spillage could occur; and suture of

the edges of the diaphragmatic incision to the margins of the superficial

wound, thus further shutting off the free pleura. This procedure, which was

devised at the 155th General Hospital chest center, permitted prompt evacuation of a subphrenic abscess without the delay entailed in the usual two-stage

procedure. It was of special value in those cases in which the severity of the

clinical symptoms made prompt drainage desirable.

In the fourth case in this group, transdiaphragmatic drainage was performed extrapleurally. An incision was made in the costophrenic sinus below

the level of the pleura! reflection. An incision placed directly over the most

superficial portion of the subphrenic abscess provided adequate drainage. It

was thought that drainage of the abscess through the empyema cavity would

delay healing because of continued contamination from the more highly placed

empyema cavity.

Clotted hemothorax.—Decortication was performed in 82 cases of clotted

hemothorax, 11 of which were primarily infected. An intercostal incision was

used, with division of one rib, or, occasionally, of two ribs, posteriorly. If the

parietal membrane, was unusually thick and there was considerable restriction

and immobility of the chest, the thoracic parietes were decorticated with the

lung and diaphragm.

In 2 of the 68 uninfected hemothoraces, a minor postoperative axillary

empyema occurred; both processes were drained promptly and obliterated

without incident. A small residual axillary empyema was similarly treated in

one of the infected cases. Otherwise, the clinical course was the same in both

clean and infected cases. In the infected cases, although cultures were positive,

the fluid was not grossly purulent. Otherwise, the condition would have been

classified as empyema.

Miscellaneous conditions.—Other major procedures consisted of closure

of an external esophageal fistula in 1 case, and closure of bronchopleural

fistulas, bronchoeutaneous fistulas, and large thoracic wounds in 19 cases.

They require no special comment.
ADMINISTRATIVE CONSIDERATIONS IN EUROPEAN THEATER 159

Fatalities.—Of the four deaths which occurred at the 155th General Hospital chest center, one followed the uncomplicated removal of a superficially

situated foreign body and was caused by a cerebral hemorrahage (vol. II, ch.

VIII). The other three case histories were as follows:

Case 1.—This patient sustained a perforating wound of the trachea and a compound

comminuted fracture of the mandible, due to high explosive shell fragments. At the time

of wounding, there was considerable aspiration of blood into the tracheobronchial tree.

The patient was admitted to the chest center about 2y2 weeks after wounding, because

of extensive pulmonary suppuration in the right lung and a mediastinal abscess. Temporary improvement followed drainage of both abscesses. About 10 days later, there was

evidence of further spread of the gangrene, and death soon followed. Post mortem showed

the cause of the fatality to be septic thrombophlebitis of the pulmonary vein, anaerobic

septicemia, and multiple metastatic abscesses.

Case 2.—This patient sustained a right-sided bullet wound which involved the liver,

right diaphragm, lung, chest wall, and brachial vessels. He was received in the chest

center after amputation of the right arm, drainage of an extensive hepatic and subphrenic

abscess, and secondary laparotomy for acute intestinal obstruction. At this time, he had

a chronic empyema, with a right-sided bronehopleural fistula. He was extremely emaciated,

and a substantial excavation within the liver, with a complete external biliary fistula, was

evident through a large gaping wound in the right upper quadrant. Laboratory tests

revealed material reduction in liver function.

Drainage of the pleural infection was followed by prompt subsidence of toxic manifestations, but the patient presented serious nutritional problems, and death occurred

3 weeks after operation, after a progressively downhill course. Post mortem revealed

extensive chronic hepatoeellular damage, diffuse biliary cirrhosis, and atrophy of the liver.

Case 3.—This patient sustained a thoracoabdominnl wound on the left side, which was

followed by pleural infection, diffuse fibrinopurulent plastic peritonitis, and multiple

intra-abdominal abscesses. Neither thoracotomy nor laparotomy had influenced the septic

course, and he was admitted to the center for revision of the inadequately drained empyema.

Death occurred after the secondary drainage operation and was attributed at post mortem

to intraperitoneal suppuration with multiple encapsulations of pus throughout the abdomen,

not amenable to surgical treatment.

Results.—Evaluation of the results of therapy was not possible because

of the short time the patients were under observation. In most instances, those

who did not require evacuation to the Zone of Interior were sent to rehabilitation and reconditioning centers to be prepared for return to duty.7

Rehabilitation.—As is evident from what has already been said, the rehabilitation program at this chest center required the participation of convalescent patients in all of the activities of the center. This was an efficient

and wholesome way of expediting their recovery, and the sight of these recently

wounded men working about the wards and in other parts of the hospital, as

well as on the grounds, was a continuing source of encouragement to newly

arrived patients, who realized hopefully that they too would soon be on the

road to recovery.

The rehabilitation program as such was carried out under the direct supervision of a designated officer patient, assisted by other convalescents. It con7

Several attempts were made in the European theater to follow up patients by means of postcards

which accompanied the patient to the rear and were preaddressed to the surgeon who had treated

him in the forward hospital. None of these attempts was successful in a sufficient number of cases

to permit an analysis of results.
160 THORACIC SURGERY

sistecl of general physical exercises; special thoracic exercises; exercises

designed to restore the function of specific muscles, especially those of the

shoulder and upper arm; and graded competitive sports.

As soon as a patient arrived in the center, he was given written and personal instruction in thoracic exercises, which were engaged in by all patients,

whether ambulatory or bedridden, under supervision, at least three times a clay.

Individual exercises were prescribed as necessary. Early mobilization was encouraged, and most patients were out of bed on the second or third clay after

operation. As the patients regained their strength, they were encouraged to

participate in outdoor athletic activities, such as horseshoe pitching, badminton,

volleyball, and basketball. The volleyball and basketball courts were constructed by the patients as part of their own advanced rehabilitation activities.

Competitive activities were graded from mild to strenuous, and patients were

permitted to indulge in them as their strength increased.

References

1. Circular Letter No. 174, Office of the Chief Surgeon, Headquarters, ETOUSA,

28 Nov. 1943.

2. Circular Xo. 22, Headquarters, ETOUSA, 23 Feb. 1943.

3. Training Memorandum No. 3, Headquarters, Western Base Section, ETOUSA,

15 Feb. 1943.

4. Circular Letter No. 101, Office of the Chief Surgeon, Headquarters, ETOUSA,

30 July 1944.

5. Circular Letter No. 71, Office of the Chief Surgeon, Headquarters, ETOUSA,

15 May 1944.

0. Circular Letter No. 80, Office of the Chief Surgeon, Headquarters, ETOUSA,

10 June 1944.

7. Manual of Therapy, European Theater of Operations, 5 May 1944.

S. Circular Letter No. 23, Office of the Chief Surgeon, Headquarters, ETOUSA,

17 Mar. 1945.

9. Tidy, Henry Lethehy and Kutsehhach, J. M. Browne (editors) : Inter-Allied Conferences on War Medicine 1942-1945; Convened by the Royal Society of Medicine. London,

New York, Toronto : Staples Press, Ltd., 1947.

10. Kendriek, Douglas B., Jr.: The Blood Program. In Medical Department, United

States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I.

Washington : U.S. Government Printing Office, 19G2, pp. 121-103.

11. Circular Letter No. SI, Office of the Chief Surgeon, Headquarters. ETOUSA,

10 June 1944.

12. Circular Letter No. 32, Office of the Chief Surgeon, Headquarters, ETOUSA,

6 Apr. 1945.

13. Administrative Memorandum No. 62, Office of the Chief Surgeon. Headquarters,

ETOUSA, 3 May 1044.

14. Circular Letter No. 39, Office of the Chief Surgeon. Headquarters. ETOUSA,

5 May 1945.

15. Circular Letter No. 131, Office of the Chief Surgeon. Headquarters. ETOUSA,

8 Nov. 1944.
CHAPTER V

Administrative Considerations in the

Zone of Interior

Brian Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.

"When the United States entered World War II, thoracic surgery was not

yet a fully developed specialty. The American Association for Thoracic

Surgery, stimulated by the advances in the specialty in World War I, had

been formed in 1918, but The Board of Thoracic Surgery, Inc., was not set

up until 1948. The amount and variety of thoracic surgery performed at the

various chest centers overseas and in the Zone of Interior provided a stimulus

that took this specialty out of tuberculosis Sanatoriums and initiated its postwar advances.

THE CONSULTANT IN THORACIC SURGERY

No consultant in thoracic surgery was ever formally appointed in any

oversea theater during World War II, probably because of the still uncertain

status of this specialty at the beginning of the war. In the Zone of Interior

the situation, fortunately, was different. In July 1942, Capt. (later Col.)

Brian Blades, MC, was assigned to Walter Beed General Hospital, Washington, D.C., with the specific mission of setting up a thoracic surgery service.

Shortly afterward, he was appointed Consultant in Thoracic Surgery, Office

of The Surgeon General, and he served in both positions until the end of

the war.

When Captain Blades assumed his duties at Walter Reed General Hospital, there was no thoracic surgery service there or at any other hospital in

the Army system. At Walter Reed General Hospital, however, thoracic

surgery had a status of sorts. This was chiefly because of the continuing

influence of Col. William L. Keller, MC, who, almost singlehandedly, had

cleaned up the backlog of chronic chest infections that were the heritage of

World War I. His work was so brilliant that the most eminent chest surgeons

of the day came long distances to observe it.

The connecting link between Colonel Keller and the thoracic surgeons

who came to Walter Reed General Hospital in the first months of World War

II was Col. (later Maj. Gen.) Norman T. Kirk, MC, who had served under

161
162 THORACIC SURGERY

Colonel Keller and who had maintained his interest in chest surgery after the

latter retired.

Incidentally, it was the vivid recollection of the chronicity of those World

War I infections and the length of time—almost 10 years—it had taken to dispose of them that made General Kirk, then The Surgeon General, so unwilling

to release thoracic surgeons from service at the end of World War II.

In July 1942, when Captain Blades assumed his duties at Walter Reed

General Hospital, there were not more than a dozen civilian clinics and centers

in the United States at which thoracic surgery was being done as a separate

specialty or in any volume. Some tuberculosis surgery was being clone at

Fitzsimons General Hospital, Denver, Colo., but at the Walter Reed General

Hospital, chest surgery was chiefly limited to the type being done just after

World War I. In September 1942, when Captain Blades did the first pneumonectomy performed at any Army hospital, it was characteristic of the

opinion then held of the operation that there was considerable disapproval of

his boldness in undertaking it. The patient, fortunately, made an excellent

recovery.

By the time the first casualties arrived from North Africa, late in 1942, the

thoracic surgery service, which had originally shared a ward with the neurosurgical service, had its own ward and its own personnel. In March 1943,

Walter Reed General Hospital was designated as a thoracic surgery center

(p. 171), and as such it continued to expand until the end of the war. It is

interesting to recollect, since it was the first thoracic surgery center to be designated in World War II, that it had served the same purpose in World War I,

under Colonel Keller's direction.

In his capacity as Consultant in Thoracic Surgery to The Surgeon General, Captain Blades responded to requests for advice from that office or offered

advice himself as the situation demanded. Relations between himself and the

personnel of the Office of The Surgeon General were always cordial and close.

General Kirk, as already mentioned, had a special interest in thoracic surgery

because of his association with Colonel Keller, and with Maj. (later Col.)

Michael E. DeBakey, MC, and Lt. Col. (later Col.) B. Xoland Carter, MC, of

the Surgical Consultants Division, who had practiced this specialty in civilian

life. There was therefore a meeting of minds on policies and practices.

One of Captain Bladies' duties as Consultant in Thoracic Surgery to The

Surgeon General was the inspection of thoracic surgery centers. Each of

these centers was visited at 3- or 4-month intervals during the war, and occasionally, if special problems required solution, they were visited oftener.

This necessity, however, was not usual. All of the centers were directed by

well-trained and experienced thoracic surgeons, and while there were sometimes differences of opinion about details, there was practically always complete agreement upon principles.
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 163

SUBCOMMITTEE ON THORACIC SURGERY, DIVISION OF MEDICAL

SCIENCES, NATIONAL RESEARCH COUNCIL

The Subcommittee on Thoracic Surgery was one of the numerous subcommittees formed by the Division of Medical Sciences, National Research

Council, to act in an advisory capacity to the Surgeons General of the Army,

Navy, and Public Health Service (1). Its membership consisted of Dr.

Evarts A. Graham, Chairman, Dr. Isaac A. Bigger, Dr. Edward D. Churchill,

Dr. Leo Eloesser, Colonel Keller, Col. (later Brig. Gen.) Charles C. Hillman,

MC, Capt. (later Col.) James H. Forsee, MC, and Comclr. (later Rear Adm.)

Frederick R, Hook, USN (MC).

The general functions of the Subcommittee on Thoracic Surgery were to

give advice on the organization of hospitals from the standpoint of thoracic

surgery, on the care of thoracic wounds, and on any other phases of thoracic

surgery on which advice might be required. This Subcommittee was also to

consult with the Subcommittee on Anesthesia, National Research Council,

which was organized a little later, and to prepare a small manual on thoracic

surgery. Work on this manual had already begun (p. 167) when the Subcommittee was organized.

The Subcommittee on Thoracic Surgery held two meetings, the first on

25 July 1940 (1), before the United States entered the war, and the second

on 16 January 1942 (2), some six weeks after Pearl Harbor. At both meetings, the chief discussions concerned thoracic surgery personnel, and at the

first, the general point of view seemed somewhat unrealistic, the chief dissenter being Colonel Keller. Contrary to the views of most of those present,

he doubted that the supply of trained thoracic surgeons would be in any way

adequate to the demand. In his opinion, therefore, these surgeons should be

carefully assigned and employed only in the largest installations, where they

could be utilized to their full capacity. He repeatedly emphasized that the

more generous assignments visualized by the other members of the Subcommittee must be regarded as tentative. By the second meeting, others had come

to share Colonel Keller's views.

It is a great pity that the potentialities of the Subcommittee on Thoracic

Surgery were not utilized as they might have been. There was no real liaison

between it and the operating personnel responsible for thoracic surgery in the

Office of The Surgeon General. Some of its members, particularly Dr.

Graham and Colonel Keller, had had extensive military experience in World

War I, and this experience might have been of great value, and prevented

many errors, if it had been properly utilized in World War II. In retrospect,

it almost seems that the Subcommittee met and made its suggestions in a

vacuum. Certainly its advice did not reach the quarters in which it might

have been useful.
16-i THORACIC SITRGEEY

PERSONNEL

By 1938. the American Association for Thoracic Surgery, which had been

formed in 1918, had 14 honorary members, 99 active members, 69 associate

members, and 30 senior members. It was from the group of active and associate

members that the thoracic surgeons who served as directors of thoracic surgery

centers, as heads of thoracic surgery services, and as members of thoracic

surgical teams were chiefly drawn; they numbered 168. As already pointed

out, The Board of Thoracic Surgery, Inc., was not founded until after the war,

and the reservoir of qualified specialists provided by diplomates of other

boards thus did not exist for thoracic surgery.

One of the more useful actions of the Subcommittee on Thoracic Surgery

was to group the membership of the Association, on the basis of their qualifications, for the use of The Surgeon General in assignment, as follows (ß) :

Class I, capable of being a consultant in thoracic surgery.

Class II. capable of being the chief of the thoracic surgical service in a

large hospital.

Class III, capable of being an assistant chief of the thoracic surgical

service in a large hospital or chief of service in a small hospital.

Class IV, capable of being a ward officer or assistant ward officer on a

thoracic surgery ward.

On Dr. Churchill's suggestion, a supplementary list of thoracic suraeons

was obtained by writing to all the surgeons in classes I and II and requesting

them to submit the names of young surgeons who had received all or part of

their training in thoracic surgery under their supervision within the last 5

years.

Early m the war, the assignment of thoracic surgery personnel was far

more difficult, and far less satisfactory, than it should have been because the

Personnel Division, Office of The Surgeon General, made assignments arbitrarily, without full knowledge of the capabilities and experience of the

specialists involved, and without consultation with the Surgical Consultants

Division, Office of The Surgeon General. As a result, there were some wasteful

misassignments. A medical officer, for instance, born in China and speaking

Chinese, requested an assignment for thoracic surgery in the China-BurmaIndia theater, where his peculiar combination of abilities would have made him

most useful. He was assigned to making physical examinations in the North

Atlantic Patrol, and it required almost a year to change his assignment.

Eventually, after about a year of difficulty, The Surgeon General issued

an order that no assignments were to be made in the surgical specialties without the approval of the Surgical Consultants Division of his office. It was

still necessary, as it was to the end of the war, to locate thoracic surgeons

by personal contact with the heads of civilian services, but at least the

misassignments made early in the war were practically ended.
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 165

The Consultant in Thoracic Surgery was, of course, consulted by the

Surgical Consultants Division on all personnel assignments and was of great

help in making them.

TRAINING

The possibilities of training in thoracic surgery were considered at the

first meeting of the Subcommittee on Thoracic Surgery, Division of Medical

Sciences, National Research. Council, in July 1940 (1). The question had already been discussed by the parent Committee on Surgery, with special reference to the training of Reserve officers, but nothing had been done because of

lack of funds.

It was the opinion of the Subcommittee that more thoracic surgeons should

be trained, and all who were present at the meeting expressed themselves as

glad to assist if funds could be made available. There were, however, fundamental differences of opinion as to the courses to be set up. Colonel Hillman

thought that they should not be longer than 2 weeks. Dr. Graham thought

that nothing desirable could be accomplished in less than 2 or 3 months.

Training was again discussed when the Subcommittee met on 16 January

1942 {2). There was general agreement that it was feasible to train thoracic

surgeons for the Army in civilian hospitals. Dr. Churchill displayed a map

of the United States on which he had designated certain large civilian clinics

which could provide the necessary facilities and personnel. Three months was

considered the minimum length for the courses, and Dr. Churchill thought

that, in certain instances, officers assigned for this training might be of greater

eventual value to the service if they were retained for longer periods of instruction. It was agreed that officers assigned to these courses should be selected

most carefully. If they proved unsuitable for the work, or if they did not apply

themselves, the Office of The Surgeon General would be notified at once and

they would be relieved from the assignment.

The Subcommittee agreed to advise The Surgeon General shortly of the

availability of courses in thoracic surgery in civilian institutions which could

be attended by medical officers.

The courses were set up at Columbia University, New York, N.Y., The University of Michigan, Ann Arbor, Mich., the University of Pennsylvania, Philadelphia^ Pa., and Washington University, St, Louis, Mo. Like the similar

courses in neurosurgery, these intensive courses proved a very satisfactory way

of providing intensive training in thoracic surgery for men who already had

some training in general surgery. In the beginning, the selection of students

was not handled as wisely as it might have been. Those selected did not always

have a background of general surgery, and it was sometimes difficult to see on

what basis they had been chosen. Inappropriate volunteers were also permitted. Eventually, these difficulties were straightened out, and the end results

were excellent. The majority of the graduates were sent overseas, where many

of them rendered outstanding service in various capacities in thoracic surgerv
166 THORACIC SURGERY

centers and on thoracic surgery services. A few were retained in this country.

It is interesting to note that one or two of the most outstanding graduates had

begun this course with great reluctance and with no interest at all.

In spite of the casual fashion in which students for these courses were

originally selected, the instruction was frequently of great value from the

standpoint of the medicomilitary effort. Sometimes, in addition, it had a great

impact upon the careers in service and the future medical careers of some of

the students. The following letter from Dr. (formerly Map, MC) David J.

Dugan, written in response to an inquiry concerning his instruction at the

University of Pennsylvania, makes this quite clear. Dr. Dugan wrote, in part,

as follows:

ily enrollment in the thoracic surgery course at the University of Pennsylvania was

entirely unsolicited. I was doing general surgery in Cleveland before I entered the service

in September 1942. I was assigned to "Walter Reed General Hospital, but as soon as I

arrived I received orders to report to the University of Pennsylvania to take a course in

thoracic surgery, a specialty I barely knew existed. There were nine in the class. At the

same time, courses were being given there for medical officers in neurosurgery and in surgery of the extremities. Both courses, as I recollect, had enrollments of 30 to 35 officers.

Thoracic surgery was certainly in the minority.

The object of all these courses was to train general surgeons in these particular

specialties, so that they would have additional knowledge and experience when they were

sent overseas, which, we understood, would be as soon as the courses were completed.

The thoracic surgery course lasted for 0 weeks. There were daily lectures, from 8 to

12, attended by the men in all three courses, and given by physiologists, biochemists, and

anatomists. They were very general, and much of the time was spent on antibiotic therapy,

then very new. These lectures were excellent.

In the afternoons, the students in the thoracic surgery course went to the various

hospitals in Philadelphia, particularly to observe endoscopic work. We had no practical

experience, but we did have the opport unity to observe such men as Clerf and Chevalier

Jackson while they were at work. We also operated on cadavers in the afternoons, an

experience I found very valuable, for we worked under the supervision of Dr. Batson. then

Professor of Anatomy at the University of Pennsylvania, who had a remarkable ability

to combine the academic and clinical aspects of anatomy. It was a real privilege to study

anatomy under him.

An examination was given at the end of 0 weeks, and while none of us, so far as I

know, ever found out how we had done, we all had the impression that our grades would

determine how far away from home we would be sent. Whether that rumor was true I

never found out.

At any rate, at the end of the course. I was sent back to Walter Reed. Almost as soon

as I arrived, a large convoy of chest casualties was received, and my only qualification for

assisting in their care was the 6 weeks' course I had just completed. Fortunately, my work

was done under the supervision of Colonel Brian Blades, who was in charge of the thoracic

surgery service at Walter Reed throughout the war.

I worked under Colonel Blades for the next 3 years, then was put in charge of the

thoracic surgery service at Fitzsimons General Hospital in Denver until I was separated

from service in September 194G.

The course at the University of Pennsylvania, although it was a totally unexpected

introduction to my Army service, was a real delight and completely altered my medical

career. When I left the Army, I came to Oakland, Calif., and I have been engaged here

since in the private practice of thoracic surgery.
ADMINISTRATIVE CONSIDERATIONS IN ZONE OP INTERIOR 167

ANESTHESIA

Anesthesia for intrathoracic surgery was generally satisfactory at the beginning of the war, since competent anesthesiologists, equipped to give intratracheal anesthesia, were available in all hospitals in which such surgery was

done. It became increasingly satisfactory as the war progressed, as anesthesiologists gained experience, and as more of them became available through formal

and informal training.

Equipment for anesthesia was uniformly good. Dr. Joseph Kreiselman,

Consultant in Anesthesia to The Surgeon General, was of great assistance in

the selection of the most efficient equipment for special techniques as well as

for general techniques.

EQUIPMENT

The thoracic surgery equipment which Captain Blades found when he

assumed his duties at Walter Peed General Hospital in July 1942 was chiefly

that used for the operations performed after World War I. These deficiencies

were shortly corrected by provision of the list of supplemental instruments

drawn up by Dr. Eloesser and Colonel Kirk (£), which were supplied to all

hospitals. As a matter of fact, most thoracic surgery was then—and still is—

done with the instruments used in general surgery, and these were in ample

supply.

Instruments for thoracic surgery were eventually of the highest quality

and were provided in sufficient numbers, though those used by the hospitals

supporting the North African invasion in November 1942 were deficient in

both quality and quantity (p. 84). Part of Captain Blades' duties as Consultant in Thoracic Surgery to The Surgeon General concerned the revision of

the lists of thoracic surgery equipment.

MANUAL ON THORACIC SURGERY

The work of the Subcommittee on Thoracic Surgery on a manual on this

subject was initiated 10 July 1940, when Colonel Hillman, Chief, Professional

Service Division, Office of The Surgeon General, notified Dr. Graham that

among the technical manuals which his office considered necessary was one on

thoracic surgery. He requested that Dr. Graham submit to him a list of subjects

that should be covered in such a text.

Two weeks later, when the first meeting of the Subcommittee was held

(1), a considerable start had been made on this book. The members of the

Subcommittee were asked to study and comment on the 40 pages already prepared, and Dr. Eloesser, who had worked on the material with Dr. Graham,

displayed a chart that tabulated the material to be included in the text and

which was suitable for use in operating rooms.
168 THORACIC SURGERY

In discussing the manual at this meeting', Colonel Hillman stated that he

wished the book to be loose-leaf, to be very brief, and to cover the treatment of

chest injuries only from wounding until the casualty reached an evacuation

hospital. The book was not to include definitive treatment, since the medical

officers responsible for that phase of therapy would not need such a book.

Colonel Hillman thought that a list of texts should be included. It was his

idea that the manual be distributed only to medical officers responsible for first

aid; the expense of a wider distribution would be too great.

Shortly before this meeting, Dr. Graham had written Colonel Hillman that

the preparation of this manual had become more complex than he had anticipated. The final revision was not accomplished until the meeting of the Subcommittee on Thoracic Surgery on IG January 1942 (2), when both the text

and the illustrations were approved. By this time, the original concepts had

been altered in a number of respects. The manual, which is described in detail

elsewhere (p. 190), did not appear until 1943 (3), and did not play the role that

had been visualized for it.

THORACIC SURGERY CENTERS

Historical Note

In World War I, certain hospitals were staffed and equipped by the

Medical Department for the care of special groups of casualties. There were

no thoracic surgery centers, as might have been expected. At that time, few

surgeons were qualified in this specialty or interested in limiting their activities

to diseases and injuries of the chest. In a few hospitals, suppurative pleuritis

was segregated, but the patients with this condition were usually cared for on

septic surgery sections. In any event, segregation went no further.

In the interval between the World Wars, a limited amount of specialization became the policy in Army hospitals, but it was chiefly confined to radiology and neuropsychiatry. If specialized surgery was required, it was provided

by civilian surgeons working under contract.

Evolution of Policies

In 1939, when planning began for the war that seemed imminent, changes

in the tables of organization of hospital units began to reflect the civilian

tendencies toward increased specialization (.£). New tables published during

1940 listed, for the first time, the specialists required to serve as chiefs of

professional services and as ward officers. These tables also allotted to hospitals

more enlisted men with specialist ratings and correspondingly fewer with only

basic military training. The total number of officers and enlisted men assigned

to hospitals was also increased. In a 1,000-bed general hospital, for instance,

the number of officers was increased from 42, of whom 30 were medical officers,
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 169

to 73, of whom 55 were medical officers. The number of enlisted men assigned

to such a hospital was also increased, from 400 to 500.

As increasing numbers of specialists in various fields entered the Army,

civilian emphasis upon specialization began to be reflected in Army policy.

By the end of 1942, The Surgeon General made it clear that he intended to

formalize and extend this policy. The circumstances were ripe for his action.

By this time, new general hospitals were beginning to open one after

another, and it was soon clear that the limited supply of specialists in various

fields would not be sufficient to permit the staffing of each of them for all

varieties of medical and surgical work. At the same time, with the transition

from defensive to offensive warfare which occurred with the invasion of North

Africa, the Medical Department was obliged to visualize the arrival in the Zone

of Interior of increasingly large numbers of combat casualties who would

require specialized treatment. The plan of specialized centers therefore began

to take shape.

There was, however, a serious obstacle to its implementation. In the fall

of 1942, there was growing public insistence that casualties should be hospitalized as near as possible to their homes, and in December of that year,

The Adjutant General proposed the establishment of hospitalization policies

to meet this demand. If these policies had been adopted and applied rigidly,

they would have conflicted with The Surgeon General's (still unpublicized)

plan to transfer casualties who required specialized treatment to hospitals

specializing in the treatment of particular diseases or injuries.

The Surgeon General proposed to resolve the conflict in two ways:

1. By sending patients who needed specialized treatment to general hospitals designated to supply such treatment.

2. By sending those who required prolonged, but not specialized, treatment

to hospitals in the vicinity of their homes.

This policy was announced on 1 February 1943. For the next several

weeks, the Hospitalization and Evacuation Division, Office of The Surgeon

General, worked on the problem, and on 6 March 1943, upon their recommendation, the War Department designated 19 general hospitals for the treatment

of 6 specialties, including chest surgery.

In 1939, only two hospital centers were conceived of in the medical planning,1

and until the middle of 1944, specialty centers in general hospitals were

established piecemeal, to meet needs as they arose, without regard to eventual

requirements. Up to this time, too, the beds allotted for specialized treatment

in general hospitals occupied only a small proportion of the total hospital

bed capacity.

1 At the first meeting of the Subcommittee on Thoracic Surgery, there had been some discussion

about concentrating casualties with thoracic injuries in specialized hospitals, but the plan was not

then considered practical.

653681T—62 13
1T0 THORACIC SURGERY

There were atleasttwo reasons for this chaotic situation:

1. An army in training, which the U.S. Army was, for the most part,

in the first months of the war, had less need for specialized services than an

army in combat.

2. Early in the war, it was difficult to predict the types and amounts of

specialized care that would be needed. In the summer of 1944, the Facilities

Utilization Branch, Office of The Surgeon General, engaged in a study of the

anticipated need for specialized centers and the preparation of a comprehensive

plan to meet it. By the time of the invasion of Europe, enough casualties had

been received from the North African theater and from the Pacific to permit

the breakdown of the anticipated casualty load in terms of wounds, injuries,

and diseases.

The general features of this plan, which were announced in War Department Circular No. 347, issued on 25 August 1944, remained in effect throughout

the war. They were as follows:

1. As far as practical, related specialties were grouped in the same hospital

centers, in order to improve the quality of professional care.

2. Attempts were made to locate centers for specialized treatment in

relation to population density, to permit the utmost compliance with the policy

of hospitalizing patients as near their homes as possible. Success in this respect

was limited by several considerations. One was the uneven initial distribution

of hospitals: there were proportionately fewer hospitals in the densely crowded

areas of the northeastern United States than there were in the South and

Southwest, where, logically, they had been located to serve large concentrations

of troops in training. Another reason for difficulty in hospitalizing patients

in need of specialized care was that all specialties did not require the same

number of centers. Neurosurgical and orthopedic casualties, for instance, required provision for many times the numbers of beds required for blinded and

deafened casualties.

There was some disagreement concerning the most useful size for the

centers. Professional consultants in the Office of The Surgeon General preferred that they be kept reasonably small. The Facilities Utilization Branch

in that office considered it more economical to limit the number of centers

and increase their size, in view of the increasing shortage of specialists, which

required them to be so assigned that they could be utilized to the fullest.

As the patient load increased, much of this argument became academic.

In the last months of the war, some centers had 2,000 or more beds, and in a

number of instances, general hospitals became, in effect, specialized hospitals.

When the peak of the patient load in the Zone of Interior was reached, in

June 1945, there were 234 centers for treatment of the various specialties,

located in 65 hospitals, and with a total of 132,178 beds.

Operation of hospital centers for thoracic surgery in the Zone of Interior

was attended with all the advantages of their operation in oversea theaters

(p. 98). In addition, these centers offered unusual opportunities for the
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 171

study of diseases of the chest, many of which are seen in too small numbers in

civilian practice to permit conclusions as to their management.

Thoracic surgery centers also had another highly practical advantage.

The strict regulations that required patients in need of thoracic surgery to be

sent to them kept surgeons untrained in this specialty from performing operations for which they were not qualified. This was an important consideration

at a time when thoracic surgery was still a developing specialty.

Location of Centers

Four thoracic surgery centers were designated on 6 March 1943, at Walter

Reed General Hospital, Fitzsimons General Hospital, Kennedy General

Hospital, Memphis, Tenn., and Hammond General Hospital, Modesto, Calif.

Within a short time, it was evident that these four centers would be unable to

handle the anticipated patient load, and in May 1943, Brooke General Hospital,

San Antonio, Tex., was also designated as a center for thoracic surgery. Bruns

General Hospital, Santa Fe, N. Mex., although it was never formally designated as a chest center, received most casualties with tuberculosis who required

surgery and also received a small number of patients who required chest

surgery for other reasons.

In August 1944, Baxter General Hospital, Spokane, Wash., was designated

as a chest center, to replace the center at Hammond General Hospital. In

July 1945, consideration was given to relocating the center at Walter Reed

General Hospital, partly for administrative reasons and partly because a

thoracic surgery center was needed in the northeastern United States. Halloran General Hospital, Staten Island, N.Y., was recommended for this purpose,

but the Hospital Planning Division did not agree, and the chest center at

Walter Reed General Hospital was maintained even after other chest centers

were closed.

Facilities and Equipment

Some thoracic surgery centers occupied existing facilities throughout the

period of their operation. At Fitzsimons General Hospital, for instance,

active surgical patients were treated in two wards of 163 beds, with 23 of the

196 beds assigned to the chest service reserved for tuberculosis surgery.

Ambulatory convalescent patients were cared for in outlying wards while

awaiting ultimate disposition.

At Baxter General Hospital, the special facilities constructed for the chest

center were not ready until 1 October 1945. They included offices for the

director of the center and his assistants, conference rooms with view boxes,

a recovery ward for postoperative patients (with provision for bedside oxygen

and negative pressure suction), a complete roentgenologic and fluoroscopic

unit, a central dressing room for ambulatory patients, an operating room for

minor surgery and bronchoscopy, and kitchen facilities for the postoperative

recovery ward.
172 THORACIC SURGERY

After the first months that the centers were operated, instruments and

other equipment were generally both excellent and plentiful. There were,

however, occasional exceptions. Thus in March 1945, the center at Baxter

General Hospital still had no Heidbrink anesthetic machines, which were

urgently needed for efficient intratracheal anesthesia. Intratracheal anesthesia could be given with the equipment available, but patients would have

been anesthetized more safely and more easily had the proper specialized

equipment been provided.

Policies and Practices

As part of the planning for special centers in the summer of 1944, Brig.

Gen. Fred W. Eankin, Chief Consultant in Surgery, Office of The Surgeon

General, wrote to the Chief, Personnel Service, in the same office, that for a

thoracic surgery center of 350 beds, he considered that minimum personnel

should consist of a chief of service, an assistant chief, and two ward officers.

This minimum was always met, in spite of the shortages of thoracic surgeons,

and on busy services, it was frequently exceeded.

When the thoracic surgery center at Baxter General Hospital was opened,

a medical consultant with wide experience in diseases of the chest was assigned

jointly to the medical service and the thoracic surgery center, as liaison officer.

This greatly facilitated consultation procedures. Similarly close liaison was

established with the Radiology Section by the appointment of a junior officer

to work on both services. At daily conferences, all newly taken roentgenograms were jointly reviewed by the roentgenologist, the staff of the surgical

center, and the liaison officers. Treatment was facilitated and its quality

greatly improved by these conferences, which, in one form or another, were

held at all centers.

A certain proportion of the patients assigned to chest centers, averaging

about 20 percent, required consultation with, and treatment by, other specialists. This was especially true of casualties with neurosurgical and orthopedic

injuries. No time was lost in seeking these consultations, and the turnover

of beds was rapid. At the Fitzsimons General Hospital chest center, the

average period of hospitalization was less than a month.

Clinics for diagnostic procedures, and, occasionally, for therapeutic pi'ocedures, were an important phase of the work of all centers. In 1944, the

clinic at Fitzsimons General Hospital carried out 1,665 such procedures, including 35 laryngoscopies, 474 bronchoscopies, 52 gastroscopies, 513 fluoroscopies, 23 esophagoscopies, 462 bronchographies, 71 other installations of contrast media, and 35 dilatations of the esophagus.

Associated Convalescent Hospitals

When convalescent hospitals were first opened in the Zone of Interior in

1944, they were frequently established on the same posts as general hospitals.

At first, most of them were administered under separate commands and with
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 173

a separate administrative organization for the control of patients and all other

activities. Later, convalescent hospitals were operated as hospital centers, a

policy which had a number of advantages. Under it, the administration,

supply, and service activities of both installations were carried out in a single

headquarters, which freed hospital commanders of much administrative

detail, reduced personnel, and eliminated duplicating and overlapping effort.

Centralization also made it easier to shift personnel between the hospitals

and the convalescent centers as they were needed. One of the chief advantages was the operation of a single registrar's office for both installations.

This made it possible to move patients from one to the other by simple internal

transfer rather than by the complicated procedures necessary when they were

moved between separate installations.

The thoracic surgery centers began to close before final plans for the most

efficient operation of the convalescent hospitals in connection with them could

be put into effect.

REPORTS OF THORACIC SURGERY CENTERS

The methods of operation and the experiences of the thoracic surgery

centers in the Zone of Interior varied in details, but policies and practices were

much the same in all. The experiences of the Kennedy General Hospital

thoracic surgery center during the war and of the Walter Eeed General Hospital thoracic surgery center after the war are presented as typical.

Kennedy General Hospital

Population.—The chest surgery service at Kennedy General Hospital began in June 1943, with a few patients in a single ward.2 At the end of the

year, the service had an average census of 40 patients. By the end of 1944,

it had spread to five wards, and the average daily census was more than 400.

During 1944, 721 of the 6,237 hospital admissions were to the thoracic surgery

service. During 1945, when the capacity of the center was 350 beds, 2,268 of

the 12,813 hospital admissions were to the center. During this same year,

1,502 of the 6,010 operations performed were for chest conditions; the figures

include 833 endoscopies.

Personnel.—Lt. Col. Richard H. Meade, MC, was in charge of the chest

service at Kennedy General Hospital from its inception until 1 December 1945.

The medical officers originally assigned to the center, who remained for varying lengths of time, had had no training in chest surgery with a single exception, Capt, William I. Glass, MC. Maj. (later Lt. Col.) Felix A. Hughes, Jr.,

MC, who had a good background in thoracic surgery, was attached to the

center on 22 July 1944. At various times thereafter, a number of other experienced chest surgeons arrived, including Maj. (later Lt. Col.) Earle B.

Kay, MC, who had headed the chest service at Percy Jones General Hospital,

2 Tliis report was prepared by Lt. Col. Richard H. Meafle, MC, in December 1945.
174 THORACIC SURGERY

Battle Creek, Mich.; Capt. Lawson S. Whitaker, Jr., MC, who had had a wide

experience in the South Pacific; Capt. Joseph Estrin, MC; Maj. Theodore R.

Hudson, MC; and Maj. Julian Johnson, MC, who had previously been assigned

to the China-Burma-India theater.

The center was most fortunate in the ward officers, the nurses, and the

technicians assigned to it. The ward officers included Capt. William B. Blake,

Jr., MC, Capt. (later Lt. Col.) Prince D. Beach, MC, Capt. Max A. Forse, MC,

and Capt. Henry G. Munclt, Jr., MC. Captain Blake and Captain Beach

assisted in the operating room, in addition to their ward duties. Captain

Forse and Captain Mundt for a long time had charge of the wards through

which the patients passed who needed little treatment; they kept the rate of

disposition on these wards at a very high level. Nursing care was under the

supervision of Lt. Alison Bolyea, ANC. T. Sgt, Samuel P. Crucilla was in

charge of dressings and also handled intravenous therapy for all critically ill

patients.

Additional personnel were assigned to the Kennedy General Hospital

thoracic surgery center, chiefly for training purposes. They included medical

officers from Lawson General Hospital, Atlanta, Ga., from 1 January to

3 March 1944: from the 141st General Hospital, which was stationed on the

reservation from 1 January to 10 June 1944; and from the 4th Auxiliary

Surgical Group, surgeons from which were assigned to the center on detached

service.

In spite of the help furnished by these officers, the ratio of patients to

officers was usually undesirably high. It required unceasing effort to keep the

backlog of operations and dispositions under control.

Organization and operation.—Patients were received in the center from

overseas, from other hospitals in the country, and from other services at the

Kennedy General Hospital. Each week, at a special conference of the staff of

the center, all new patients were discussed, and the problems that concerned

them and other patients were worked over and settled. The staff of the center

had excellent cooperation from all other services in the hospital.

In addition to the wards occupied by bed patients, the center had other

space which could be designated for such special purposes as they wished.

Until late in 1944, operations were done in the general operating rooms.

Thereafter, the center had its own operating room.

While battle casualties accounted for most admissions to the center, the

majority of the surgical work performed was for conditions unrelated to warfare. After his assignment, all lesions of the esophagus were handled by

Major Kay. The remainder of the surgery was quite evenly distributed among

the other thoracic surgeons.

Battle casualties.—Up to December 1945, more than 1,950 patients with

battle wounds had been admitted to the center. The great majority had been

so well treated overseas that they required little major surgery. The principal

treatment necessary was maintenance of previously established drainage of

empyema. The distribution of cases was as follows:
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 175

1. Of 113 patients with chronic empyema, 99 had sustained combat wounds.

Of these, 76 were treated by drainage, 28 by decortication, and the remainder

by some form of thoracoplasty.

2. Of 113 patients who had had decortications overseas, 91 had healed

wounds when they were admitted. The remaining 22 had empyema or had

draining wounds which required treatment.

3. In all, 64 operations were done for the removal of foreign bodies.

Only those objects were removed that were more than 1 cm. in diameter; were

giving rise to symptoms; were irregular; or were in contact with the esophagus

or with some other structure that, it was feared, might be damaged by the

contact.

4. A number of patients had defects of the chest wall, but operation was

done in only five cases, in which the location of the defect introduced elements

of clanger. " In two instances, the defect was over the heart, and the soft tissues

were adherent to the pericardium; in both cases, the insertion of a protective

plate was thought safer than an attempt at plastic repair.

5. The majority of the 21 operations for diaphragmatic hernia were done

for residua of perforating wounds of the diaphragm or crushing injuries.

Several of these hernias, which are discussed in detail elsewhere (vol. II, ch.

IV), were not apparent until several months after the original injury.

6. The 19 patients with lung abscess were all treated by drainage and

all recovered.

7. The single patient with suppurative pericarditis was treated by drainage and penicillin and recovered smoothly.

Non-combat-incurred lesions.—Operations for civilian-type thoracic

lesions at Kennedy General Hospital were distributed as follows:

1. The most frequent disease for which surgery was required was bronchiectasis, for which 129 lobectomies were clone, with 1 death. These lobectomies are analyzed in detail elsewhere (vol. II, ch. X). Two total pneumonectomies were also performed for bronchiectasis.

2. The next most frequent indication for lobectomy was pulmonary cysts,

for which 14 operations were clone. Other indications included tuberculosis

in two cases, on the mistaken diagnosis of infected cysts; bronchial adenoma

(two cases) ; chronic suppurative lesions which did not respond to simple drainage (three cases) ; and actinomycosis (one case). There were no deaths in

these 22 operations.

3. In addition to the 2 pneumonectomies already mentioned for bronchiectasis, this operation was performed in 14 other cases, for bronchial adenoma

(6 cases, in 1 instance malignant) ; for carcinoma (2 cases) ; for chronic nonspecific inflammation (2 cases) ; for bronchial stenosis (2 cases) ; and for

actinomycosis and multiple cysts (1 case each).

There were 3 deaths in these 16 pneumonectomies, 2 on the operating table,

as the result of complete blockage of the contralateral bronchial tree with

tenacious mucoid material; both occurred immediately after removal of the
176 THORACIC SURGERY

involved lung, though in both, there had been repeated aspirations of the

tracheobronchial tree during operation.

Three of the patients who had undergone pneumonectomy later required

thoracoplasty. The others did well.

4. Tumors or cysts were removed from the mediastinum in 19 instances.

Subtotal removal of the growths in two other instances ended fatally. One

patient had a malignant teratoma, and death was caused by cerebral anoxia

during operation. The other patient, who had a tumor of the thymus associated with myesthenia gravis, died of his disease.

In a number of other instances, exploratory thoracotomy was carried out,

but the malignant lymphomas and other tumors thus revealed were considered

inoperable.

5. Although the Kennedy General Hospital thoracic surgery center was

not intended for the treatment of pulmonary tuberculosis, it treated five

patients who were receiving therapeutic pneumothorax and all of whom were

referred for division of adhesions. This proved possible in only one instance.

The other four patients underwent thoracoplasty, with excellent results in all.

6. Ten patients with chronic spontaneous pneumothorax of nontuberculous

origin, which had lasted from 2 to 18 months, were treated surgically. In three

instances, the pneumothorax was the result of rupture of large pulmonary

cysts. In two instances, only a small amount of pulmonary tissue had to be

removed along with the cyst. In the third case, subtotal resection of the lobe

that contained the cyst was necessary. In one case, the only surgery necessary

was division of a band of adhesions that was maintaining the patency of a

bronchopleural fistula. In the six remaining cases, the procedure was limited

to removal from the pulmonary surface of the constricting thickened pleura

that had apparently followed the complete collapse of the lung after rupture

of a peripheral bleb. In all instances, there was prompt reexpansion of the

collapsed lung.

In an additional case, a patient with three recurrences of chronic spontaneous pneumothorax over a 2-year period refused surgery, and complete expansion of the lung finally occurred without it.

7. The 137 patients treated at the chest center with various lesions of the

esophagus are described in detail elsewhere (vol. II, ch. X).

Endoscopy.—As in all other chest centers, the performance of peroral

endoscopy was a responsibility of the thoracic surgeons. Practically all

members of the staff were qualified, and during the period the center was in

operation, they performed 966 bronchoscopies, 525 bronchographies, and 50

esophagoscopies.

Results.—The excellent results obtained in the lobectomies and other

operations performed at the Kennedy General Hospital chest center can be

attributed to a combination of factors: The patients were young and in

generally good condition. Their wounds had been well handled overseas.

Their diseases were usually of relatively short duration. Anesthesia was

excellent. Surgery Avas competent. Adjunct therapy included the liberal use
ADMINISTRATIVE CONSIDERATIONS IN ZONE OP INTERIOR 177

of whole blood. Finally, the postoperative nursing care was of the highest

quality.

Walter Reed General Hospital

Facilities.—In May 1945, facilities for the thoracic surgery center at Walter Reecl General Hospital were of four types:3

1. Two open wards, each containing accommodations for from 30 to 45

enlisted men. Additional facilities were obtained as necessary by borrowing

beds from other specialty services.

2. A smaller ward containing accommodations for from 15 to 25 officers.

3. Wards for ambulatory enlisted men and officer personnel. These wards

were temporary structures on the hospital grounds, capable of accommodating

from 50 to 100 patients. These patients reported daily to the central nursing

station in the center for dressings or, if necessary, changes of therapy.

4. Convalescent wards at Forest Glen Annex, Forest Glen, Md., a converted

girls' school about 3 miles from Walter Reed proper.

Population.—The population of the Walter Reed General Hospital chest

center consisted of the following groups of patients:

1. Occasional single admissions, particularly transfers from other hospitals

in the Zone of Interior.

2. Chest casualties from overseas, who were usually received in groups

after they had been returned to the Zone of Interior by plane or hospital ship

and had been designated for a chest center after triage at the port of

embarkation.

3. Patients from overseas with intrathoracic neoplasms or other chest

conditions, which might or might not have existed before induction.

4. Patients with neoplasms or other chest conditions found after induction

or on separation from service. Roentgenologic examination was a routine part

of the preinduction examination, but neoplasms were occasionally overlooked

or, as inquiries of the patients suggested, roentgenograms were occasionally not

made. The surprising number of asymptomatic lesions detected on the final

survey clearly indicated the advantages of this method of case finding. In all

such cases, the patients were referred to chest centers.

5. Patients referred from other chest centers as they were closed. When

Walter Reed and Fitzsimons General Hospital chest centers were the only

centers to be kept open, patients remaining in the other centers were referred

to them. As a result, the Walter Reed chest center did not show the steady

decline in population which occurred immediately after the war in other centers

for specialized care. Unfortunately, as the patient census rose, the staff of the

center suffered a gradual attrition as key personnel in it returned to civilian

life.

3 No final report of the Walter Reed General Hospital thoracic surgery center was prepared, but

at my request, Dr. Donald B. Effler searched his files and his memory and prepared the material

summarized herewith. It is of particular value because of the light it sheds upon the opportunities

for training in this specialty which were available to a medical officer whose sole concern was the

professional care of his patients and his own professional education.—J. B. C., Jr.

6536S1 v—62——14
178 THORACIC SURGERY

The population of the chest center provided three chief clinical problems:

battle wounds, suppurative disease, and tumors. From 60 to 70 percent of the

casualties with war wounds arriving from overseas needed no active treatment,

simply routine clinical and roentgenologic examinations before discharge. As

the war drew to an end, the surgery of trauma decreased, and civilian-type

diseases occupied most of the time of the staff; these conditions were not related

to military service but were, of course, considered in line of duty. The distribution of the work in chest centers was in contrast to that in neurosurgical and

orthopedic surgery centers, in which practically all therapy during their entire

period of operation was for combat-incurred injuries.

Organization.—The thoracic surgery service at Walter Reecl General Hospital did not depend on surgical officers of the day from other services. Instead,

it was covered 7 clays a week, 24 hours a clay, with its own staff. This was

probably one of the reasons that disciplinary problems were almost unheard of

among the patients on this service.

Departmental conferences, usually informal, were held at least 5 days a

week. Here new patients were surveyed, problem cases discussed, and surgical

schedules for the following week drawn up. The patients were assigned by

the chief of the center (in May 1945, Colonel Blades) to the medical officers best

equipped to handle them. Patients were proposed for operation by the various

officers on the staff, but all decisions concerning major surgery were ultimately

passed on by the chief of service. The schedule for elective surgery was so

heavy that it ordinarily ran from 2 to 5 weeks behind.

A tumor board met weekly, at which all patients suspected of harboring

neoplasms were presented and discussed. This policy resulted in the best possible care for these patients and also provided a most instructive teaching

technique.

There was close liaison with all other departments in the hospital, particularly the departments of anesthesia and radiology. Both furnished

excellent supporting services.

Processing and disposition of patients.—Many patients with chest injuries received at the Walter Keed General Hospital chest center required no

treatment. They were admitted simply for processing and ultimate disposition ; that is, either return to duty or separation from service.

Each of these patients was interviewed and examined by a member of

the staff of the center, and a complete record was compiled for him. Although

this plan sometimes resulted in a duplication of paperwork, it seemed justified:

In many instances, the original records had either been lost or were entirely

inadequate. Most professional personnel who had treated these patients

initially were not thoracic surgeons but harassed medical officers, who were

frequently swamped by the tremendous volume of casualties.

This policy was executed smoothly and in a surprisingly short time; one

reason for this was the competent service of the Women's Army Corps and

civilians who supplied secretarial aid. Each patient thus had a satisfactory,
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 179

complete record that assisted in his disposition and also protected both him

and the hospital from the military standpoint.

Patients who had recovered from major surgery were transferred to the

convalescent section of the hospital if supportive therapy such as physical

medicine or remedial exercises was needed. Otherwise, they were given 30-day

sick leaves. When they had returned from leave, they were reexamined, and,

if no further professional care was indicated, their disposition Avas undertaken.

If they were to be returned to duty, they were transferred to a nearby reassignment center.

Recommendations for separation from service were made by the staff of the

thoracic surgical section, to the surgical staff, and thence to a disposition board,

which recommended either retirement or disability separation. As indicated

elsewhere (vol. II, ch. IX), a great many patients in World War II were classified as partly or totally disabled because they had undergone lobectomy, excision

of nonmalignant tumors, or other chest surgery, or because they harbored retained foreign bodies. In the light of present knowledge, they would not be

so classified. During World War II, however, and immediately afterward,

the time factor was too short, and knowledge of the specialty was too incomplete, to determine the ultimate fate of the casualty who had undergone major

chest surgery. As a result, doubts were resolved in his favor, which worked

an economic hardship on the Government, There is no doubt that many a

casualty who was honorably discharged on full disability in World War II

would now be considered to have undergone a routine elective operation that

would not require him to be away from his duties for more than from 6 to

10 weeks.

Clinical policies.—Surgical policies at the Walter Reed General Hospital

chest center were essentially the same as at other centers. Two points might

be commented on:

1. The recovery room that is now standard in most hospitals was a novelty

in World War II, and it is believed that the one set up on the thoracic surgery

service at this hospital was the first of its kind in Army hospitals, at least in

this specialty. It was provided with constant wall suction, oxygen, and other

mechanical devices and equipment for routine care and to meet any emergency.

2. Penicillin was used aggressively by the depot technique devised by

Romansky.

3. Early ambulation was an important part of the postoperative program,

though it was still not generally accepted in either military or civilian hospitals.

What this plan really amounted to was the application of outpatient principles

to an inpatient service. As soon as a patient was classified as ambulatory, he

reported as necessary to the central dressing room, where dressings were

changed, sutures removed, and empyema cavities treated. This was excellent

treatment for the patient, who recovered his strength much more rapidly when

he was permitted to get out of bed promptly. It was also a laborsaving plan,
180 THORACIC SURGERY

for 20 patients could be processed in this manner by the short-handed professional staff in the time it would have taken to care for 5 bed patients. This

plan also facilitated the training of new corpsmen.

Training.—The quality of the training received at the Walter Eeed General Hospital thoracic surgery center is apparent in the comment on it in a

letter received from Dr. Donald B. Effler, on 1 September 1960. He wrote, in

part:

Wlien I reported to Walter Reed for duty, after a year's internship and 2% years of

oversea service, I made it quite clear to Colonel Blades that I had absolutely no knowledge

of thoracic surgery. This seemed to delight him, on the ground that he would have one

man on the service who would offer no suggestions for changing anything.

I received an immediate impression of high professional and patient morale not only

in thoracic surgery but throughout the whole hospital. I doubt if any civilian or military

institution ever had staff or faculty of a higher overall quality. Administrative problems

were always subordinated to patient care. I believe all of the men in the thoracic surgery

service are now heads of thoracic surgery departments in important medical schools.

The intensive training program offered me was accompanied by a steady increase in

my professional responsibilities. This was almost necessary. As the war drew to a close,

with the capitulation first of the Germans and then of the Japanese, a mass evacuation of

civilian physicians from the Army began. Those who had the most experience and were

oldest in service were naturally the most anxious to leave. Along with the attrition of the

staff went the increase in the population of the center as other centers closed. At the

same time, there was an influx of civilian and military visitors, most of whom were greatly

interested in the functioning of the thoracic surgery service. Many ranking medical officers returning from administrative posts overseas also returned to Walter Reed for

refresher courses.

When Colonel Blades was separated from service, he was immediately appointed by

The Surgeon General as civilian consultant in thoracic surgery at Walter Reed. He visited

the hospital regularly, and he was always available for telephone consultation, or he would

visit the hospital aside from his regular visits if I needed his opinion on any patient. Maj.

Vincent M. Iovine, who left the hospital to become chief of surgery at Mt. Alto Veterans

Hospital in Washington, also retained his interest in the department and was very helpful

to me.

At this time I was still a captain in the U.S. Army Medical Corps, perhaps the only

captain in the history of Walter Reed who was chief of thoracic surgery (and also in

charge of ward 8, later converted into the Presidential suite). Considerable humor was

added to the situation by the fact that my two senior residents were full colonels and my

assistant resident a lieutenant colonel (this was Lt. Col. Jack Paul, who 2 years later

became chief of the thoracic surgery service). I doubt if in the hospital annals anybody

with the rank of captain carried as much professional responsibility or had as much rank

under him as I did in the last months of 1946. I was still a captain when I was separated

from service January 1, 1947, but I was promoted to major the following day. This was a

source of great amusement to many of my friends, as indeed it was to me. But the training

at Walter Reed was so superb and the opportunities so tremendous that in themselves they

furnished the only reward I wanted.

A letter such as this needs no editorial or other comment.
ADMINISTRATIVE CONSIDERATIONS IN ZONE OF INTERIOR 181

REGISTRY OF FOREIGN BODIES

A proposal during the war that a registry of retained foreign bodies be set

up, along the lines of the Peripheral Nerve Registry, did not materialize,

chiefly because the statisticians consulted did not think it feasible to obtain

sufficient controls. After the war, another attempt was made to initiate such

a study through the Veterans' Administration, but again the plan did not

prove workable. It was easy enough to find patients from whom foreign

bodies had been removed but more difficult to persuade patients with retained

foreign bodies to report to the Veterans' Administration for observation and

roentgenologic studies; many of them frankly stated that they feared the loss

of disability pensions. It is unfortunate that the proposed registry could not

be established because only such a study will eventually settle the question of

whether or not retained foreign bodies should be removed, and, if they should

be, on what indications.

References

1. Minutes of meeting, Subcommittee on Thoracic Surgery, Division of Medical

Sciences acting for Committee on Medical Research, National Research Council, 25 July

1940.

2. Minutes of meeting, Subcommittee on Thoracic Surgery, Division of Medical

Sciences acting for Committee on Medical Research, National Research Council, 16 Jan.

1942.

3. Neurosurgery and Thoracic Surgery. Prepared and edited by the Subcommittees

on Neurosurgery and Thoracic Surgery, Committee on Surgery, Division of Medical Sciences, National Research Council. Philadelphia and London: W. B. Saunders Co., 1943.

4. Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services.

Washington: U.S. Government Printing Office, 1956.
Part III

GENERAL MANAGEMENT OF WOUNDS

OF THE CHEST
CHAPTER VI

Evolution of Clinical Policies in the Mediterranean (Formerly North African) Theater

of Operations

Thomas H. Burford, M.D.

GENERAL CONSIDERATIONS

Until the Korean War, which broke out 5 years after World War II

ended, all the wars in which the United States has been engaged were relatively widely spaced. Surgeons therefore had to approach their medicomilitary duties without practical experience of combat-incurred trauma. This

meant that, in every new war, the lessons of the previous war had to be

relearned.

In World War II, thoracic surgeons had to overcome three special difficulties :

1. They had to learn, as do all civilian surgeons who enter the Army, that

the problems of medical care in wartime are not entirely clinical. The

clinical care of battle casualties is closely related to other considerations, including supply; personnel; evacuation and transportation, which in turn are

related to terrain, time factors, the weather, and other military necessities;

the facilities available for medical care; and, most of all, the tactical situation,

in which the enemy often plays a determining role.

2. Thoracic surgeons were practicing a relatively new specialty in World

War II. Their number was limited, and the thoracic surgery of civilian life,

even of the traumatic variety, had only a limited application to military

thoracic surgery.

3. The experience in World War I—this aspect of it, as least, was generally known—had been so overwhelmingly concerned with empyema of nontraumatic (postinfluenzal, postpneumonic) origin that it was only natural for

the chest surgeons of World War II to enter upon their duties believing that

their major problem would be the prevention of intrathoracic infection. As

a matter of fact, this type of infection was to prove a relatively minor problem

in this war.

The management of thoracic casualties as it finally evolved in MTOUSA

(Mediterranean Theater of Operations, U.S. Army), and was later carried

out in the European Theater of Operations, U.S. Army, was based on sound

physiologic principles and good surgical practices. The care of the casualty

185
186 THORACIC SURGERY

began with the all-important emergency measures instituted—often heroically—on the battlefield by the company aidman, and it extended uninterruptedly through the entire chain of evacuation. Consistency of concepts

underlay continuity of treatment. There were no pathophysiologic echelons.

The program instituted countenanced no compromise short of ideal surgical

results. The assiduous application of sound surgical and physiologic concepts

made apologies for the exigencies of war entirely unnecessary. Experience in

the Mediterranean theater, and later in the European theater, showed that

ideal results were entirely feasible and could be achieved.

Such a program did not exist at the beginning of World War II. It was

developed by a process of evolution. Furthermore, more than mere formulation of such a program was necessary. The hiatus that originally existed

between the concepts at consultant and other specialized surgical levels and the

practices on other, lower levels had to be bridged by didactic teaching, demonstrations, discussions, and directives. In all hospitals, as might have been

expected, the single factor that contributed most to the success achieved in

the management of chest injuries and the promptness with which it was attained was insistence by the chief of section upon rigid and undeviating

adherence to the surgical principles and practices laid down by the chief consultant in surgery in the theater.

The policies by which thoracic injuries were managed were not, of course,

instituted in their final efficient form in the early operations in World War II.

Circumstances of military care varied from theater to theater and changed as

the war progressed. As a result, the outstandingly good results achieved late

in the war were not achieved early in the war. In the last months of fighting,

however, perhaps from 70 to 75 percent of the casualties received in Zone of

Interior general hospitals and thoracic surgery centers from the Mediterranean

and European theaters were practically well from the standpoint of their

thoracic wounds. (Casualties from the Pacific theaters always presented

different problems.) Many of them were evacuated because of associated

wounds. When the chest injury was the principal wound, in many instances

only the original severity of the wound, the need for reconditioning, and the

uncertainty regarding the man's ability to perform full military duty in an

oversea theater indicated his return to the United States.

STAGING OF SURGICAL CARE

At the deliberate risk of repeating what has already appeared in published

volumes of the history of the U.S. Army Medical Department in World War

II and will appear, in greater detail, in volumes in the administrative series

now in preparation, certain facts concerning the general care of the wounded

in a combat zone must be described before the management of thoracic injuries is discussed. The repetition is necessary because chest injuries were

managed according to these basic principles as well as according to principles

applicable only to these special injuries.
EVOLUTION OF CLINICAL POLICIES 187

The entire system of meclicomilitary care in World War II was based on

the following premises:

1. Medical care must be accomplished in echelons.

2. The mission of each echelon is both specified and limited.

3. Medical installations in combat and communications zones, as well as

in the Zone of Interior, are designed, equipped, staffed, and designated for

specific missions.

4. Medical officers must not only perform the duties specified for their

particular echelons but must also limit themselves to the duties specified for

them at those levels.

The surgical management of battle casualties was rendered in phases

which, in general, conformed with the personnel and facilities provided by

the medical installations in the several echelons of medical service. These

phases included:

1. Emergency measures on the battlefield and in the battalion aid stations

and other installations forward of the clearing station (division area).

2. Initial wound surgery, which was rendered, according to the condition

of the casualty and other circumstances, in the field hospital (division area) or

the evacuation hospital (army area).

3. Separative surgery, which was rendered in general or station hospitals

or in centers for specialized care (communications zone).

4. Eeconstructive surgery, which was rendered in the Zone of Interior.

5. Eeconditioning and rehabilitation, which were carried out overseas or

in the Zone of Interior, depending upon where the casualty had received his

final surgical care and whether he could be returned to duty from a hospital

overseas or had to be evacuated to the United States.

The entire process of evacuation of the wounded man had three objectives:

1. To get him out of the way of battle, in which he was no longer useful

and might never be useful again.

2. To restore him to combat efficiency, if that were possible.

3. To save life, relieve suffering, and prevent deformity.

While these objectives are listed in the order of their military importance,

there was, of course, no conflict between the humane considerations of the third

objective and the military necessities of the first two objectives.

The process of evacuation and the determination of the forward echelon in

which the patient would receive initial care depended upon two considerations:

1. His transportability (p. 204), which was determined by the character of

his injury and his physiologic reaction to it.

2. The measures required to care for his wound.

The continued backward movement of a military casualty from area to

area was in sharp contrast to the management of civilian victims of trauma,

who are practically always managed throughout their clinical course in the

same hospital to which they are first admitted. It was also responsible for
188 THORACIC SURGERY

other differences between the civilian and the military surgery of trauma:

1. In military surgery, the timelag between wounding and definitive care

was many times longer than in civilian practice because of the necessity for

evacuation of the casualty from the battlefield through the battalion aid station

and the collecting station to the clearing station, at which level hospital facilities were first available.

2. Perhaps the most important difference between civilian and military

practice concerned personnel. In civilian surgery, a single surgeon usually

makes all the important decisions for a single casualty. In military surgery,

these decisions had to be made by a number of surgeons. From the time a

wounded man was tagged on the battlefield and removed to a battalion aid

station, until the completion of his cycle of treatment, evacuation, and disposition, he was cared for not only in a series of medical installations but also by a

series of medical officers whose judgment and performance were interwoven in

the threads of his care. Every medical officer who treated a wounded man was

called upon to evaluate the patient's status. He also had to estimate his own

surgical capabilities and limitations and the facilities at hand to perform the

necessary surgery. In the division area, and frequently in the army area as

well, all surgery was attended with some degree of urgency, and the decisions

had to be made in the light of circumstances peculiar to a field army in combat,

Two planned policies compensated for these obvious disadvantages in the

care of casualties:

1. The precise definition and timing of surgery in the various echelons

of medical care. Every procedure was timed and graded in relation to the

total picture, including the tactical situation, the particular point in the chain

of evacuation, and the wounded man's own status. Hospitals, as already noted,

were designated and equipped for surgery of varying degrees of urgency and

magnitude, and with due consideration of the necessary duration and other requirements of postoperative care. They were strategically placed in reference

to these considerations, and professional personnel of the appropriate competence were assigned in accordance with the function of the installations and

the type of surgery to be performed in them.

_ 2. Standardization of management, or, as many medical officers fresh from

civilian life preferred to term it, "regimentation." This policy was essential

because of the transfer of the care of the wounded man from medical officer to

medical officer as he was evacuated farther to the rear. For reasons of simplification, expedition, and safety, individual variations of any consequence

could not be permitted. The surgeon who cared for a casualty in the rear area

had to know exactly what had been clone by the surgeon in the forward area,

so that he could relate his own therapy to what had already been done and

what remained to be done.

With the passage of time since the end of World War II, some of the

general principles and practices just summarized may have been forgotten. It

is particularly important that these principles and practices be clearly understood as the background of the discussion of thoracic wounds in World War II.
EVOLUTION OF CLINICAL POLICIES 189

They greatly affected the management of these wounds. There were no other

combat-incurred wounds in which alterations of physiology could be so rapidly

fatal, and no others in which physiologic disturbances could be corrected so

simply and so rapidly by the proper measures. When these disturbances had

been corrected, the majority of chest casualties became safely transportable.

The corollary was that a casualty who, in his original status, would have required definitive treatment far forward could be treated with safety and convenience farther to the rear, thus relieving the strain on the medical installations

that were always most heavily taxed.

The continuous system of triage (p. 202) in the chain of evacuation made

it possible for a casualty to receive adequate treatment, as he required it, at

each hospital along the evacuation route. The hospitals were in no sense stopping-off places. Each was established for the specific purpose of treating the

casualty at the optimum time that his wound and his reaction to it required

some special measure, including surgical measures.

OFFICIAL POLICIES IN CHEST INJURIES

When the United States entered World War II, the only official policies

for the management of chest wounds were laid clown in military manuals then

in preparation and in a manual, also in preparation, by the Subcommittee on

Thoracic Surgery of the Committee on Surgery, Division of Medical Sciences,

National Research Council (1).

Military Manuals

War Department Field Manual 21-11, First Aid for Soldiers, published on

7 April 1943, was intended to teach the soldier what he could do for himself

or for a fellow soldier if injury or sickness occurred when no medical officer

or medical corpsman was nearby. The material on wounds of the chest was,

in substance, as follows:

If the chest wound is one in which air is sucking in and blowing out, the

life of the injured man may depend upon the speed with which a dressing,

large enough to cover the wound and stop the flow of air through it, is applied.

If the dressing applied does not completely stop the back-and-forth movement

of air, additional dressings should be applied. A large piece of any available

material (raincoat, overcoat, blouse, or shirt) applied tightly over the dressing

may be useful in making it airtight.

The casualty with a wound of the chest is more comfortable and can

breathe more easily if he lies on the injured side.

War Department Technical Manual 8-210, Guides to Therapy for Medical

Officers, published on 20 March 1942, contains, in reduced form, essentially the

same material appearing in the thoracic surgery section of the National Research Council military surgery manual entitled "Neurosurgery and Thoracic

Surgery" (1).
190 THORACIC SURGERY

National Research Council Manual

Plan of manual.—When a manual on chest surgery was first under discussion, it was the desire of Dr. Evarts A. Graham, who served as Chairman

of the Subcommittee on Thoracic Surgery, that it should not exceed 50 pages.

When it was finally published, in 1043, it had exceeded this length by 29 pages.

It is unfortunate that this manual did not fulfill its potential usefulness. It did

not appear until policies were being evolved as combat necessities developed.

It had no general circulation among medical officers, and no official instructions

for its use were issued. The thoracic surgeons in the Mediterranean theater,

who had most to do with the evolution of policies for chest injuries, were not

even aware of its existence as such, though the substance of the material in it,

as just stated, was available to them after March 1942 in War Department

Technical Manual 8-210.

It was stated in the preface to the National Research Council manual that

the high mortality rate of chest wounds—33 percent on the field, 25-30 percent

in dressing stations, and 20-25 percent in ambulances—made it clear that if any

reduction were to be achieved in the number of deaths from these injuries, the

improvement must take place in the combat zone. The desired improvement

would not be brought about by the indiscriminate application of heroic surgery

in advanced surgical stations. It could be achieved only by accurate appraisal

of the individual patient, prompt emergency measures, and definitive attention

to special aspects of thoracic wounds.

Among the subjects specifically excluded from the manual was the complete

exposition of the physiopathology of the cardiorespiratory mechanism, on the

ground that this information could be obtained from standard texts. This, of

course, is true, but in view of the complete change of emphasis in the management of wounds of the chest between World Wars I and II and the emphasis

in World War II upon physiologic derangements, it is unfortunate that space

was not utilized to emphasize this important phase of these wounds.

The book is divided into four parts. The first concerns the general principles of management of chest injuries. The second is a synopsis in outline

form of the treatment and disposition of these injuries. The third deals with

their complications and sequelae. The fourth deals with operative surgery.

The substance of the recommendations was as follows:

First aid measures.—First aid measures outlined in this manual include arrest of

hemorrhage from the thoracic wall, physical correction of physiologic disturbances, and

measures to prevent infection. In the brief discussion of these measures, both sucking

wounds and their closure are specifically mentioned, as in stove-in chest. It is recommended that hemorrhage from a lacerated lung should be treated by aspiration and

simultaneous artificial pneumothorax, although the practice of air replacement had long

since been discontinued when this manual appeared. Aspiration is recommended for

pericardial tamponade.

Definitive treatment.—Subsequent surgery is to be carried out under intratracheal

anesthesia, to provide differential pressure. Debridement, by a somewhat elastic definition

of the term, might include removal of high explosive fragments from the lung, though in
EVOLUTION OF CLINICAL POLICIES 191

some instances, their delayed removal is wiser; resection of devitalized or bleeding pulmonary tissue, a policy that was seldom employed in chest wounds in World War II;

hemostatic suture; airtight closure of divided bronchi; removal of foreign bodies and

devitalized tissue from the pleura and thoracic wall; reexpansion of normal pulmonary

tissue; and airtight closure of the thoracic wall.

Prompt intervention is urgently necessary in the presence of progressive bleeding,

early open pneumothorax, pressure pneumothorax, and cardiac tamponade. The early control of infection is desirable but much less imperative and is never an excuse for an inadequately equipped medical officer to undertake thoracotomy. If empyema occurs, in spite

of efforts to prevent it, proper drainage is to be instituted, to prevent a chronic phase.

The question of whether or not intervention is carried out in a forward installation

often rests upon the ease or difficulty with which evacuation can be accomplished. Air

transportation is desirable but, unless oxygen is available en route, it must not be employed

in anoxemia or in wounds associated with large closed pneumothoraees.

Special typos of injuries.—Injuries and conditions covered in the second chapter of this

manual include tangential or nonpenetrating wounds, in which the pleural cavity has not

been entered and which may or may not be associated with hemoptysis; similar wounds

associated with simple rib fractures; compression injuries with traumatic asphyxia; extensive mobilization of the chest wall by rib fractures; massive atelectasis; penetrating

injuries, with and without serious hemorrhage and shock and sometimes associated with

subcutaneous emphysema ; perforating injuries ; pleuroabdominal wounds ; rupture of the

diaphragm; and blast injuries. Treatment under each of these headings is divided into

first aid measures and definitive treatment. As will be evident later, both the nomenclature

and the emphasis in a number of these injuries differ from the nomenclature and the

emphasis in the injuries encountered in World War II.

Complications and sequelae.—Complications and sequelae dealt with in the third

chapter of the manual include pneumothorax, emphysema, hemothorax, empyema, retained

foreign bodies, infections of the chest wall, lung abscess, massive hemorrhage into the

subfascial spaces of the thoracic wall, and complications of wounds of the heart.

It is striking that hemothorax, the management of which proved so highly important

in World War II, receives little attention in this volume. In chapter I, it is pointed out

that hemorrhage into the pleural cavity may be fatal "without serious disturbance of

respiration being caused by encroachment on pulmonary volume" ; that the mechanical

effects of hemothorax are delayed because they are produced by a traumatic effusion

superimposed upon an initial collection of blood; and that the tendency to spontaneous

hemostasis is the result of a low head of pressure in the pulmonary circulation plus the

collapse of the lung from attendant hemothorax or pneumothorax.

In the chapter on complications and sequelae, hemothorax is covered in a page, practically all of which is devoted to differential diagnosis (massive pulmonary collapse, rupture of the diaphragm with displacement of the abdominal viscera into the thoracic cavity,

pleural effusion of infectious origin, and consolidation of a contused or pneumonic lung).

Treatment is limited to cross-references to hemorrhage and shock; penetrating injuries

with shock and hemorrhage from pulmonary lacerations; and infected hemothorax, which

receives only half a page of the 3

]

/2 pages devoted to empyema. Neither clotted hemothorax

(vol. II, ch. I) nor decortication (p. 27) is mentioned.

Technique.—The final chapter of this manual describes the techniques for autotransfusion, bronchoscopy and tracheal intubation, thoracentesis, pericardicentesis, artificial pneumothorax, intercostal catheter drainage, elevation of stove-in chest, perieostal

suture for hemorrhage from the intercostal artery, ligation of the internal mammary

artery, rib-resection drainage in empyema, thoracotomy for penetrating wounds, exteriorization of the lung, drainage of lung abscess, removal of foreign bodies from the lung,

cardiorrhaphy, pericardiostomy, management of mediastinal emphysema and wounds of

the trachea, tracheotomy, mediastinotomy, repair of thoracoabdominal injuries, repair of

traumatic diaphragmatic hernia, and the management of cardiac arrest.
192 THORACIC SURGERY

There are some techniques in this list that were abandoned in World War II because

better methods were found or because there was no need for them. Exteriorization of the

lung, for instance, was never practiced. Pericostal sutures for any purpose were found

harmful. Lung abscess was very infrequent. It will be observed that, again, there is no

mention of decortication in this list of procedures.

Anesthesia.—Differential pressure anesthesia is recommended for all major operations in which the pleura is widely opened. It is preferably carried out by tracheal intubation. Agents combined with a high percentage of oxygen are preferred to those whose

use is associated with anoxia. Regional block or infiltration anesthesia may be used for

operation on the thoracic wall, and local anethesia may be employed to supplement general

anesthesia.

Adjunct therapy.—The infusion of blood substitutes rather than whole blood is recommended in any injury that reduces pulmonary volume and causes shock accompanied

by hemoconcentration. By the time this manual appeared, a great deal more had been

learned about shock, and it had long since been found that plasma was not an acceptable

substitute for whole blood in seriously wounded men. The advice to delay blood replacement as long as possible in the presence of continuing intrapulmonary hemorrhage was

sound if steps were taken to control the hemorrhage at once, and the warning against

overhydration of casualties with chest injuries was also sound.

Oxygen is recommended for "asphyxia." Morphine is to be used cautiously, because the

advantage of relief of pain may be counterbalanced by abolition of the cough reflex or the

production of respiratory depression. Atropine may be used to lessen vagal reflexes and

diminish the secretion of mucus, though it has the disadvantage of increasing the viscosity

of bronchial secretions and making it more difficult to clear the bronchial tree by coughing.

Barbiturates are usually eontraindicated. Codeine or cough mixtures are not used when

it is necessary to evacuate purulent secretions by coughing. Respiratory stimulants are

seldom required or effective. Carbon dioxide is used with caution. If tobacco does not

incite coughing, it may be used in moderation during recovery. Early ambulation and deep

breathing are stressed.

A crystal sulfonamide is used in the plcural cavity and in the wound of the thoracic

wall, and systemic chemotherapy is also employed. The manual warns that the sulfonamides

are not a substitute for proper surgery.

Some of these measures were used in the management of chest injuries

in World War II, but many of them were replaced by far more energetic

measures, including catheter suction, and bronchoscopy as indicated, to clear the

tracheobronchial tree. Even before penicillin had become available in World

War II, local sulfonamide therapy had been generally discontinued.

Comment.—Excellent as are many of the recommendations in this manual,

the book suffers from the same fault that surgeons in other specialties have

attributed to other manuals in the series: It is somewhat removed from the

realities of combat, and the World War II experience did not bear out some of

the statements in it, as the following example indicates: "* * * Necessity

for prompt evacuation need not be understood to contraindicate treatment at

advanced stations, for men wounded in the manner considered here often stand

transportation better in the first twenty-four hours after operation than they

do a few days later."

In the World War II experience, casualties with chest injuries stood

transportation well after the correction of their carcliorespiratory disturbances

and were also less susceptible to infection. Provision was made in both field

and evacuation hospitals for holding patients after operation; the disasters of
EVOLUTION OF CLINICAL POLICIES 193

the prompt evacuation practiced in the first months of the war had proved

conclusively that casualties with serious chest injuries do not tolerate transportation well at this time.

The warning against radical forward surgery was in agreement with the

World War II experience with that variety of management:

Choice of station at which definitive surgical treatment of thoracic injuries with

severe laceration of the lung is instituted is governed by military exigencies and the

equipment and assistance available. Decision between operation and conservative treatment must be shaped by the facilities at hand and the competence of the surgical team.

Remember that infection of the pleural cavity may be dealt with later, while open operation

under unfavorable circumstances may lead to disaster.

This means, as is pointed out in more than one place in this manual and

as was proved by the early experience in World War II, that early open

thoracotomy by an inexperienced surgical team is extremely hazardous.

EARLY EXPERIENCE IN THE MEDITERRANEAN THEATER

North Africa

There was considerable confusion in the management of all combat injuries

in the earty days of the fighting in North Africa, for several reasons:

1. Official policies, as just pointed out, did not yet exist. The manuals in

which they were described appeared late and were incorrect, in a number of

areas, in both emphasis and techniques.

2. The lessons of World War I, explicitly set forth in the official history

of the Medical Department, were generally unknown. No real attempt had

been made to utilize this valuable material. The emphasis in thoracic injuries

in World War I was, as already noted, overwhelmingly on the septic rather

than the traumatic side, but there was still a great deal in the story of chest

trauma that would have been of great practical value.

3. Almost no U.S. Arnry medical officers in the North African theater

were familiar with the lessons the British had learned in the 3 years in which

they had been at war; during this period, the British had had an extensive

experience in this theater. Eventually, untried American thoracic surgeons

learned a great deal from British surgeons, but early attempts to capitalize

on their experience were only partly successful. When the 77th Evacuation

Hospital was in England in 1942, before it was sent to North Africa, the time

which its thoracic surgical team finally spent in British chest centers was only

a fraction of what had been originally planned (2).

When this and other evacuation hospitals and auxiliary surgical group

teams arrived in North Africa, in November 1942, and took over the hospitals

in Oran, they found that many patients with chest wounds had received little

or no care. Wounds had not been debrided. Sucking wounds had not been

closed. Hemothoraces had not been aspirated. Even with the vigorous treatment immediately instituted, including chemotherapy, a great many hemo-
194 THORACIC SURGERX

tlioraces went on to empyema. Other handicaps existed at this time. Thoracic

surgical instruments were in extremely short supply (p. 84), and there were

no facilities for intratracheal anesthesia.

In March 1943, Maj. (later Col.) Howard E. Snyder, MC, head of the

thoracic surgical team of the 77th Evacuation Hospital, was placed on temporary duty in II Corps headquarters, to evaluate the surgery performed in the

early campaigns just concluded in North Africa and to make recommendations

for the future care of casualties. His observations, which were reported to

the Surgeon, II Corps, 3 April 1943 (ß), were based on:

1. Visits to clearing and treatment stations, in some of which organic

personnel had been supplemented by general surgical and shock teams from

the 2d Auxiliary Surgical Group. Nontransportable casualties were treated

at the clearing station of a medical battalion from 5 to 24 hours after wounding,

after passing through two installations farther forward.

2. The 48th Surgical Hospital, 50 miles to the rear, to which transportable

casualties were sent.

Major Snyder's report stated that, on the whole, triage had been well done,

though some deaths that had occurred at the 48th Surgical Hospital might

have been avoided if initial wound surgery had been performed at more forward installations. Other lives might have been saved if there had been less

speedy evacuation of casualties operated on in forward installations; a number

of these patients had been evacuated before they had even reacted from anesthesia. The selection of cases for surgery by teams of the 2d Auxiliary Surgical

Group showed excellent judgment, and the surgery performed was generally

commendable.

Major Snyder's recommendations were generally applicable to chest

injuries:

1. Provision should be made for a more convenient method of blood

transfusion, as well as for a source of blood other than clearing station

personnel.

2. Provision should be made for oxygen therapy.

3. A shock team from an auxiliary surgical group should be assigned to

every clearing station set up to act as a forward surgical hospital.

4. Caution should be exercised in the administration of morphine, to avoid

overdosage, particularly in chest and intracranial injuries.

5. Better anesthetic equipment should be provided.

G. Facilities should be provided to hold casualties for a safe period of

time in whatever installation they underwent major surgery.

7. More explicit directions should be issued concerning the emergency

treatment of head and chest wounds and the disposition of these casualties.

8. Specialty teams for the treatment of these injuries should be assigned

nearer the front than in evacuation hospitals, at least as these hospitals were

located in North Africa; in some instances, they were as far as 145 miles behind the frontline.
EVOLUTION OF CLINICAL POLICIES 195

Circular letters. After the Tunisian campaign and before the invasion

of Sicily, several circular letters were issued from the Office of the Surgeon,

Headquarters, NATOUSA (North African Theater of Operations, U.S.

Army), in which there were sections dealing with chest surgery.

Letter No. 13 (,?), dated 15 May 1943, gave the following information

concerning chest wounds in forward medical installations:

1. A sucking wound of the chest should be closed tightly enough "to prevent to-and-fro blasts of air with respiration but not so tight that air cannot

escape from the chest if a pressure pneumothorax builds up from an accompanying wound of a bronchus." A pad of petrolatum-impregnated gauze

should be folded to fit the wound: held in position by adhesive tape; and

secured with one or two sutures, to prevent its loss into the pleural cavity.

2. Pressure pneumothorax should be promptly corrected by needle aspiration. If it re-forms, a small catheter should be inserted in the second interspace anteriorly.

3. Oxygen therapy may be as important as the administration of plasma.

Aspiration of blood and air may make an otherwise nontransportable casualty

transportable. Air replacement is "rarely" advisable. Internal bleeding is

usually from the chest wall and requires revision of the wounds of entrance

and exit. If the hemorrhage is from a large visceral or mediastinal vessel,

thoracotonry is necessary.

4. Definitive surgery for thoracic wounds should be postponed until X-ray

examination is possible, It is disastrous to assume that large retained foreign

bodies will not promote infection.

Letter No. IG (.£), dated 9 June 1943, dealt with forward surgery with

special reference to amphibious operations. In it, the instructions given in

Circular Leiter No. 13 concerning the closure of sucking wounds and the use

of a catheter in pressure pneumothorax were repeated. Extensive surgical

emphysema was to be managed by the correction of pressure pneumothorax.

Initial definitive surgery should be limited to debridement and closure

of the wound of the chest wall, without complete suture of the superficial

layers and skin. Local anesthesia was often satisfactory and eliminated the

risk of asphyxia. Transfusions should be given slowly and only when

essential.

Thoracic casualties (without specification) should be evacuated by air

as "priority" patients, after preliminary aspiration of hemothorax without

air replacement.

Letter No. 20 (5), dated 22 June 1943, contained the comments by hospitals in the communications zone on the treatment of battle casualties in

forward areas during the Tunisian campaign. Generally speaking, these

patients had been well treated and were received in good condition, but there

were two adverse comments:

1. Some patients with chest wounds who had undergone exploration and

removal of foreign bodies had been received with hemopneumothoraces and
196 THORACIC SURGERY

collapse of the affected lung. Measures should have been taken to maintain

an expanded lung.

2. Several patients were received with large, untreated hemopneumothoraces after being held in forward hospitals for as long as 10 clays. Although

X-ray facilities were available, they had not always been used. One patient

with a large foreign body in the chest had a fulminating hemothoracic infection, but there was no mention of any examination of the chest, although the

wound of entrance was obvious.

Sicily

In Sicily, as described elsewhere, there were two important advances in

surgical management, both of which directly influenced the results obtained

in all serious injuries. The first was the establishment of platoons of field

hospitals directly adjacent to clearing stations, for surgery on nontransportable

casualties (p. 91). The second was the effective use of auxiliary surgical

group teams to augment the intrinsic personnel of field hospitals (p. 92).

Circular letter.—Circular Letter No. 3 (G), dated 7 August 1943 and issued in the field to all unit surgeons, dealt with the care of the wounded in

Sicily. The section on wounds of the chest covered the following points:

1. The management of nontransportable casualties with wounds of the

chest in field hospitals. Their number would be limited, the majority of such

casualties being cared for in evacuation hospitals. Indications for transfer

to a field hospital included dyspnea, sucking wounds, continuing hemorrhage,

imminent shock, and thoracoabdominal wounds.

2. Indications for first aid measures in battalion aid stations, collecting

stations, or clearing stations. These included:

a. Shock. The patient with a chest wound must not be placed in the

Trendelenburg position. The amount of blood and plasma used should be only

what was absolutely necessary, and it should be administered slowly.

b. Continuing hemorrhage from the chest wall, which should be controlled

by ligature, hemostatic suture, or a mushroom pack.

c. Tension pneumothorax, which should be relieved as early as possible

by the insertion of a large-bore needle in the second interspace anteriorly. For

evacuation, a small catheter should be substituted for the needle, or a flutter

valve should be used.

d. Open or sucking wounds, to be closed by the technique already

described.

3. Initial wound surgery at a field hospital. This should be limited to

debridement except in the occasional case of continued severe bleeding from

the lungs, mediastinum, or heart; then thoracotomy should be clone. Thoracoabdominal wounds required emergency surgery, which could sometimes be

performed in toto through the thoracic approach.

4. Chemotherapy. Sulfanil amide should be dusted into the pleural cavity

before closure, and an adequate sulfadiazine blood level should be maintained

for from 7 to 10 days after admission.
EVOLUTION OF CLINICAL POLICIES 197

5. Postoperative care, which was extremely important, whether or not

thoracotomy had been done. Hemothoraces were to be aspirated daily if necessary. If drainage had been instituted, the catheter or tube was to be removed

within 48 hours.

DEVELOPMENT OF CONCEPT OF CHEST INJURIES

When Col. Edward D. Churchill, MC, arrived in the North African theater

in March 1943 and assumed his duties as Consultant in Surgery to the Surgeon,

NATOUSA, then Brig. Gen. Frederick A. Blesse, it was the beginning of a

fruitful association that was reflected in the care of all wounded, and not least

in the care of thoracic casualties. Up to this time, in the absence of official

directives, each chest surgeon had been proceeding according to his own training, experience, and personal preferences. There was no uniformity of opinion

or practice concerning the indications for thoracotomy, its timing, the management of foreign bodies, or any other problem related to combat-incurred chest

injuries. For all practical purposes, the chest surgeons at hospitals in the

theater and those on the teams of auxiliary surgical groups were establishing

their own policies.

Almost as soon as he arrived in the theater, Colonel Churchill began to

emphasize the division of wound management into the initial phase, the reparative phase, and the reconstructive phase. The division proved increasingly

sound because it made for more precise thinking and more logical management.

The concept was particularly adaptable to the problems of thoracic trauma.

In spite of the obvious need for standardization in the management of

chest injuries, Colonel Churchill issued no immediate directions for their management but set up, instead, what amounted to a number of clinical research

problems in the hospitals in which thoracic surgeons were working, particularly

the 9th, 11th, 38th, and 77th Evacuation Flospitals. The observations in these

hospitals, and the policies developed from them, represented one of the truly

significant advances in military surgery in World War II.

With careful observation of large numbers of chest wounds, it became clear

that the reaction to them fell into two phases:

1. An immediate, urgent phase, characterized by disturbances of carcliorespiratory physiology that were often profound and that could be fatal if

they were not corrected immediately, though not necessarily by surgery.

2. A delayed, nonurgent phase, characterized by infection. Infection was

not an inevitable result of chest injuries, and, if it did develop, it was not an

immediate complication.

The division of the bodily reaction to wounds of the chest into these two

phases made it clear that their management also fell into two phases:

1. The immediate application of procedures that would result, expeditiously and uniformly, in the correction of acute cardiorespiratory abnormalities of traumatic origin. These measures, to be carried out in the most forward

installations in which the proper facilities existed and competent personnel
198 THORACIC SURGERY

were available, formed an essential part of resuscitation. As already indicated,

they were not necessarily surgical. When they were effective, as they usually

were, major surgery could safely be deferred until an evacuation hospital was

reached.

2. The later performance, in the evacuation hospital, of debriclement and

such other surgery as might be indicated.

This routine frequently prevented infection. If infection developed in

spite of these measures, it could be cared for in a fixed hospital in the communications zone.

It is important to note the shift of therapeutic emphasis in the management of chest wounds in World War II. In the First World War, the focus

of attention was on the pleural space. In the Second World War, the focus of

attention was on the cardiorespiratory apparatus. In the earlier war, the

casualty was thought to be progressing satisfactorily as long as no pleural

infection was evident. The same concept prevailed in the first few months of

fighting in the Mediterranean theater in World War II. Then the emphasis

shifted from the management of posttraumatic pleural infections to the preservation and restoration of pulmonary function, which frequently prevented

the development of these infections or at least minimized their seriousness.

What this amounted to was a complete reversal of the World War I concept

that a casualty was in good condition if he did not develop empyema and the

substitution for it of the concept that, unless pulmonary function was satisfactory, progress was not satisfactory.

One temptation had to be overcome: The sweep of technical advances in

chest surgery between the World Wars was not a criterion of their applicability to the types of chest trauma encountered in wartime. The limitations

of these procedures and their correct timing, as well as the echelon of medical

care in which they were to be instituted, had to be defined by trial and error, in

the hard school of medicomilitary experience.

FORMULATION OF POLICIES

As described elsewhere (p. 82), the first medical meeting of any Army

on the European mainland during World War II was held in the King's Palace,

Caserta, Italy, on 11 November 1943. The meeting was an outgrowth of the

great interest in wound surgery on the part of the military surgeons who were

doing the work and, particularly, on the part of the Surgeon, Fifth U.S. xlrmy,

and his administrative and consultant staffs. At this meeting, which was devoted entirely to chest wounds, there were laid clown many of the principles of

the rational approach to chest trauma which was later to become theater policy.

By this time, it had become clear to many of the thoracic surgeons in the

Fifth U.S. Army that a conservative approach accomplished better results than

a more radical approach; that is, the limited use of thoracotomy in forward

hospitals. At this meeting, Capt. (later Maj.) Lyman A. Brewer III, MC,
EVOLUTION OF CLINICAL POLICIES 199

presented an analysis of 90 penetrating wounds of the chest that he had personally handled by conservative measures.

The keystone of the conservative policy was the use of thoracotomy in

forward hospitals only on strictly limited indications. Captain Brewer's personal experience to date, as well as the general experience in the chest center

at the 53d Station Hospital at Bizerte, also showed that foreign bodies, whether

metallic objects or bone fragments, even when they were of considerable size,

did not, in themselves, constitute valid indications for either traumatic or formal thoracotomy in these hospitals. There was, of course, no objection to their

removal if they were accessible through the wound used for debriclement, In

the course of the discussion, it was pointed out that the time required to stabilize

these patients and transport them to hospitals in the base was so brief that the

risk of infection supervening before the necessary surgery could be done was

very slight indeed. The composite experience to date at the Bizerte thoracic

surgery center showed that the case fatality rate in chest wounds was reduced

by half when thoracotomy was performed only on limited indications and that

the morbidity record was also greatly improved.

In March 1944, Colonel Churchill met at Marcianise, Italy, with Major

Snyder, Consultant in Surgery, Office of the Surgeon, Fifth U.S. Army;

Lt. Col. (later Col.) Frank B. Berry, MC, later Consultant in Surgery, Office

of the Surgeon, Seventh U.S. Army; and a number of thoracic surgeons from

the 2d Auxiliary Surgical Group, including Captain Brewer; Maj. Thomas IT.

Burford, MC; Maj. (later Lt. Col.) Lawrence M. Shefts, MC; Maj. (later

Lt. Col.) Paul C. Samson, MC; and Maj. (later Lt. Col.) Beeve H. Betts, MO

Critical review of the experience with chest wounds in the theater showed the

same pattern as at the November 1943 conference; that is, results were increasingly good when thoracotomy was performed in forward hospitals on strictly

limited indications and were much less good when it was used on ill-defined

indications. At the 24th General Hospital chest center, near Bizerte, for instance, Major Samson had found that 30 percent of all casualties with intrathoracic injuries had been submitted to major initial wound surgery at forward

hospitals, and that half of this group had poor results. Maj. William M.

Tuttle, MC, and his associates at the chest center at the 36th General Hospital,

Naples, had had a similar experience: 39 percent of the patients admitted had

already been subjected to major thoracotomy, and in 37.8 percent of this group

the results were poor.

Basic Principles

The discussion at this meeting made it clear that considerable uncertainty

still existed in the minds of many forward surgeons as to what constituted valid

indications for thoracotomy as part of the initial wound surgery of chest injuries. It was agreed that the accrued experience of the theater was now

sufficient to permit crystallization of the indications for major chest surgery in

forward hospitals and for the establishment of a uniform, mandatory, theaterwide policy for the management of chest injuries.
200 THORACIC SURGERY

As a result of the extended, detailed discussion at this meeting, it was

decided that hereafter the policy for the management of these injuries should

be based on the following principles:

1. The prime concern in the management of penetrating wounds of the

chest is the timing of surgical intervention, and the proper spacing of surgical

procedures, in forward and rear hospitals. In the forward area, the goal of

therapy is the restoration of physiologic equilibrium. The complications of

infection are usually delayed and, if they occur, they can, as a rule, be adequately

managed at the base.

2. The physiologic disturbances that attend wounds of the chest are serious

and urgent, but thoracotomy is not the way to control them. Appropriate

measures include needle aspiration of air and blood from the chest, aspiration

of blood and mucus from the tracheobronchial tree, control of pain by injection of the intercostal spaces with procaine hydrochloride, control of pressure

pneumothorax by insertion of a catheter with a flutter valve, oxygen therapy,

blood replacement, and debridement of sucking wounds (with hemostasis of

bleeding vessels and approximation of deep structures of the chest wall to close

the pleural opening).

3. Thoracotomy should be performed only on strict indications.

4. Closed drainage of the pleural space should be instituted after thoracotomy or after extensive surgery for a wound of the chest wall with involvement of the parietal pleura unless there are definite contraindications to its

institution. The catheter should be removed as soon as the clinical course

permits, which is usually within 48 hours.

5. A patient with an injured lung should be kept slightly dehydrated and

depleted, since pulmonary edema can be invited by the too-liberal use of intravenous infusions or excessive transfusion.

6. The preferred thoracotomy incision or the extension of a missile track

should be in the posterolateral area of the thoracic cage. Anterior incisions

should be avoided, as they frequently break down after closure.

Indications and Contraindications for Thoracotomy

Indications for primary thoracotomy, either by extension of the wound or

by separate incision at a site of election, were to be limited to:

1. Continuing intrapleural hemorrhage not controlled by hemostasis in the

course of debridement of the chest wall, which was uncommon.

2. Anatomic or clinical evidence of penetration of the diaphragm, which

was common.

3. Large intrapleural foreign bodies or other debris readily accessible by

simple extension of the wound.

4. Wounds of large bronchi or of the intrathoracic portion of the trachea,

which were uncommon.

5. Passage of a missile through, or its lodgment in, the mediastinum, with

reason to suspect visceral damage, particularly injury to the esophagus.
EVOLUTION OF CLINICAL POLICIES 201

The following conditions were not, in themselves, to be regarded as indications for thoracotomy either by extension of the wound or by a separate incision:

1. Foreign bodies, whether metallic objects or fragments of bone, whether

they were in the lung or the pleural space.

2. Hemothorax. Evacuation of blood from the pleural cavity by suction

at the time of debridement of the chest wall wound was not considered a

thoracotomy.

3. Laceration or contusion of the lung in the absence of definite evidence

of continuing hemorrhage.

Traumatic thoracotomy.—A considerable part of the meeting at Marcianise was taken up with a discussion of the advantages and disadvantages of

traumatic thoracotomy; that is, thoracotomy performed through an extension

of the traumatic wound or through the wound itself. As Colonel Churchill

pointed out, it permitted such procedures as removal of accessible foreign

bodies from the pleural space and of indriven bone fragments from the lung;

control of bleeding from the chest wall remote from the wound of entrance;

suture of presenting lung lacerations; evacuation of clotted blood; and visualization, appraisal, and sometimes suture, of diaphragmatic perforations.

It was dangerous, Colonel Churchill continued, to attempt to extend the

utilization of this procedure beyond these definite limits. Its wise use depended upon a number of variables, including: The condition of the patient,

the experience of the surgeon, the tactical situation with respect to evacuation

and hospitalization, the anatomic location and the size of the wound, and the

presence or absence of retained foreign bodies.

Traumatic thoracotomy thus occupied an intermediate position between

simple debridement and formal thoracotomy. When the defect in the chest

wall was large, little additional exposure was needed. When it was small, it

could bo enlarged by intercostal extension or rib resection. When it was

properly employed, it could save life, prevent infection, and obviate the necessity for a second operation at the base.

Traumatic thoracotomy, however, had all the risks of any operation

undertaken without a precise and predetermined goal and performed through

an incision determined by the missile and not chosen by the surgeon. Intrapleural surgery in the presence of a traumatized and partially collapsed lung,

instead of being beneficial, could delay pulmonary reexpansion and invite

pleural complications or, if they already existed, make them more serious.

Unwisely used, therefore, traumatic thoracotomy could unnecessarily delay

the casualty's evacuation to the rear and even endanger his life.

Dissemination of Information

The policies just outlined were formally set forth in Circular Letter No.

46 (7), issued in NATOUSA on 29 August 1944. These policies were also

incorporated in War Department Technical Bulletin (TB MED) 147 (8),

653fl81T—G2 :5
202 THORACIC SURGERY

issued from the Office of The Surgeon General and dealing with the care of

battle casualties. The same information was repeated in Circular Letter No.

8 (9), Office of the Surgeon, Headquarters, MTOUSA, in March 1945.

TRIAGE AND TRANSPORTABILITY

Triage

Some years after World War II ended, Colonel Churchill, Consultant in

Surgery, Office of the Surgeon, Fifth U.S. Army, stated one of the eternal

truths of military surgery (10) : "* * * The biologic processes of wound infection and wound healing will not compromise with faulty medical administration * * * and are beyond the reach of command decision.'"

It was in the light of this truth that the evacuation of all wounded

casualties was conducted. Evacuation was a selective process, determined by

triage, which meant the sorting or selection of patients from the basic standpoint of whether or not they could withstand transportation farther to the

rear. A number of other considerations also played a part. The degree of

selection that was practical was profoundly influenced by the military situation. The number of available beds might be limited. There might be restrictions, imposed by the terrain or the tactical situation, on the movement

or on the placement of hospitals. Transport might be in short supply. The

patient might be able to withstand evacuation if it were not unduly extended

but entirely unable to withstand it for any long period. Triage required a

high degree of clinical ability, but it also had to be a completely objective

process, in which humanitarian considerations could not be permitted to take

precedence over medicomilitary necessities.

The closer to actual combat the casualty was seen, the less the element of

selection determined his evacuation and the more weight was given to the

single factor of his transportability. At the battalion aid station, the only

selection possible was the separation of casualties rendered noneffective by

their wounds from those who could be returned to their combat duties almost

immediately. The same policies prevailed at the collecting station. At the

clearing station, evacuation first became really selective, for both surgical and

military reasons. It was militarily undesirable to perform major surgery

in a forward area on any casualty who could be moved out of the combat zone

without detriment to his condition. It was essential to move any casualty

whose need for surgery was urgent to the field hospital adjacent to the clearing

station.

Triage was always an individual matter. Only when a general retrograde movement was in progress did evacuation ever become a mass movement

of all casualties away from the combat zone. Even then, certain nontransportable patients could bo left to the care of an enemy known to respect the

Geneva Convention. In all theaters, U.S. Army surgeons cared for many

enemy wounded who had been left behind as their armies retreated.
EVOLUTION OF CLINICAL POLICIES 203

Triage was also a continuous function. In the clearing- station, the decision was made as to what casualties should go to the field hospital. In the

field hospital, reevaluation after resuscitation often showed that the casualty

who was originally nontransportable had become transportable and could

safely be evacuated farther to the rear. On the other hand, no chances were

taken. If there was any doubt at all as to his transportability, the casualty

was kept in the field hospital and operated on there. Particular care was

necessary in the group of patients just mentioned, those who seemed to become

transportable after resuscitation. In some of them, recovery was more apparent than real, and fatalities occurred among them both during transportation and after they were received in evacuation hospitals.

Triage was of major interest to the individual casualty, but it was also

important from the standpoint of other casualties. A platoon of a field hospital, even when supplemented by the personnel and equipment of attached

auxiliary surgical group teams, still had a limited capacity. It was commendable to treat all casualties as far forward as possible, but it was impractical, and it was also harmful. Generally speaking, when the census of even

an expanded platoon of a field hospital exceeded from 40 to 50 patients, these

men could not bo properly cared for. If a casualty whoso condition permitted

his evacuation were operated on in a field hospital, he occupied space, and

utilized the time and attention of medical personnel, which might be desperately needed by another, more severely wounded casualty who could not

withstand transportation.

Triage was thus a function of the greatest importance. Whenever possible, it was performed by the surgeons assigned to the particular hospital

from an auxiliary surgical group. It could be properly carried out only by

experienced medical officers.

The importance of triage was not immediately realized. Major Snyder,

after an analysis of 80 deaths which had occurred in Fifth U.S. Army

evacuation hospitals in January 1944 (2), concluded that some of them could

have been prevented by more careful triage in clearing stations. If a larger

number of casualties had been directed to field hospitals and cared for there,

the results would certainly have been improved. Of 44 patients in deep shock

or with first priority (nontransportable) wounds whose case histories Major

Snyder studied, 36 were sent directly to evacuation hospitals from clearing

stations. The other eight, although they were sent to field hospitals, were

merely observed there and then sent to evacuation hospitals for initial wound

surgery.

As a result of this survey, a medical circular was issued on 7 April 1944

(11), from the Office of the Surgeon, Headquarters, Fifth U.S. Army, dealing

with the disposition of battle casualties in forward echelons. At the same

time, an educational program was carried out in the clearing stations. The

prompt improvement that occurred in the triage of casualties was reflected in

improved results in all injuries and was maintained until the end of the war.
204: THORACIC SURGERY

The improvement in triage which occurred in 1944-45 is evident in remarks made by Brig. Gen. (later Maj. Gen.) Joseph I. Martin, then Surgeon,

NATOUSA, some years after the war (12) :

* * * The conflict that exists between the necessity of clearing the field of wounded

and of bringing; treatment and hope to those so badly wounded that they could not be moved

reached a fine balance in the Fifth Army during the last year of the war in Italy. This

efficiency was in great measure due to the professional zeal, devotion to duty, and judgment

of the members of the 2d Auxiliary Surgical Group * * *. Their written record speaks

for itself. It will constitute an excellent primer for the inexperienced military surgeon

who will be faced with this problem at some future time.

Criteria of Transportability

When the general principles just described were fully established and

properly followed, about 7 or 8 percent of all casualties passing through clearing stations reached field hospitals. When these principles were applied to

thoracic casualties, in the light of the principles agreed upon at the meeting

in Marcianise in March 1944 (p. 199), the majority of men with chest wounds,

perhaps from 60 to 65 percent, were cared for in evacuation hospitals.

Since thoracic surgery as a specialty was of quite recent development, the

criteria of transportability as applied to chest wounds were not clearly established at the beginning of the war and had to be clarified as the fighting proceeded. In some instances, the indications for holding patients in a field

hospital were clearcut. A casualty with a thoracoabdominal wound, for instance, was always nontransportable. All decisions, however, were not so

evident.

The chief reason for the original confusion was lack of realization of how

well thoracic casualties tolerated transportation if cardiorespiratory disturbances were stabilized before evacuation. As a result, early in the war, many

patients were operated on in field hospitals who could safely have been transported to the rear, while others were transported to evacuation hospitals before

their cardiorespiratory balance was stabilized, and some of them lost their

lives because of the error.

At the division clearing station, criteria for diverting casualties to the

nearby field hospital included continuing hemorrhage; severe shock; sucking

(blowing) wounds; wounds associated with respiratory distress of any degree;

cardiac wounds; wounds of the trachea, esophagus, or large bronchi; and

thoracoabdominal wounds, whether the diagnosis was established or merely

tentative.

These indications, however, were not always absolute. For instance:

1. Continuing hemorrhage was more often from the chest wall and into

the pleural cavity than it was external, and even persistent shock, rapid pulse,

and low blood pressure were not always indications that bleeding was occurring. The shock might well be on a cardiorespiratory basis. In such cases, the

diagnosis had to be established by repeated aspiration and the response to

transfusion.
EVOLUTION OF CLINICAL POLICIES 205

2. Sucking wounds* were numerous, because of the predominance of high

explosive shell fragments as wounding agents, but the wounds were usually

small, and the open pneumothorax was not in itself a common cause of respiratory embarrassment. A sufficiently large petrolatum-impregnated dressing

served as an adequate corrective measure, accomplishing sufficient occlusion

while at the same time providing an escape for air if a bronchial leak existed.

3. Both pressure pneumothorax and subcutaneous emphysema were surprisingly infrequent in the Mediterranean theater. The explanation was the

size of the wounds, which were usually either too small to produce the phenomenon of an open pneumothorax or too large to seal off the escape of air

under pressure. Another possible explanation was that preexisting pleural adhesions, which play a role in the mechanism of both these conditions, were

uncommon in combat troops in World War II. Whatever the reason, these

complications, which had been so frequent and so terrifying in the past, seldom

furnished an indication for surgery in field hospitals in World War II.

I. Tracheobronchial obstruction was also not an absolute indication for

surgery in the field hospital. It could be controlled by the use of a catheter

or by bronchoscopic aspiration to clear the respiratory passages of blood and

secretions. When these measures were combined with procaine hydrochloride

(Novocain) block of the intercostal spaces involved in the wound, relief of

pain AY as accomplished, and the patient was willing to cough frequently and

thus achieve evacuation of his own tracheobronchial tree.

These and other cardiorespiratory disturbances, although they were frequent and urgent, did not require surgery in a field hospital. They could

usually be controlled by the measures just outlined plus the ordinary routine

of resuscitation.

The nontransportability of the casualty with a thoracic wound was not always caused by the thoracic wound. Multiple wounds were frequent, and it

was often the severity of one or another of these, or their cumulative effect,

which made it impossible to move him farther to the rear. In such cases, it

was the usual rule to care for the thoracic wound before treating the others.

Unless defects in the pleura were closed, the pleural cavity was evacuated of

both blood and air, and the tracheobronchial tree was free of blood and mucus,

the patient would be handicapped during the performance of the other procedures by incompetent respiratory function.

Air Evacuation

A significant part in the improved results of chest injuries was played by

the increasing utilization of air evacuation in transporting patients to base

hospitals from forward hospitals (p. 79). The comfort and speed of this

method of evacuation undoubtedly hastened convalescence.

1 Although the term "sucking wound" has the respectability that comes from long usage, actually,

it is neither accurate nor descriptive. Any open pleural wound is potentially a sucking wound, but

it does not suck in air all the time. What it really does is blow the air in and out, and for that

reason, the term "blowing wound" would be more accurate and more truly descriptive. The use of

the term "sucking wound" is continued in this volume merely because it is in general use.—T. H. B.
206 THORACIC SURGERY

Routine evacuation of thoracic casualties by air was not possible. A high

altitude flight in a nonpressurized plane, which involved respiratory strain,

might prove harmful, or even fatal, if the chest wound was associated with

any degree of preexisting respiratory difficulty. With careful selection, however, most casualties tolerated flights at from 4,000 to 5,000 feet remarkably

well.

Numerous theoretical criteria were set up by which to gage the fitness of

thoracic casualties for air travel, but experience in receiving, questioning, and

evaluating patients showed that the necessary selectivity involved only a few

practical points. Casualties with adequate stabilization of the cardiorespiratory mechanism, with a clear airway, without bronchopleural fistulas or sucking

wounds, and without dyspnea, traveled well. Small to moderate pneumothoraces and hemothoraces, if static, were not contraindications to air transportation. Patients with empyema, who had been on open drainage for a

short time, also traveled well if the mediastinum were stabilized. It was an

additional precaution to be sure that no casualty was evacuated by air who

had any appreciable degree of anemia.

Special Study of Evacuability

The following study of the evacuability of 113 consecutive casualties with

penetrating or perforating thoracic and thoracoabdominal wounds was made

by Major Shefts of the 2d Auxiliary Surgical Group (12). These patients

were encountered between 15 January and 4 July 1914 and were examined

immediately on admission to the 94th Evacuation Hospital. During this period,

this hospital was variously located at Riardo, Mignano Monte Lungo, Anzio,

Rome, Montalto di Castro, and Montepescali.

The distance which each casualty had been transported was considered to

be the shortest distance between the geographic location of wounding, as far as

it could be determined, and the location of the hospital at the time he was admitted. For a number of reasons, the distance traversed was often considerably

longer than the estimated shortest distance. The average distance these casualties were transported was 22.2 miles, the range being 60 miles at one extreme and

5 miles at the other. The average lapsed time between wounding and arrival

at the evacuation hospital was 8 hours, with the range from 34 hours to 30

minutes.

After careful clinical examination, the 113 patients were divided into two

categories, the first based on the severity of their wounds and the second on

their general status. The following data were obtained:

1. Of the 73 patients with severe wounds, 33 were received in good condition, 28 in fair condition, and 12 in poor condition.

2. Of the 40 patients with moderately severe wounds, 38 were received in

good condition, 1 in fair condition, and 1 in poor condition.

3. These combined figures mean that 71 of the 113 patients were received

in good condition, 29 in fair condition, and 13 in poor condition.
EVOLUTION OF CLINICAL POLICIES 207

4. There were 7 deaths among the 113 patients, all after operation. One

death occurred in the group classified as in poor condition and three each in

the groups in fair condition and in good condition.

5. Five of the deaths occurred in the twenty-four patients with thoracoabdominal wounds, all of whom were classified as severely wounded. Two of

the deaths occurred in the thirteen patients who arrived in good condition, and

two in the eight who were in fair condition; the remaining death occurred in

the three who arrived in poor condition.

On the Anzio Beachhead, where 73 of the 113 casualties were treated, the

94th Evacuation Hospital performed the functions of a field, not of an evacuation, hospital. Although the average mileage and elapsed time were nearly

double at locations other than Anzio, the additional distance and lapsed time

did not materially alter the condition of the casualties on hospitalization. From

the clinical standpoint, those received at Anzio and those received elsewhere

represented about the same proportions of good, fair, and poor risks, and substantially the same results were obtained in their management.

In view of these observations, it is not unreasonable to assume that most

thoracic wounds can be safely treated in an evacuation hospital.

It is important to emphasize that the figures in this study and the conclusions drawn from them must be interpreted in the light of the criteria for

thoracotomy in field hospitals set up at the meeting in Marcianise, in March

1944 (p. 200).

RESULTS OF THERAPY

The policies employed for the management of chest wounds during the

Tunisian campaign were individualistic and unstandardized. The experience

in Sicily was much the same. The establishment of the first chest center in the

theater, at the 53d Station Hospital in Bizerte in July 1943, provided opportunities to evaluate the various policies employed to date, particularly the liberal

use of thoracotomy. The evaluation left no doubt of the fallacy of this policy

and of the far better results with conservative measures. These measures became standard policy after the meeting at Marcianise in March 1944.

For the last year of the war, therefore, there was a well-established, uniform

policy for the management of wounds of the chest in the Mediterranean theater.

The techniques employed had been known at the beginning of the war. Indications and contraindications had to be learned, however, as did timing and

spacing of the necessary procedures. Still another important lesson that had

to be learned was thatthe objective of resuscitation was to improve the casualty's

condition to the point at which he could withstand surgery, which in itself was

often the ultimate necessary purpose of resuscitation.

A comparison of the results of chest surgery before and after the new

policies went into effect, after March 1944, left no doubt of the soundness of the

change. That the results were related to the policies is quite evident, for the

proportion of successful results overseas improved as the proportion of thoracotomies decreased.
208 THORACIC SURGERY

The improvement in the condition of patients received in Zone of Interior

hospitals was equally gratifying. An evaluation of the first 500 patients received at the Kennedy General Hospital chest center, Memphis, Tenn. (vol. II,

appendix), was proof of the wisdom of conservatism in the management of

thoracic injuries.

SPECIAL TYPES OF WOUNDS

Thoracoabdominal Wounds

Military manuals.—Thoracoabdominal wounds are not mentioned as such

in War Department Field Manual 21-11, First Aid for Soldiers, 7 xlpril 1943,

although wounds of the chest and of the abdomen are both briefly mentioned.

The material on thoracoabdominal wounds in War Department Technical

Manual 8-210, Guides to Therapy for Medical Officers, 20 March 1942, is

entirely derived from the manual on thoracic surgery prepared by the National

Research Council.

National Research Council manual (_?).—The concept of prompt surgery for abdominal wounds was firmly established by the end of World War I,

and there was an almost equal realization of the importance of similarly prompt

surgery in thoracoabdominal wounds. It is therefore surprising to find that in

the manual on thoracic surgery prepared by the Subcommittee on Thoracic

Surgery of the Committee on Surgery, Division of Medical Sciences, National

Research Council, less than four pages are devoted to these wounds, which are

termed "pleuro-abdominal" wounds. It is equally surprising to find the approach unexpectedly casual. Unless the injury is "compounded," the text

states, repair "is usually not an emergency operation." There is a later discussion of the management of adhesions, whose presence, in themselves, would

indicate that surgery had been cleferred.

In substance, the material on thoracoabdominal wounds in the National

Research Council manual is as follows:

1. First aid includes the administration of morphine; chemotherapy; the

management of shock, including the administration of blood or plasma; and

the immediate closure of a sucking chest wound.

2. Definitive treatment includes examination for abdominal injuries (the

implication is that there are a large number of missed diagnoses, including

rupture of abdominal viscera); excision of the chest wound; suture of the

diaphragm; crushing of the phrenic nerve if the diaphragmatic injury is

extensive; control of pulmonary hemorrhage by suture or resection; and tight

closure of the chest wall, by use of the diaphragm if necessary.

3. Operation is always performed under intratracheal differential pressure

anesthesia.

4. If the diagnosis of thoracoabdominal injury is made before operation,

access coukl be transpleural or abdominal, depending upon the circumstances.
EVOLUTION OF CLINICAL POLICIES 209

The abdominal route offers a satisfactory approach in early cases "without

dense adhesions" and is quicker and easier for surgeons more accustomed to

working in the abdomen than in the chest. The transpleural route, however,

has its own advantages: When it is used, the pressure in the thoracic and abdominal cavities is immediately equalized, and it is thus easier to reduce the

prolapsed abdominal viscera. Repair of the diaphragm is facilitated by lightly

crushing the phrenic nerve with a hemostat, thus producing temporary

paralysis, a maneuver which is simplified by the ready access to the nerve possible through the thoracic incision. Finally, intrathoracic adhesions between

the prolapsed viscera and the lung can be divided under direct vision. Since

these adhesions are often dense and troublesome, the thoracic approach is the

approach of choice when the injury is "of more than a few weeks' standing."

If the preoperative diagnosis is rupture of a viscus, a median incision is

likely to be used, prolonged to the xiphoid process. If the correct diagnosis of

thoracoabdominal injury is made and a separate abdominal approach is used,

the best exposure is provided by a left paramedian incision, extending from

the xiphoid process to the umbilicus. If more exposure is required, it can be

secured by cutting the left rectus muscle across at one of the transverse lines.

For right-sided injuries with lacerations of the liver, the subdiaphragmatic

space is packed and drained. A posterior or lateral incision is used, with rib

resection below the diaphragm if necessary. Left-sided injuries involving the

stomach or spleen do not require abdominal drainage.

The entire discussion of thoracoabdominal wounds, in addition to being

surprisingly casual, is also surprisingly incomplete. One of the notable omissions is the lack of any directions for the management of wounds of the colon,

for which exteriorization or colostomy became the required treatment very

early in the war.

Official directives.—As the war progressed, the thoracic approach to thoracoabdominal wounds became increasingly popular in the management of

thoracoabdominal wounds in the Mediterranean theater, but no official policy

to that effect was ever published. There is not a great deal, in fact, on the

subject of these wounds in any of the official directives.

In an analysis of the management of the wounded in the Tunisian campaign (5), it was mentioned that in thoracoabdominal wounds, thoracotomy

should be clone in the field or the evacuation hospital, particularly if the wound

was on the right. In a commentary on the care of the wounded in Sicily (6),

it was stated that initial surgery should be performed in thoracoabdominal

wounds in the field hospital. A sucking wound required priority, but otherwise, either the abdomen or the chest might receive first attention. In an

occasional case, everything could be clone through a thoracic approach. In

other circular letters from the Office of the Surgeon, the official directives did

not go beyond the instructions, repeated several times, to treat these patients

as first priority, to be cared for in field hospitals.

G5SC81V—02 16
210 THORACIC SURGERY

Cardiac Wounds

As related elsewhere (p. 44), cardiac surgery was no longer a clinical

curiosity when the United States entered World War II. Nonetheless, the

infrequency of wounds of the heart susceptible to surgical treatment—that is,

of cardiac wounds not immediately fatal—is implicit in the scant attention

paid to them in the instructions for their management issued during World

War II.

Cardiac wounds are not mentioned in any of the circular letters published

in the Mediterranean theater during the war. Nor are they mentioned in War

Department Technical Bulletin (TB MED) 147 (8), dealing with the general

care of battle casualties.

Apparently the only detailed instructions for the management of cardiac

wounds during World War II appeared in the thoracic surgery section of the

National Besearch Council manual published in 1943 (1). These instructions,

like the rest of the material in the manual, were repeated in substance in

TM 8-210, These instructions are as follows:

1. The usual first aid treatment should be instituted, including the use of

blood or plasma in wounds associated with hemothorax, with a communication

between the pericardial and pleural cavities. Replacement therapy is not

mentioned in the management of cardiac tamponade.

2. Aspiration should be instituted in wounds associated with both hemothorax and cardiac tamponade, whether they have been caused by bullets or

shell fragments.

3. Cardiorrhaphy should be performed if bleeding recurs.

4. Prompt open drainage should be instituted if purulent fluid is obtained

from the pericardial cavity.

5. The management of foreign bodies in the heart and pericardium depends upon whether the objects have penetrated these structures directly or

have been carried to them by venous channels. If they have entered directly,

treatment should be directed to the wounds rather than to the foreign bodies.

Postural methods should be employed, in an attempt to throw the object into

the circulation, if it is in either ventricle, particularly the left ventricle, whose

thick walls make palpation and identification quite difficult. If the object has

entered the heart chambers via the circulation, postural methods are also employed. If they are contraindicated or are unsuccessful, conservatism is practiced. Whether or not the object is removed later depends upon whether or

not it gives rise to symptoms. Then the risk of removal should be weighed

against the severity of symptoms. Objects which are first free in the cardiac

chambers and later become fixed should not be disturbed.

The technique of cardiorrhaphy is described in detail. The surgeon is

warned that double wounds of the heart are not uncommon and that a wound

of the anterior surface is an indication for inspection of the posterior surface.
EVOLUTION OP CLINICAL POLICIES 211

THE SEVENTH U.S. ARMY

The policies for the management of thoracic (and other) casualties in the

Seventh U.S. Army were generally those employed in the Fifth U.S. Army and

base sections in the Mediterranean theater, many of whose surgeons were

assigned to the Seventh U.S. Army before the invasion of southern France.

The general policies of surgical care of casualties, including thoracic

casualties, were stated in Circidar Letter No. 2 (13), dated 18 July 1944.

These policies were reiterated in Circular Letter No. 17 (lb), on 30 December

1944. The material in this letter was the same as the material in Circular

Letter No. 46 (7), issued from the Office of the Surgeon, Headquarters, North

African theater, in August 1944. This letter stated the policies for the management of chest injuries which had been agreed upon at the Marcianise meeting

in March 1944.

The chief difficulty in new units, according to Colonel Berry, Consultant

in Surgery, Office of the Surgeon, Headquarters, Seventh U.S. Army, was

failure of their surgeons to realize the extreme importance of performing debriclement according to fundamental principles. This was as true of chest

wounds as of all other wounds. In theory, these new medical officers fully

appreciated the necessity for clebridement. In practice, they failed to abide

by the theory.

In the Seventh U.S. Army, almost all casualties with wounds of the chest

were sent first to field hospitals for examination, evaluation of their wounds,

and such resuscitation as might be necessary. About 40 percent were then held

in these hospitals for treatment.

Early in the Seventh U.S. Army experience, some surgeons believed that

formal thoracotomy should be performed rather frequently at the time of

initial clebridement and that the official policy of conservatism would produce

less good results. This was exactly the same state of affairs that had prevailed

in the first days of the fighting in North Africa and Italy. As the campaign

in southern France progressed, it became clear, just as it had in North Africa

and Italy, that results were better and fatalities fewer when the official policy

was strictly followed. When these patients were treated conservatively, they

were usually well on their way toward regaining normal lung expansion and

function by the time they reached evacuation hospitals. The results reported

by general hospitals and observed in visits to them showed that these results

were permanent and not ephemeral. As late as May 1945, however, it was

necessary to issue another warning against the use of formal thoracotomy in

forward hospitals, which had resulted in an increase of empj^ema (15).

References

1. Neurosurgcry and Thoracic Surgery. Prepared and edited by the Subcommittees

on Neurosurgery and Thoracic Surgery, Committee on Surgery, Division of Medical Sciences, National Research Council. Philadelphia and London : W. B. Saunders Co., 1943.
212 THORACIC SURGERY

2. Snyder, Howard E.: Fifth U.S. Army. In Medical Department, United States Army.

Surgery in World "War II. Activities of Surgical Consultants. Volume I. Washington:

U.S. Government Printing Office, 1962, pp. 333-464.

3. Circular Letter No. 13, Office of the Surgeon, Headquarters, NATOUSA, 15 May 1943.

4. Circular Letter No. 16, Office of the Surgeon, Headquarters, NATOUSA, 9 June 1943.

5. Circular Letter No. 20, Office of the Surgeon, Headquarters, NATOUSA, 22 June 1943.

6. Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, 7 Aug. 1943.

7. Circular Letter No. 46, Office of the Surgeon, Headquarters, NATOUSA, 29 Aug. 1944.

S. War Department Technical Bulletin (TB MED) 147, March 1945.

9. Circular Letter No. 8, Office of the Surgeon, Headquarters, MTOUSA, 10 Mar. 1945.

10. Churchill, E. D.: Selective Evacuation Versus Hitchhiking. J.A.M.A. 145: 841,

17 Mar. 1951.

11. Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army,

7 Apr. 1944.

12. Shefts, L. M.: The Evacuability of Patients With Thoracic Wounds With a Foreword by Brigadier General Joseph I. Martin. Bull. U.S. Army M. Dept. 9(5) : 357-363,

May 1949.

13. Circular Letter No. 2, Office of the Surgeon, Headquarters, Seventh U.S. Army,

IS July 1944.

14. Circular Letter No. 17, Office of the Surgeon, Headquarters, Seventh U.S. Army,

30 Dec. 1944.

15. Circular Letter No. 9, Office of the Surgeon, Headquarters, Seventh U.S. Army,

IS May 1945.
CHAPTER VII

Emergency Measures

Lyman A. Brewer III, M.D.

The management of the casualty with a chest injury from the moment he

was wounded until his arrival at a forward (field or evacuation) hospital was

directed to the same end as was the management of all other wounded: To

state it bluntly, it was to keep him alive until he reached an installation in

which his wounds could be evaluated and suitable measures of resuscitation

administered to make a safe candidate for surgery. There was often, however, a particular urgency about the care of thoracic casualties because their

wounds seriously interfered with the physiologic function of respiration and

had a secondary, often equally serious, effect on cardiac function.

MANAGEMENT ON THE BATTLEFIELD

Emergency care of the wounded was begun on the battlefield by company

aiclmen. The thorough training of these medical corpsmen, and of the battalion surgeons who received casualties from them, in the proper emergency

measures to be applied in thoracic wounds is not susceptible of statistical

analysis but was an unquestionable factor of real significance in the steadily

improving mortality and morbidity of these wounds. Medical corpsmen were

fully alert to the dangerous possibilities of chest wounds, particularly sucking

wounds, and to the importance of their correct initial management. Forward

surgeons were agreed that the number of patients with these wounds who

arrived in forward hospitals without proper occlusive dressings steadily decreased during the war and was, on the whole, gratifyingiy small.

Corpsmen were always instructed to do no more than was really necessary

in any type of wound. In chest wounds, battlefield care was limited to several

simple measures:

1. Open wounds of the chest (so-called sucking wounds) were closed in

one of several ways (figs. 18 and 19). The simplest method was to occlude the

wound with a gauze dressing, preferably petrolatum-impregnated, large

enough and applied tightly enough to stop the characteristic blowing sound.

Petrolatum-impregnated gauze was preferred to plain gauze for the first layer

of the dressing, partly because it provided a more nearly airtight closure and

partly because it could be more easily removed.

213
m THORACIC SURGERY

4EN:v* i ;

FIGUEE IS.—Emergency packing of sucking chest wound by medical corpsmen.

The wound was not tightly plugged. The dressing was simply laid over

it, and well beyond it, on all sides. It was held in place by adhesive straps.

This simple measure usually proved entirely satisfactory. It eliminated the

risk of an open pneumothorax during transportation to the rear and at the

same time provided a means for escape of air under tension, so that tension

pneumothorax could not develop.

Early in the war, it became the policy in the Mediterranean Theater of

Operations, U.S. Army, to dress practically all wounds of the chest as if they

were sucking wounds, as indeed many of them could become with changes of

position (vol. II, ch. I).

2. Paradoxical motion of the chest, caused by multiple injuries of the bony

thoracic cage (the so-called stove-in chest), was controlled by the snug application of a bandage.

3. Patency of the airway Mas maintained by urging the wounded man to

cough. This measure was particularly urgent if his breathing was noisy or

there was a rattle in his throat. Coughing could be encouraged if the corpsman could take the time to support, the chest manually during the act.

4. A casualty who had difficulty in breathing when he lay recumbent was

transported in a sitting or semisitting position if his condition and his other

wounds permitted. The recumbent position often materially reduced the vital

capacity.
EMERGENCY MEASURES 215

5. Morphine was administered only if the patient was in real enough pain

from thoracic or other wounds to make its use necessary (p. 244). A close of

gr. 14 was considered the maximum.

6. Associated wounds were given the required attention. If their severity

warranted it, they were given precedence over chest wounds not associated

with respiratory difficulties.

II

tin

tifftf

"-7

A

_ » > c

FIGURE 10.—Emergency management of sucking chest wound on battlefield or

at battalion aid station. A. Occlusion of wound with cloth, plain gauze, or

petrolatum-impregnated gauze. B. Approximation of wound edges with adhesive

tape. C. Approximation of wound edges with safety pins. D. Manual approximation of wound edges. E. Positioning of patient on pad or pack so as to cover

opening in chest wall. E. Temporary mattress suture of wound. This measure

could be used only at the battalion aid station, as corpsmen were not provided

with suture material and were not trained to insert sutures.

7. Early in the war, it was the policy to sprinkle sulfanilamide in all fresh

wounds. As the war progressed, this measure was recognized as useless, if

not actually harmful, and it was gradually abandoned.

Local chemotherapy.—At the beginning of the war, as described elsewhere, powdered sulfanilamide was part of the contents of the first aid kit,

and the wounded soldier was taught to begin his own chemotherapeutic treatment, whenever he was able, by dusting his own wound with the powder. If

he could not, the corpsman was taught to do it for him. Similarly, until

almost the end of the war, sulfanilamide tablets were included in the first aid

kit, and if the wound did not involve the abdomen, the soldier, if he was able,

took them according to instructions as soon as he was wounded. Later, it
216 THORACIC SURGERT

came to be realized that dusting an undebrided wound with sulfanilamide and

covering it with gauze was no more than a gesture, and an ineffectual one at

that.

MANAGEMENT IN BATTALION AID AND COLLECTING STATIONS

Wien the casualty arrived at the battalion aid station, he was observed

by a medical officer, whose functions were:

1. To examine the dressings over the wound, making sure that they were

properly applied and readjusting them as necessary. If they had become

stiffened by blood, they had frequently ceased to be airtight and had to be

changed. Dressings over large sucking wounds were examined with particular care. Unless circumstances required it, however, dressings which had

been applied satisfactorily were simply inspected; they were not changed.

2. To administer morphine if it were really needed for pain and if it had

not been given by the company aidman (p. 244). Intravenous administration

was preferred in patients in shock.

3. To begin a plasma transfusion if the patient were in shock or seemed

to be verging on shock. From the most forward point, care was taken not to

overload the circulation of a thoracic casualty.

At the beginning of the war, it was the practice of some medical officers

to dust the wound with sulfanilamide crystals at battalion aid stations. The

practice was never uniform, and eventually it was discontinued. It was never

useful.

When penicillin became generally available, in the spring of 1944, it was

given in the battalion aid station or the clearing station, in the amount of

20,000 units intramuscularly every 3 hours.

At the collecting station, the next point of medical care within the division,

the same procedures were employed. Dressings were inspected carefully, but

they were not adjusted or changed unless circumstances required it (fig. 20).

It was often difficult to persuade inexperienced medical officers to obey these

instructions.

MANAGEMENT IN THE CLEARING STATION

Once the casualty reached the divisional clearing station, he was subjected to

triage (sorting) to determine his further management (p. 202). His disposition depended upon the character and severity of his injuries and the urgency

of surgery for them, his physical status, and the number of other casualties and

the urgency of their wounds.

A casualty whose wounds were slight and who could probably be returned to

duty promptly was held in the clearing station. Early in the war, a

casualty who was in shock, regardless of the kind of wound he had sustained,

was treated for it at the clearing station, and his disposition was determined

after resuscitation. Later, it became the policy to send all patients in shock,
EMERGENCY MEASURES 211

fMS^^S^^^Wßi !U&jj!MjifS9^&2S3$]yi1

!/4u1'u'

|VfPJ*

^ US

f^fiSP^;

HI

SU?

•öäärtt

FIGUKE 20.—Adjustment of surgical dressings on ambulatory chest casualties

at collecting station. A. Adjustment of dressings on anterior wound. B. Adjustment of dressings on posterior wound.
218 THORACIC SURGERY

regardless of the kind of wounds tliey had sustained, to the shock ward of the

adjacent field hospital and to determine their further disposition there.

Whether or not he was in shock, a casualty who required urgent surgery,

which the majority of casualties with thoracic injuries did not, was always sent

to the field hospital. Otherwise, he was evacuated to an evacuation hospital

for initial wound surgery.

The clearing station was the farthest forward point at which whole blood

was available for transfusion. The policy was to administer it here to patients

who, it was thought, would then be safely transportable to an evacuation

hospital.

TRANSPORTATION

From the time he was picked up on the battlefield, the wounded man was

transported to the rear as rapidly as possible until he reached the clearing station, where the plan of management he required was determined \ipon. The

timelag from injury to triage varied according to the combat activity of the

division, the number of casualties, and the terrain over which they had to be

moved. Sometimes, it was a matter of minutes. More often, it varied from

2 or 3 hours to 15 hours or more. Occasionally, when the tactical situation was

particularly difficult, it was 24 hours or more.

Casualties with superficial wounds of the chest were permitted to be ambulatory. All other thoracic casualties were carried. They were usually moved

by litter from the battlefield, though during the fighting in the Apennines, as

already mentioned, they were frequently brought down the mountain by mules.

Movement from the battalion aid station to the collecting station, depending

upon the tactical situation and their relative locations, was by litter, by jeep

with improvised litter racks, or by ambulance. Transportation from the collecting station to the clearing station was usually by ambulance. The clearing station and the field hospital were so closely adjacent that casualties were

moved from one to the other by litter carry.
CHAPTER VIII

Diagnosis

Lyman A. Brewer III, M.D.

GENERAL CONSIDERATIONS

Refinements of diagnosis in thoracic injuries (and all others) were deferred, as a practical matter, until the patient had reached the field or evacuation hospital in which initial wound surgery was to be carried out, Up to

that point, all that was necessary for the care of the patient was the general

information that he had a wound of the chest which was or was not sucking

and in which hemorrhage was or was not a factor.

When the casualty arrived in a field hospital, a preliminary appraisal was

made of his wounds and of his general status. His pulse, respiration, and

blood pressure were determined immediately and recorded. If he was in shock,

or seemed to be verging on shock, resuscitative measures were instituted at

once, to prepare him for surgery or to make him safely transportable farther

to the rear.

The dressing was checked, to make certain that the wound was not sucking

and bleeding was not active. Then, if the patient was in shock or was thought

to be verging on shock, diagnostic measures were discontinued and resuscitative measures (p. 241) were instituted at once. The manner in which he reacted

to these measures often aided considerably in the determination of his disposition. Many times, after pain had been relieved and vital capacity improved,

it became evident that transportation farther to the rear could be safely undertaken. In other instances, when no improvement occurred or when a period

of temporary improvement was followed by regression, it became equally

evident that operation was an essential part of resuscitation and must be undertaken without delay.

Aside from the fact that resuscitation, from the lifesaving standpoint, was

frequently imperative, anything but a tentative diagnosis was often difficult, if

not actually impossible, until the casualty had been brought out of shock

and his impaired cardiorespiratory balance had been improved or entirely

corrected. A soldier admitted to a shock tent groaning with pain, dyspneic,

cyanotic, and hypotensive, did not lend himself to examination or appraisal.

An experienced chest surgeon, however, or even a considerably less experienced

medical officer on a shock team, usually had little difficulty in arriving at a

precise diagnosis and making a decision as to the urgency of surgery after

such resuscitative measures had been employed as forced coughing, endo219
220 THORACIC SURGERY

traclieal catlieterization or bronchoscopy, replacement therapy, thoracentesis,

and intercostal nerve block.

There were five main points to be considered in the diagnosis of a thoracic

wound:

1. The course of the missile and the probable direct damage that it had

done.

2. The possible blast effect of the missile.

3. The presence or absence of signs of a completely or partially obstructed

airway.

4. The presence of a sucking wound.

5. The presence and degree of pulmonary compression caused by air

(pneumothorax) or blood (hemothorax) in the pleura! cavity.

While it was frequently impossible, it was always desirable that casualties

with thoracic injuries, both before and after operation, should be kept away

from the noise of gunfire. The apprehension created by it increased dyspnea

and had other bad effects.

HISTORY-TAKING AND PHYSICAL EXAMINATION

History-Taking

History-taking in the manner in which it was usually practiced in civilian

medicine was not possible in military medicine, partly because there was no

time for such a detailed inquiry and partly because the casualties were, for

the most part, in no condition to endure it. It was an invariable rule not to

question any patient who was seriously wounded or who was in shock or verging

on it until he had been sufficiently resuscitated for the questioning to impose

no additional strain on him. If it was possible, however, it was important to

learn the position of the patient when he was wounded, for this information

helped to clarify the probable course of the missile through the body and its

final resting place. It was also important to learn how near the patient was

to the actual site of a shell explosion, so that its blast effects could be estimated.

Multiplicity of Wounds

Careful examination of the entire body was a matter of the greatest

importance. Serious diagnostic errors, and consequent errors of management,

could result if the attention were concentrated on a single wound however

obvious it might be. The associated wound was sometimes more serious than

the chest wound and might require more radical surgery (fig. 2!).

Wounds of the abdomen were sometimes a part of the thoracic wound and

sometimes independent of it. Spinal cord injuries were frequently associated

with chest injuries (vol. II, ch. I). Associated wounds of the arm and shoulder
DIAGNOSIS 221

\ 3

^

IS i

/

—f ,#* /

*.-i.. *

FIGURE 21.—Chest casualty with multiple other wounds, including an injury of the

buttock for which colostomy was necessary. The pictures were taken in a base hospital,

after closure of the wound of the chest wall. A. Patient recumbent. B. Patient in left

lateral position.

were also frequent, and some chest wounds were sometimes overlooked because

of the more conspicuous perforating wounds of the upper arm. It was particularly important in injuries of the arm and shoulder that complete chest roentgenograms be made.

Multiplicity, in short, was a factor which influenced every phase of chest

injuries, from battlefield management to disposition, and it accounted for a

certain rather sizable proportion of the fatalities in such injuries. Multiple

wounds, as might be expected, were particularly notable in battlefield deaths

(figs. 22, 23, 24, 25, 26, and 27). In the study of a thousand such deaths made

by Capt. William W. Tribby, MC, in Italy in 1944 (1), there were only 312

cases in which the wounds were not multiple. In the 572 wounds of the chest

included in the series, the wounds were limited to the chest in only 84.
222 THORACIC SURGERY

FIGURE 22.—Diagrammatic showing of multiple wounds of head, neck, chest, and both

upper extremities caused by shell fragments (mortar). Many small penetrating wounds

are present in the face, neck, chest, and both arms. The largest wound, 2 by 3 cm., is in

the left anterior axillary line near the shoulder; its track perforates the thoracic wall.

(Redrawn from Tribby, case No. 17.)
DIAGNOSIS 223

FIGURE 23.—Multiple wounds, head, chest, and upper extremities, caused by shell fragments. Penetrating wounds, one above right ear and one in right cheek, 1 by 1.5 and

2 by 6 cm. Right side of chest shows a crushing injury with partial evisceration of lung

and fractures of ribs and sternum. Right axillary region mutilated, with a compound

comminuted fracture of upper end of humerus. Through-and-through wound in right

forearm, with a compound comminuted fracture of ulna ; lateral point of entry, 1 by 2 cm.;

posterior point of exit, 2 by 5 cm. Wound of left hand, 3.5 by 6 cm., shows a compound

comminuted fracture of second metacarpal bone. (From Tribby, case No. 58.)
224 THORACIC SURGERY

FIGUKK 24.—Multiple wounds, lieticl. chest, and both upper extremities caused by high

explosive; penetrating wound, 1.7 cm. in diameter, located below left eye; two penetrating

wounds, 1 cm. and 1.5 cm. in diameter, in right cheek; anterior wound enters cranial

cavity. Four penetrating wounds in anterior chest vary from 1 cm. to 3 by 6 cm.; all four

wounds enter thoracic cavity, largest in left upper chest. Left shoulder is mutilated, with

compound comminuted fracture of proximal end of humerus; severe mutilation of left

hand; penetrating wound, 1.5 cm. in diameter, in right arm in middle of biceps muscle.

(From Tribby, case No. 105.)
DIAGNOSIS 225

FiGUiiE 25.—Multiple wounds, chest and abdomen, caused by high explosive. Wound,

1 cm. in diameter, perforates thoracic wall in anterior left side, in anterior axillary margin

at level of first rib. Wound, 1 cm. in diameter, enters thorax in anterior right side at

margin of sternum through third intercostal space. Wound, 1.5 by 2 cm., enters thorax in

anterior right side in anterior axillary line, level of eighth intercostal space; penetrating

wound, 7 mm. in diameter, lateral right side of chest, posterior axillary line, level of eighth

intercostal space. Wound 1.2 cm. in diameter, perforates abdominal wall in midline of

epigastrium near tip, xiphoid process. (From Tribby, case No. 513.)
226 THORACIC SURGERY
DIAGNOSIS 227

FIGURE 26.—Diagrammatic showing of multiple wounds of head, neck, chest, abdomen,

right upper extremity, and both lower extremities caused by shell fragments. There is a

penetrating lacerated wound, 4 by 10 cm., in the right posterior side of the skull in the region

of the squamous suture; both parietal bones, the occipital bone and the right mastoid bone,

are extensively crushed. A penetrating wound, 2 cm. in diameter, enters the base of the

neck in the right lateral side. A penetrating wound, 2 by 3 cm., in the right mid chest area

in the anterior axillary line enters the thoracic cavity through the fourth intercostal space

through a transverse fracture of the fourth rib. A through-and-through wound is present

in the lower abdomen; the point of entry, 2 cm. in diameter, is in the left lower quadrant,

and the point of exit, 4 cm. in diameter, is in the right side near the umbilicus. A wound,

4 by 6 cm., penetrates the right anterior shoulder without a palpable fracture. A throughand-through wound in the proximal third of the right mid arm reveals a compound comminuted fracture of the humerus; the point of entry is located laterally and measures 10

cm. in diameter; the point of exit is located medially and measures 12 cm. in diameter.

A penetrating wound, 5 cm. in diameter, in the right distal arm, exposes a compound

comminuted fracture of the lateral epicondyle of the humerus. There are several large

lacerated, penetrating wounds in both anterior thighs, in the knees, and in the right mid

leg. The largest wound is in the distal anterior right thigh and measures 20 cm. in

diameter; there is a compound comminuted fracture of the femur in this latter wound.

(Redrawn from Tribby, case No. 465.)
228 THORACIC SURGERY
DIAGNOSIS 229

FIGTJKE 27.—Diagrammatic showing of multiple wounds of neck, chest, abdomen, and

left upper and right lower extremities caused by high explosive. A penetrating wound,

2 cm. in diameter, is found in the tip of the left shoulder. The track extends downward

and medially and enters the left side of the thorax. There are comminuted fractures in

the head of the left humerus and in the lateral end of the clavicle, in the acromion process

of the scapula, and in the first rib. Four lacerated penetrating wounds are present in the

posterior right side of the neck and chest between the levels of CT and T4. The largest

wound, 4.5 by 8 cm., is near the inferior angle of the right scapula. There are compound

comminuted fractures in the first four ribs, in the right scapula and in the body of T2. A

superficial lacerated wound, 3 by 5 cm., is present in the lower posterior left side of the

chest. A wound, 1 by .5 cm., enters the abdominal cavity above the posterior left crest of

the ilium. A penetrating wound, 2.5 cm. in diameter, enters the abdomen in the right

flank near the tip of the eleventh rib. There is a through-and-through wound in the

proximal end of the right leg adjacent to the knee joint. The medial opening measures 3 by

4 cm., the lateral opening, 3 by 5 cm. The proximal ends of the tibia and fibula are severely

comminuted. (Redrawn from Tribby, case No. 580.)
230 THORACIC SURGERY

Methods of Physical Examination

Physical examination was carried out after the clothing- had been cut away

and removed, to avoid the possibility of overlooking associated wounds.

Wounds that were adequately dressed when the casualty was received in the

field hospital were not disturbed until it was possible for both the chest surgeon

and the shock officer to examine them together. Multiple inspections were

avoided. They invited infection and, if a sucking wound was present, permitted the further entrance of air into the pleura! cavity. Examination included the head, neck, and extremities, as well as the chest, back, lumbar area,

and abdomen, to insure that a small wound of entrance or any source of hemorrhage was not overlooked.

Experience showed that in the circumstances that prevailed in a field hospital, a gross physical examination offered more useful information than could

be obtained from more refined methods applicable in civilian practice. For

example, a check of the position of the trachea in the suprasternal notch or of

the position of the apex cardiac impulse gave as much evidence, and sometimes

more evidence, of the presence of a clinically significant hemopneumothorax

than did time-consuming percussion and auscultation, measures that were often

difficult to carry out in a busy, noisy resuscitation ward. Minor deviations from

the normal, such as would have been found by more refined methods of diagnosis, were seldom of particular significance in the plan of management.

Projection of the Course of the Missile

Physical examination was carried out by the usual routine, supplemented

by accurate localization of the external thoracic wound or wounds and by projection of the probable course of the missile, beginning with the information

provided by roentgenologic examination. It was necessary to take into consideration the location of the external wound or wounds, to identify fractures of

the ribs, and to visualize any metallic fragments which might be present, It

was also necessary, when possible, to determine the patient's position at the

time of wounding.

As a general rule, missiles traveled in a fairly straight line, but if they

struck the bony thoracic cage, deflections were to be expected. The voluminous

literature on the erratic course of missiles within the body has always tended

to put too much emphasis on the exceptional case in which the missile, because

it struck a rib or some other bony structure and was reflected from it, failed to

take the usual straight course.

Foreign bodies lying free in the pleura! cavity could be quite misleading.

In one such case, no wound of entrance could be found, and the only associated

wound was over the deltoid tubercle. When the patient was asked about his

position at wounding, he said that he was lying on the ground, with his arm

extended upward alongside his head, when he was injured (fig. 28). This was
DIAGNOSIS 231

only one of many cases in which, when the facts were secured, the course of the

missile ceased to be mysterious.

If the patient's condition permitted, it was always best to move him to a

clean litter before roentgenologic examination. In more than one case, a foreign body which lay free on the litter was sometimes erroneously thought to be

in the body.

Details concerning the localization of retained foreign bodies appear under

that heading (vol. II, ch. VII).

FIGURE 28.—Diagrammatic showing of apparently bizarre

course of missile, with only wound of entrance over deltoid

tubercle. A. Course of bullet at wounding, when patient

was lying with left arm extended above his head. B. Course

with arm at side.

CLINICAL PICTURE

Symptoms

Among the points on which the casualty with a chest wound was questioned

when time and circumstances, including his own status, permitted were the

following:

1. His chief complaint. This was not always related to the obvious

wound or wounds, and such an inquiry sometimes directed attention to a wound

which had not been entered on the emergency medical tag.

2. Pain, including its type, location, and relation to respiration. Pain of

some degree was the rule in thoracic wounds, although its intensity was frequently dulled by morphine before the patient was received in the field hospital. It was often located in the chest wall, but pleura! pain was a definite
232 THORACIC SURGERY

entity. Even if the wound was limited to the thorax, it was frequently associated with abdominal pain and tenderness.

3. Dyspnea, including its onset in relation to wounding and whether it was

increasing or decreasing. True shortness of breath implied deficient oxygenation, and, in the absence of severe blood loss, was usually attributable to decreased function of the pulmonary parenchyma. Among the conditions which

could contribute to it were hemothorax, pneumothorax, and hemorrhagic infiltration of the lung. A history of increasing dyspnea suggested increasing

pressure on the lung by blood or air.

4. Whether blood had been coughed up, and, if so, when the episode had

occurred in relation to wounding and how copious the hemoptysis had been.

Hemoptysis of some degree could be expected in almost all penetrating wounds

of the chest. It was also common in severe wounds of the thoracic wall, in

contusions of the lung, and in blast injuries. Hemoptysis was always a warning sign, though the amount of blood coughed up varied with the particular

wound and was not correlated with its severity.

5. K"ausea and vomiting, in relation to the time of wounding and the time

of the last meal before wounding. Nausea and vomiting were not commonly

associated with wounds limited to the thorax, but they occasionally occurred.

In at least one instance, they were present in a wound of the heart (vol. II,

ch. II). Frequently, however, these manifestations were related to the stress

and strain of combat conditions, under which undigested food might remain in

the stomach for many hours, to be ejected under the additional stress of

wounding.

6. Any period of unconsciousness, and, if it had occurred, how long it had

lasted. A short period of unconsciousness was not infrequent in injuries caused

by high explosive shells. Longer periods, especially if the casualty had previously been fully conscious and oriented, were more likely to be caused by shock,

severe blood loss, cerebral concussion, or cerebral damage from prolonged

anoxia. Maniacal manifestations, which were sometimes observed, always

indicated severe anoxia.

The clinical picture of severe shock in a thoracic casualty was sometimes

the result of loss of blood by the usual routes but was sometimes the result of

a rapid decrease in the vital capacity caused by pulmonary collapse from bleeding into the pleural cavity, with mediastinal shift. This picture might also

be produced by the reduced respiratory excursion resulting from pleural pain,

most often caused by fracture of the ribs.

7. Sucking (blowing) of the wound. A story of sucking or exchange of

air through the wound was presumptive evidence that the missile had penetrated the pleura. The same observations were occasionally made in extensive

soft-tissue lesions without pleural involvement, especially if the chest wall was

flaccid as the result of multiple rib fractures. The presence or absence of

sucking had no bearing on the course of the missile or on the damage it might

have done.

8. The wounding agent, the patient's position at the time of wounding, and

his distance from the high explosive shell or other missile.
DIAGNOSIS 233

9. Whether the time of wounding, as far as the patient knew, corresponded

with the time recorded on the emergency medical tag.

A quick runthrough of these questions, which could be asked as the physical examination was proceeded with, often provided a surprising amount of

useful information. It also played a part in establishing the physician-patient

relation so often necessarily, but always unfortunately, lacking in medicomilitary circumstances.

Signs

General considerations.—The general appearance of the patient, including his color, was more important than the physical signs elicited in the chest.

If cyanosis and ctyspnea of any degree were present, it had to be assumed that

the cardiorespiratory mechanism was out of balance. Cyanosis was always a

sign of comparatively advanced anoxia. Even under these circumstances,

however, it was not always present: If there had been severe blood loss, cyanosis

might not be detectable because of the lower hemoglobin content of the blood.

It coxild be missed in poor light.

The type and character of the respirations were important. Patients with

badly contused lungs from direct injury or from blast often exhibited the signs

of wet lung (vol. II, ch. V). Eapid, rattling respirations, with frequent,

ineffectual coughing, were clear evidence of difficulty in maintaining a patent

airway.

Chest findings.—Both cyanosis and dyspnea indicated the necessity for

careful examination of the chest for signs of pressure pneumothorax, a large

hemopneumothorax, or an incompletely sealed sucking wound. Any perforating or penetrating wound of the chest of any consequence necessarily resulted

in the entrance of at least a small amount of blood or air or both into the

pleura! cavity. Small amounts did not materially influence the cardiorespiratory mechanism, but when either was present in sufficient quantity to restrict

lung expansion, adequate oxygenation could not occur. Physical signs could

be most misleading in estimating the size of the pleural collection, and the

severity of symptoms was often entirely unrelated to the amounts of fluid or

air detected on physical examination.

Unilateral rigidity of the chest wall was frequently associated with hemothorax, but its absence was of no diagnostic significance.

Abdominal findings.—Careful examination was carried out in all thoracic

injuries to determine whether the wound was thoracoabdominal or whether a

separate abdominal wound was also present. Abdominal examination in all

chest inj uries was also required for other reasons:

1. A large number of patients with uncomplicated thoracic injuries developed acute gastric dilatation soon after wounding, though many times it was

not apparent until roentgenologic examination was carried out (vol. II, ch. IAr).

Gastric dilatation increased respiratory difficulties aiid was an indication for

immediate decompression by nasogastric suction.

2. Even a wound limited to the thorax was frequently accompanied by

abdominal pain, tenderness and rigidity (the phrenodiaphragmatique rigidity

053081''—02 17
23-1 THORACIC SURGERY

referred to by French writers). The abdomen might be completely silent.

The origin of these symptoms and signs has never been fully explained. Irritation or injury of the intercostal nerves and diaphragm did not seem to cover

all cases. The picture was further confused by the fact that in some intraabdominal injuries, especially if only the spleen or the liver was injured,

physical findings soon after wounding might be very slight.

Differentiation between thoracic wounds accompanied by abdominal findings and thoracoabdominal wounds was frequently difficult, but it was imperative to lose no time in making it. As a rule, the abdominal spasm winch

accompanied a thoracic wound tended to be unilateral and to become less

evident upon inspiration, while spasm caused by an abdominal injury tended

to be bilateral. Anesthetic block of the intercostal nerves in the involved areas

sometimes furnished useful diagnostic aid. If pain and cutaneous tenderness

disappeared after the block, it could be concluded that the wound was limited

to the chest. If some degree of spasm, rigidity, and tenderness on deep pressure persisted in spite of the nerve block, it could be concluded that an abdominal injury was present in addition to the thoracic wound. This was a

time-consuming method, which would not be used in patients in poor condition.

The correct interpretation of clinical symptoms and physical signs was

most important in patients whose condition was too precarious to permit

roentgenologic examinations until extensive resuscitative measures had been

employed.

Details of the diagnosis of thoracoabdominal wounds are discussed under

that heading (vol. II, ch. III).

ROENTGENOLOGIC DIAGNOSIS

X-ray facilities, as already mentioned, were somewhat limited during the

North African campaign, and a field hospital had only a single apparatus for

its three platoons. This situation was remedied before the invasion of Italy,

and thereafter each platoon had its own machine and accessories.

An essential part of the preoperative routine in chest injuries in which

pleural penetration was evident or was a possibility was a roentgenologic

survey of the chest and upper abdomen. In many cases, it could be determined

clinically exactly what the damage was and what procedures were required for

its correction. It was better, however, to take unnecessary pictures than to

find out, in the midst of an operation, that they should have been secured.

All films were developed and dried at once and taken to the operating room

with the patient.

Posteroanterior and lateral films of the chest and upper abdomen were

taken in the upright or semiupright position whenever the patient's condition

permitted. Pictures in this position provided highly accurate information

concerning the extent of the trauma and the organs involved and also revealed

fluid levels. This routine was never followed in severely shocked patients. If

lateral films were not satisfactory, as they rather frequently were not, oblique
DIAGNOSIS 235

/

FIGUEE 20.—Anleroposterior roentgenogram showing track of missile in left lung, •with

foreign body in left axilla.

films were made, or fluoroscopic examination was resorted to if the information

was considered necessary. Neither method was employed routinely as part

of the initial examination, though both were extremely useful later.

The usefulness of roentgenologic examinations in thoracoabdominal

wounds has already been mentioned, as has their employment to demonstrate

gastric dilatation which could not always be established by physical means.

Foreign bodies are discussed in detail elsewhere in this volume (vol. II,

ch. VII), but a few words should be said about them at this point. If it was

considered important to localize them at this echelon of medical care, additional

films were made with the Potter-Bucky grid. The possibility that a foreign

body was free in the pleural cavity always existed when roentgenograms showed

the missile to be at a considerable distance from the point suggested by physical

examination of the injury (fig. 29), especially if it lay low in the thorax.

To substantiate the diagnosis, another film was taken with the patient in

another position, to allow for a shift in the position of the object.

In cases in which there was no wound of exit on examination and roentgenograms revealed no evidence of a foreign body, there were two possible

explanations:

1. The missile might have been of low velocity when it struck the chest

and might have fallen back after causing the wound of entrance.
236 THORACIC SURGERY

2. The missile might have had sufficient velocity to penetrate the abdomen

or neck after passing through the chest. The number of these injuries was so

large that in some hospitals it was routine to take films of both the abdomen

and the thorax in all chest injuries. The policy was perhaps somewhat wasteful of films, but it saved time and eliminated the annoyance of having to take

additional films later.

Reference

1. Tribby, William W.: Examination of One Thousand American Casualties Killed in

Action in Italy. Report to Surgeon, Fifth U.S. Army, 1944, G vols. [Official record.]
CHAPTER IX

Resuscitation and Preoperative Preparation

LymanA. BrewerIII, M.D.

GENERAL CONSIDERATIONS

Adequate resuscitation of the wounded man before initial surgery was the

policy that most clearly distinguished professional care in World War II from

that of World War I. It was probably also the single factor that contributed

most directly to the improved salvage rate. Essentially, it was based on the

surgeon's appreciation of the entire status of the patient as well as of the nature

and severity of his regional wound or wounds. For all battle casualties, regardless of the type of wound sustained, this led to the better management of shock.

For the thoracic casualty, it led to consideration of his disturbed cardiorespiratory physiology not as an entity separate from shock but as a condition

precipitating it or aggravating it.

About 2 percent of all casualties admitted to field hospitals were either dead

on arrival or were in such poor condition that intensive resuscitation failed to

improve them sufficiently to permit operation. Under no circumstances, however, was the condition of a patient who was admitted alive considered so hopeless that resuscitation was not attempted. This policy paid rich dividends.

Many a casualty received without obtainable pulse or blood pressure responded

to resuscitation and recovered after surgery.

Surgical Timing

In military practice, casualties with wounds of the abdomen were operated

on as soon as their general condition permitted because continuing intraperitoneal hemorrhage or infection was always a serious possibility. Casualties

with injuries confined to the thorax, on the other hand, ran their chief risks

from altered cardiorespiratory mechanisms. Even if the timelag was prolonged, infection was not the serious possibility that it was in all abdominal

injuries. It was imperative to correct the altered cardiorespiratory mechanism

as promptly as possible; but it was seldom necessary to operate immediately

in the absence of intra-abclominal injuries (thoracoabdominal or associated

abdominal), traumatic amputations, or continuing hemorrhage within the chest

or elsewhere.

It was the general opinion, founded on sound evidence and experience, that

a casualty with a severe wound of the chest, was in better condition for opera237
238 THORACIC SURGERY

tion, and convalesced more rapidly afterward, if time were taken before operation for his blood pressure, pulse, and respiration to be restored to satisfactory

levels. In such conditions as extensive pulmonary contusion from blast (vol. II,

ch. I) or myocardial contusion (vol. II, ch. II), it was best to allow from 24 to

48 hours, or longer, to elapse before even minor surgery was undertaken. In

blast injuries and contusions, in particular, it was a major, and often fatal,

error to operate too promptly. Casualties who were held at the clearing station

or field hospital for replacement therapy, oxygen, and other resuscitative measures, and who were held until full recovery from primary shock, were always

received in better condition at an evacuation hospital than if they were rushed

through without such care.

Eesuscitation was not an end in itself, simply a means to an end. The end

was corrective and restorative surgery. When the patient had reached an optimum stage of recovery, which in thoracic casualties was after cardiorespiratory stabilization, it was essential to operate without delay, for the status of a

wounded man was never static, and deterioration was the rule if surgery was

too long deferred.

The initial treatment of all thoracic casualties was always resuscitation,

whether they required immediate operation in the field hospital or could be

evacuated farther to the rear for surgery. No decision was made for or against

emergency surgery until adequate resuscitative measures had been instituted

(fig. 30). After they had been, emergency surgery in the field hospital that

originally had seemed inevitable, often proved unnecessary. Even when the

indication for emergency surgery was unquestionable, as it was when the injury

was a large traumatic thoracotomy or an obvious thoracoabdominal wound,

operation was never carried out without adequate resuscitation and preoperative

preparation.

As far as the time element was concerned, it was important to shorten to

the minimum the interval in which diminished oxygenation of the blood could

produce, cerebral damage. Once normal oxygenation of the tissues had been

reestablished, the time interval from that point to surgery was not of major

importance.

Personnel of Shock Ward

The medical officer who cared for casualties in the shock ward and prepared

them for operation was a vital link in the successful management of chest injuries. Early in the war, there was an inclination to delegate the duties in this

ward to anybody who happened not to have more pressing duties at the time.

The fallacy of this policy was soon learned, and at a heavy price. It took experience and sound judgment to resuscitate a thoracic casualty intelligently

and successfully. It took expert judgment to determine the optimum time for

operation. A patient who was permitted to slip back into shock because advantage had not been taken of the optimum recovery to be expected was far
RESUSCITATION AND PREOPERATIVE PREPARATION 239

FIGUKK 30.—Resuscitation of casualty with chest wound in shock ward of field hospital.

more difficult to resuscitate a second time and represented a far poorer surgical

risk. . .

The evaluation of one special category of casualties could be quite misleading unless it was remembered that the combination of anoxia and excessive

carbon dioxide could result in an elevation of the blood pressure, even when

blood loss had occurred. If such a patient were taken to the operating room

without any preparation at all, in the belief that he did not need it, surgery

might prove fatal. Surgeons with an experience of combat-incurred chest injuries were aware of these cases, but an inexperienced medical officer was likely

to feel a false sense of security about them. Such a patient might show a fall

in blood pressure when the proper shock therapy was instituted.

The duties in a shock ward were best carried out by medical officers who

were well grounded in the physiology of the cardiorespiratory system. As a

rule, a well-trained internist was a better shock officer than a surgeon, however

technically brilliant, who was poorly trained in physiology. Members of shock

teams of auxiliary surgical groups proved ideal for this purpose. There

was no single reliable guide to the status of shock in thoracic or other casualties,

but the clinical impressions of an experienced medical officer were generally

more useful than the measurement and numerical record of any body function.
240 THORACIC SURGERY

Case Histories

The two case histories that follow illustrate the improvement that occurred

in concepts and practices of resuscitation as the war progressed. The first

patient was treated during the northern Tunisian campaign in the spring of

1943 and the second a year later, on the Cassino-Minturno sector, just before

the drive on Eome.

Case 1.—This patient received a severe penetrating gunshot wound of the right posterior chest on 29 April 1943 at 0000 hours. He was admitted to a forward evacuation

hospital, in severe shock, 10 hours later. Preoperative measures consisted of the administration of 500 cc. of plasma and 1,000 ce. of glucose solution by vein. Thoracotomy was

performed at 1845 hours. The procedure consisted of removal of 1,000 cc. of blood from

the right pleural cavity; segmental resection of the lower portion of the lower lobe of the

right lung, which was badly lacerated; repair of a laceration of the diaphragm; crushing

of the right phrenic nerve; and wound closure. Although a laceration of the loin was

present, subcostal drainage was not provided. The patient was given 500 cc. of plasma

and 1,000 cc. of glucose by vein. He did not react after operation and died at 0700 hours

on 30 April, 25 hours after wounding.

Comment.—This case history illustrates a complete failure to apply the principles that

should govern the initial management of all intrathoracic injuries. Although the patient

was in severe shock, he was not adequately resuscitated before operation. He received no

blood either before or during operation, though he had lost at least 1,000 cc. into the pleural

cavity. The fluids he received must have resulted in dangerous hemodilution. He was

submitted to major surgery while still in a state of shock. It is no wonder that he never

reacted from it.

Case 2.—This patient was wounded at 0830 hours on 2 May 1944. He received multiple

penetrating shell-fragment wounds, including a wound of the left chest and another of the

left thigh, with a compound fracture of the left femur. When he was admitted to a platoon

of a field hospital at 1200 hours, his blood pressure was 70/40 mm. Hg. He was moderately

dyspneie and had a wet cough. The abdomen was diffusely tender and rigid in both upper

quadrants.

As soon as the patient had received 500 cc. of low titer O blood, and 1.200 cc. of bright

red blood had been aspirated from the left chest, his breathing became quieter, and his

color improved. The aspirated blood was discarded, as the abdominal findings made its

contamination likely. Intercostal nerve block on the left side was followed bv prompt

relief of pain in the chest wall, which was followed, in turn, by effective coughing and

obvious clearing of the tracheobronchial tree.

After a second 500 cc. of blood had been given, the blood pressure was 105/60 mm. Hg,

and the patient's general condition was greatly improved. Roentgenograms of the chest,'

abdomen, and left thigh in two planes showed a foreign body in the left upper abdominal

quadrant and a complete fracture of the middle third of the shaft of the left femur.

Operation was performed at 1445 hours, after another transfusion of 500 cc. of low

titer O blood. The occlusive dressing placed over the chest wound was not removed until

an endotraeheal tube was introduced. The sucking wound, 2.5 cm. in diameter, found in

the fourth intercostal space in the midaxillary line was thoroughly debrided. and the

pleuromuscular layers were closed.

A posterolateral thoracotomy incision was then made, with resection of the ninth rib.

Approximately 500 cc. of blood was removed from the pleural cavity. A laceration of the

left lower lobe was sutured with fine silk.

A 2-cm. laceration was found in the left hemidiaphragm and was extended. Exploration revealed a fractured spleen and a perforation of the splenic flexure with fecal spillage.

The foreign body visualized by roentgenogram was found free in the peritoneal cavity.

The spleen was removed. Spur colostomy was done after mobilization of the splenic flexure,
RESUSCITATION AND PREOPERATIVE PREPARATION 241

and the bowel was brought out through an incision in the left lower quadrant of the

abdomen. After lavage of the peritoneal cavity with physiologic salt solution, 25,000 units

of penicillin was instilled into it. The diaphragm was closed with silk. After copious

lavage of the thoracic cavity, 25,000 units of penicillin was instilled into it. The lung was

expanded and the chest wall closed.

The wound in the thigh was debrided, the fracture reduced, and a plaster spica applied.

As the final step in the procedure, the trachea and bronchi were thoroughly aspirated.

During the operation, 1,500 cc. of blood was given, bringing the total amount administered

to 3,000 cc.

At the end of the operation, the blood pressure was 110/75 mm. Hg and the patient

was in excellent condition. Penicillin was given intramuscularly for 5 days after operation.

Recovery was entirely uncomplicated.

Comment.—The management of this patient represents the mature application of

modern resuscitative practices. The initial appraisal was careful and accurate. Resuscitation was prompt and expert. Cardiorespiratory physiology was brought back to almost

normal. "Whole blood was administered judiciously. In short, this was careful, expert

preparation for major surgery, and the results were gratifying.

ROUTINE OF RESUSCITATION

The resuscitation of the soldier with a thoracic wound comprised five

principal components:

1. The treatment of shock, which was usually hemorrhagic in origin, by

adequate blood replacement.

2. Correction of the impaired cardiorespiratory physiology.

3. The relief of pain.

4. Restoration of the fluid balance.

5. Measures to prevent infection.

Although these procedures are discussed separately as a matter of convenience, in reality, they were carried out simultaneously and were all interrelated, just as the pathologic conditions which required correction were

interrelated.

Treatment of Shock

The problems of resuscitative therapy in World War II were greatly simplified once there was general acceptance of the concept that the cause of the

deterioration of the status of any seriously wounded man, regardless of the

site of his wound or wounds, was a reduction in the circulating blood volume

caused by loss of blood. These problems were still further simplified when the

additional concept won general acceptance that, except for processes leading to

dehydration, fluid loss from the circulation could be explained by local losses

of fluid at the site of injury.

Concepts.—In thoracic casualties, the concept of shock had to be somewhat

modified. The patient's condition was related, just as in wounds of any other

area, to such factors as blood loss, tissue trauma, exposure, the timelag between

wounding and medical care, and his status before he was injured. Although

external blood loss might occur, bleeding was more often internal, into the

pleural cavity, in which blood was not only lost to the circulating blood volume

053081' —62 IS
242 THORACIC SURGERY

but in which it interfered mechanically with the cardiorespiratory function

by preventing expansion of the lung. The principal causes of shock in thoracic

casualties included, in addition to the loss of blood just described, painful

wounds of the chest wall; sucking wounds; pneumothorax and tension pneumothorax; paradoxical respiration; cardiac tamponade; the accumulation of

blood, mucus, or both in the tracheobronchial tree; and anoxia from any of

these causes.

The most frequent cause of anoxia in thoracic injuries was the presence

of blood, air, or both, in the pleural cavity, with a corresponding reduction

of the functioning pulmonary tissue to a degree insufficient to maintain adequate oxygenation of the blood. Amounts of blood or air that would be of

little consequence in the normal individual were of grave significance in the

wounded man. They were superimposed upon the burden he was already

bearing because of loss of blood, tissue trauma, and concomitant wounds.

Combined dyspnea and anoxia in a thoracic casualty might result in a sharp

decrease in vital capacity that might prove fatal unless vigorous resuscitative

measures were instituted without delay. When anoxia was profound, there

was also some fluid loss because of the general increase in capillary permeability associated with it.

The principal difference between a thoracic casualty and a casualty with

any other type of injury was that the thoracic casualty, in addition to his

actual chest wound and associated wounds, also had the all-important handicap of a disturbed cardiorespiratory physiology, and that this imbalance was

likely to be the dominating factor in his condition. All attempts at resuscitation, including all measures to treat shock, would inevitably prove futile

unless they included correction of the cardiorespiratory imbalance.

In thoracoabdominal wounds, another factor entered the picture. There

might be spillage, sometimes massive, of fecal matter into the peritoneum or

into the pleura through the transdiaphragmatic wounds or into both cavities.

Shock arising from abdominal injuries and from other associated injuries

compounded, and was itself compounded by, the shock caused by thoracic

injuries.

The. typical manifestations of shock were usually present in thoracic injuries, including a systolic blood pressure below 100 mm. Hg and frequently

much lower; a rapid, frequently irregular pulse; rapid, shallow respirations;

a lowered skin temperature; sweating; and pallor or cyanosis. In addition,

the thoracic casualty was likely to be dyspneic. He also presented the extreme restlessness and apprehension characteristic of hypoxia and indicative

of impending cerebral anoxia.

Posture.—Thoracic casualties who were hypotensive but who were not

cyanotic or dyspneic were placed in the Trendelenburg position. In the absence of shock, the sitting position was ideal, since vital capacity was greater

and coughing more effective when it was used. The semirecumbent position,

however, was usually better tolerated by freshly wounded men, and it was

therefore more generally used both for transportation and durino- resuscita-
RESUSCITATION AND PREOPERATIVE PREPARATION 243

tion. In this position, the patient lay on his back, with his head and chest

slightly elevated, to permit the diaphragm to function more efficiently. A

patient not in shock was sometimes more comfortable recumbent than semirecumbent or sitting, and he was permitted to assume whatever position made

respiration easier for him.

It was possible to perform an effective and complete thoracentesis without

requiring the patient to change his position, no matter how he was lying or

sitting.

Replacement therapy is considered later, under a separate heading (p. 253).

Correction of Cardiorespiratory Imbalance

Measures to correct the cardiorespiratory imbalance in thoracic injuries

included oxygen therapy; the relief of pain; evacuation of the tracheobronchial tree; stabilization of the thoracic cage; thoracentesis for hemothorax,

pneumothorax, or hemopneumothorax; management of sucking wounds; and

management of tension pneumothorax. These measures are discussed separately, as a matter of convenience, and the order of presentation is no indication of their relative importance, which depended upon the special conditions

present in each patient, As a matter of fact, the success of one of these

measures was likely to depend upon the institution of one or more of the other

measures. Oxygen therapy was urgently necessary in cyanosis, for instance,

but it was not effective unless the airway was open.

Oxygen Therapy

The general appearance of the thoracic casualty furnished a useful guide

to his need for certain therapeutic measures. The presence of cyanosis, which

is an indication of comparatively advanced anoxia, was a warning that vigorous measures must be instituted, and instituted promptly, to correct the

cardiorespiratory imbalance. Other signs of cerebral anoxia, such as unconsciousness or maniacal manifestations, made the correction of the decreased

blood oxygenation even more urgent.

The efficacy of oxygen in the management of shock was a frequent source

of discussion during the war, but there was never any argument over the indication for its use in all thoracic injuries associated with any degree of respiratory difficulty. All casualties diverted to a field hospital were admitted to the

shock ward (fig. 30) immediately upon their arrival, regardless of the nature

and severity of their wounds, and here the shock officer practically always

instituted oxygen therapy for those with thoracic injuries. Specifically, it

was used promptly and freely for any patient who was restless or dyspneic

or whose pulse remained elevated (over 110). It was even better to administer it before cyanosis and restlessness developed. A patient could readily

pass from a state of simple restlessness into a manic state that was frequently

the immediate precursor of death.
24i THORACIC SURGERY

Once normal oxygenation of the tissues had been restored, the timelag to

surgery became of less importance. The essential consideration was to

shorten to a minimum the period in which a diminution of the blood oxygen

supply could produce cerebral damage.

The most efficient way to administer oxygen was by the Boothby-Lovelace-Bulbulian mask, but it was also perfectly satisfactory to administer it by

an intranasal catheter. The minimum rate of flow was 7 liters per minute.

Administration was continued until cyanosis, dyspnea, and tachycardia were

relieved.

Relief of Pain

As pointed out elsewhere (p. 231), pain was an almost constant accompaniment of any wound of the chest. The clue to its correct management was

the realization of the fact that painful stimuli originate in the thoracic wall

and not in the lung itself. The relief of pain had a vital bearing on hastening

recovery from shock. Until it had been accomplished, the patient was unwilling to breathe deeply or cough, because of the discomfort which followed

both acts, and fluid substances therefore accumulated in the tracheobronchial

tree, which led to wet lung (vol. II, ch. V).

Administration of morphine.—When a casualty was seen at the clearing

station or field hospital, he had usually had an injection of morphine, given

by the company aidman when he reached him on the battlefield. The standard Army syrette contained gr. 14, and this was usually the size of the dose the

casualty had received. It would have been better if the standard syrette had

contained only gr. 14. The smaller close has practically the same pain-abolishing power as the large dose, without its depressant effects, but, in spite of much

discussion on the subject, gr. y2 remained the standard dose throughout the

war.1

A dose of this size was not harmful to many patients, but it was distinctly

harmful to casualties who were already in severe shock and suffering from impending or actual anoxia. It was therefore the policy, after management of

chest injuries had been standardized, not to give morphine in clearing stations

or field hospitals to patients suffering from hypoxia, particularly if restlessness

indicated that cerebral anoxia was impending.

Even a small dose of morphine dulls the sensorium, decreases respiratory

efficacy and increases cerebral anoxia, all undesirable effects in casualties with

chest injuries. Another serious effect was that the patient as he became less

sensitive, also became less aware of the accumulation of secretions in the

tracheobronchial tree and made no effort (0 remove them.

The use of morphine also presented other problems. Some wounded men

had had two, or even three, injections before they readied the field hospital.

1 As a matter of fact, although the desirability of a smaller dose of morphine in the standard

syrettes was called to the attention of the Medical Research and Development Board in .Tune 1943.

on the basis of the work of Dr. Henry K. Beecher at the Massachusetts General Hospital, official

action was not taken until August 1054. At that time, the amount of morphine in the syrette was

reduced to gr. U.
RESUSCITATION AXE PREOPERATIYE PREPARATION 245

Casualties were frequently heavy, and the medical officer in the battalion aid

station, the collecting station, or the clearing station often had no time to appraise the individual patient's symptoms and to determine whether his complaints were really caused by pain or were of some other origin. Cerebral

anoxia was frequently accompanied by restlessness that at times seemed

maniacal. In this sort of rushed atmosphere, particularly before the risks of

overseclation were realized, it was easy to consider that the patient was writhing

in pain and natural to give him an injection of morphine. The patient who

deteriorated under this policy was the one who was already in rather marked

shock, with hypotension and poor peripheral circulation. The first morphine

administered, therefore, was not picked up by the lagging circulation, particularly if the environment was chilly or cold. As a result, more was given, and

it too was not picked up. When, however, the patient was brought into a warm

environment and measures to correct his shock were instituted, the circulation

improved, and all of the morphine in the subcutaneous tissues was picked up.

The result was a cumulative effect which might result in morphine poisoning.

In view of all these considerations, there was seldom any indication for the

administration of additional morphine to the thoracic casualty in a clearing

station or field hospital. If it was indicated, the intravenous route was preferred because the effects are more predictable and can be immediately assessed.

A small group of thoracic casualties, who had received morphine, presented

a clinical picture for which no explanation was ever adduced. They were observed more often in the late fall and winter months, after they had lain out in

the cold and wet for many hours, than when the weather was more moderate.

They presented the typical picture of morphine overdosage; that is, they had

pinpoint pupils, their respiratory rate was slow, and they were difficult to

arouse. Yet their records only occasionally showed that they had had more

than a single injection of morphine, which sometimes was gr. 14 and not gr. y2.

If the records could be accepted, these patients were not suffering from morphine poisoning, which had been the original assumption.

It is of course possible that in some of these cases the records were inaccurate. On the other hand, the same clinical picture was seen too often to accept

possible recording error as the universal explanation. This condition was a

well-proved clinical entity. No definite proof for the theory was ever produced, but it was postulated that these patients presented another manifestation of relative anoxia. Almost invariably, they were severely wounded; they

had frequently suffered from exposure; and they were cyanotic unless they were

given oxygen.

Strapping.—In civilian practice, adhesive strapping is rather widely used

for the immobilization of fractured ribs and to relieve the pain caused by them.

This method was used to some extent early in World War II, but it frequently

accomplished neither of the desired purposes, and the patients complained of

the discomfort caused by the adhesive.

The chief contraindication to this method was that it is unphysiologic.

Many patients with fractured ribs showed varying degrees of wet lung (vol. II,
246 THORACIC SURGERY

ch. V), with increased bronchial secretions, hlood, transudates, and sometimes

intrapleural bleeding. When the lungs were compressed and expansion of the

chest restricted by adhesive strapping, the secretions became more difficult to

raise. Therefore, as the war progressed, it became the policy to reserve this

method for the stabilization of a flail chest associated with paradoxical motion

(p. 248).

Nerve block.—Instead of morphine, which depressed respirations, or

strapping, which mechanically limited respirations, the policy was to block the

painful impulses near their origin, which proved to be far more effective. This

was accomplished by procaine hydrochloride injection of the intercostal nerves

supplying the wounded area.

Regional block was employed in preference to local infiltration at the injured site because the probable contamination of all wounds made injections

close to the injured area undesirable. Regional block was a simple, efficacious

procedure which could be accomplished in 5 or 10 minutes (vol. II, ch. V) and

which produced lasting results. In the usual case, it was not necessary to block

the sympathetic chain, nor was there any evidence that this technique produced

any better results than those obtained by simpler intercostal injection. Any

sympathetic block probably also anesthetized the contiguous intercostal nerve

roots. Furthermore, injection of the intercostal nerves usually anesthetized

the sympathetic nerve fibers accompanying the intercostal vessels.

Unless one had observed the results of nerve block, it was hard to conceive

the immediate relief of pain and the improvement in the casualty's condition

that usually followed this procedure. A patient who had been unable to cough,

or who would not attempt to cough because of pain, now coughed without difficulty. Clearing the tracheobronchial tree of blood and other secretions by

vigorous coughing rapidly changed a hypotensive, cyanotic, dyspneic casualty

to one with deep, unhurried respirations; good color; and a prompt return of

blood pressure to more normal levels. A single injection usually gave relief

from pain for at least 24 hours, and frequently only a single injection was necessary. The relief of pain for periods of 24 hours or more, far longer than the

pharmocologic effect of procaine, was a surprise to frontline surgeons who

observed this phenomenon for the first time. The exact mechanism was not

known. The most plausible explanation was that the blocking of the sympathetic nerve fibers of the intercostal vessels, mentioned previously, improved

the blood supply to the chest wall and pleura sufficiently to prevent arteriospasm and ischemic pain.

Transportation of casualties with chest injuries was so frequently facilitated following nerve block that this method was sometimes employed in

forward installations on this indication aloneEvacuation of the Tracheobronchial Tree

Concept of wet lung.—The management of the condition that came to be

known as wet lung and that is described in detail elsewhere (vol. II, ch. V) was
RESUSCITATION AND PREOPERATIVE PREPARATION 247

so important a part of the resuscitative routine that certain details concerning it

must be repeated here.

In any kind of chest injury, including fractured ribs, blast injuries, and

both parietal and intrathoracic wounds, there were two pathologic factors.

(1) abnormal fluids in the tracheobronchial tree, and (2) the patient's inability

to expel them adequately. The pulmonary tissue, following chest trauma, reacted by producing more than the normal amount of interstitial and intraalveolar fluid. Increased mucous secretions and intrapulmonary and

intrabronchial hemorrhage further compounded the difficulty.

Inadequate evacuation of tracheobronchial fluid and blood was observed

in the majority of casualties with serious chest wounds, sometimes within a few

hours after injury, sometimes not until 6 or 7 days had elapsed. The accumulation of fluid in the chest interfered with adequate blood oxygenation because

it impaired the absorptive functions of the alveoli. It greatly increased the

surgical risk if operation was performed without its recognition or before it

was corrected. It was a serious complication in the postoperative period, and,

before its importance was realized, it was responsible for a considerable number

of deaths.

Clinical picture.—The most common symptoms and signs of wet lung

were oral wheezing; rhonchi heard constantly over one or both sides of the

chest; and a frequent, painful, ineffectual, wet cough. Only small amounts of

sputum were raised, and the bubbling character of the respirations persisted

after the secretions had been coughed up. Tenacious mucus and blood constituted the bulk of the fluid, but an occasional purulent exudate was present,

signifying a preexistent bronchitis. Wet lung was an entirely different entity

from massive collapse of the lung (atelectasis), which was the result of obstruction of the main bronchus. This latter complication was very infrequent in the

Mediterranean theater, probably because of the attention paid to the diagnosis

and management of wet lung.

Management.—The aim of treatment in wet lung was to improve bronchopulmonary drainage. Sedative cough mixtures were contraindicated. Morphine was withheld unless incontrovertible indications for its use were present;

then it was given in very small amounts and always intravenously. If the

secretions were frothy and fine rales were heard, some surgeons used atropine

(gr. 1/100), but no evidence existed that it was really useful in clearing the

tracheobronchial tree, and there was some evidence that it was harmful.

Two adjunct measures were helpful, (1) the administration of oxygen

(vol. II, ch. V), and (2) the relief of thoracic pain by nerve block (vol. II,

ch. V), after which the patient was willing to cough. Vigorous coughing was

the simplest and most effective method of clearing the chest of obstructing

secretions. If he was alert enough to understand the situation, the necessity

was explained to the patient in detail. Personnel in the shock tent were instructed to help him cough effectively by holding the chest or supporting the

abdomen if the act caused pain or discomfort in either location.
248 THORACIC SURGERY

Suction was necessary for patients who could not clear the trachea and

bronchi by the simple methods described. The introduction of a catheter, as

demonstrated by Haight (1) in 1988, was then carried out without delay.

The irritation caused by its introduction and presence stimulated all but unconscious and almost moribund patients to cough and thus rid themselves of

much more secretion than could be removed by aspiration of the catheter alone.

Catheter aspiration was a particularly useful measure in comatose or semicomatose patients or patients who had been heavily sedated, none of whom could

cough voluntarily and effectively.

Usually only one or two aspirations were necessary, but the procedure

could be repeated as often as necessary. When aspiration had to be repeated

frequently, it was best to introduce a Magill intratracheal tube and aspirate

the trachea through it by inserting the catheter at regular intervals. When a

catheter was left indwelling, oxygen was administered through it between

aspirations.

If catheter aspiration was not, promptly effective, bronchoseopy (vol. II,

eh. Y) was resorted to without delay and was repeated as necessary. Experience showed that it could be performed twice a day without any ill effects,

although one bronchoscopic aspiration was all that was usually needed. Catheter aspiration was most often effected after bronchoseopy.

Occasionally, continued bleeding prevented successful clearance of the

tracheobronchial tree. In such cases, further delay was considered unwarranted. The patient was removed at once to the operating tent, for rapid

induction of anesthesia with endotracheal intubation, whieh'permitted more

complete tracheobronchial suction. It was the general experience that the

necessary surgery could be proceeded with, without further delay, as soon as

the airway had been completely cleared.

When the retained transudates, secretions, and blood in the lung were controlled by this plan, tracheotomy was seldom necessary as an emerg-ency

measure. In some instances, however, either the patient was not in condition

to withstand a thoracotomy, or a thoracotomy was not the answer to his problem. In these circumstances, tracheotomy was performed.

The continued extravasation of fluid transudates into the alveoli and from

trauma of the bronchi resulted in a type of pulmonary edema which clinically

was similar to that seen in other conditions. Mechanical aspiration of fluid

was ineffectual in correcting it, and excess fluid continued to be formed in the

alveoli. The intermittent administration of positive pressure oxygen (vol. II,

ch. V) was found to be highly effectual in decreasing fluid production and ultimately drying up the lungs. This mode of therapy was sometimes lifesaving in

preparing casualties for surgery, though those in irreversible, shock were likely

to prove refractory to it.

Stabilization of the Thoracic Cage

Flail chest, caused by multiple rib fractures, is discussed in more detail

elsewhere. It was always serious, and, if the paradoxically moving sege
RESUSCITATION AND PREOPERATIYE PREPARATION 249

ment of the cliest wall was large, it could endanger life. Localized flail chest

could be controlled by regional nerve block, sometimes stabilized by a pressure

dressing held in place by an elastic binder. Lying with the affected side down

was sometimes useful, as was the use of small sandbags. When the affected area

was larger and paradoxical motion was excessive, mechanical means of stabilization had to be employed. Occasionally it was necessary to insert a sterile

towel clip, under aseptic precautions, around the central rib of the affected segment. This was followed by the use of light traction, obtained by a cord

attached to a weight, usually of about 3 to 5 pounds, suspended over a pulley

attached to an overhead frame. Stabilization was sometimes accomplished in

4 or 5 clays, but it might be necessary to maintain traction for from 7 to 14 days.

In severe flail chest, with extreme paradoxical respiration, management

of the wet lung syndrome might be extremely difficult. In these circumstances, strapping of the chest or the use of a firm binder was occasionally

necessary to prevent ballooning out of the chest wall. The method was never

officially forbidden, but, with very occasional exceptions, its use was avoided,

since strapping simply increased the anoxia by limiting the motion of the chest

wall. In addition, it served as an actual handicap to the propulsive mechanism of the act of coughing. In fact, it was frequently observed that patients

who had been strapped improved considerably as soon as the strapping was

removed.

Management of Sucking Wounds

Any injury to the ehest wall which produced an open wound into the

pleura! cavity caused profound disturbances in the intrathoracic physiology,

chiefly because of the exchange of air in the pleural cavity and the outside

atmosphere. As a result, the normally negative intrapleural pressure was replaced by atmospheric pressure. The type and size of the wound were generally correlated with the effects of these alterations on the cardiorespiratory

physiology.

In every so-called sucking wound, there was usually a decrease in the

vital capacity immediately after the injury was sustained. The decrease was

progressive and, if it was not interrupted, led to mediastinal flutter; interference with the right side of the heart; and increasing anoxia resulting from

pendulum respiration.

A patient with a properly treated sucking wound—as all wounds of the

chest eventually came to be managed—arrived at the field hospital with an

occluding dressing over it. The preliminary inspection was to make certain

that it had not been disarranged during evacuation. If it had been, it was at

once replaced.

Before an ineffectual dressing was replaced, it was sometimes useful to

evacuate a portion of the air or blood that had collected in the pleural cavity,

particularly if the injury were of the valvular type. This was easily accomplished by placing the patient in such a position that the wound was roughly

dependent. Its edges were held open during forced expiration and coughing
250 THORACIC SURGEEY

and were approximated during inspiration. Several hundred cubic centimeters of air and fluid could often be rapidly removed by this simple method.

When this procedure was completed, another dressing was applied, twice

as large as the wound and thickly impregnated with petrolatum. It was applied across the wound and covered with a large gauze dressing held firmly

in place with adhesive strips. This dressing was left in situ until the patient

was on the operating table. It should be stressed again, however, that the

original dressings were not disturbed if they were occluding the wound satisfactorily and the pleural opening was airtight when they were first inspected.

If there was a pulmonary, bronchial, or tracheal tear of any moment, then

a tension pneumothorax, with collapse of the lung, might develop after the

integrity of the pleural cavity had been reestablished by an occluding petrolatum-impregnated gauze pack. In these circumstances, a needle, or preferably a catheter, as used in tension pneumothorax, was placed in the

second interspace parasternally to provide for the escape of air. This was an

essential precaution if leakage of air into the pleural cavity continued.

Experience early in the war showed that any wound that was not of the

sucking or blowing type while the casualty lay in one position, might readily

become one with a change of position of the body or even of the arms. It was,

therefore, the rule that the chest wound should be closed with the type of

dressing just described in all patients who were to be transported farther to

the rear without surgery in the field hospital.

The original practice of dusting the wound with sulfanilamide powder

was generally, though not universally, discontinued in the summer of 1914.

Sucking wounds are discussed in greater detail under that heading; (vol. II,

ch. I).

Management of Tension Pneumothorax

Air entered the pleural cavity in all wounds of the chest wall. If the

amount that entered was inconsequential, or if it gave rise to no clinical signs

and symptoms, the intrapleural air was termed a pneumothorax. If the

pneumothorax was of sufficient volume to cause respiratory embarrassment,

the contained air was termed a tension or pressure pneumothorax. In other

words, the difference between a pneumothorax and a tension pneumothorax

was not in kind but in degree.

In spite of its infrequency, tension pneumothorax was a constant threat

in combat-incurred chest wounds, and preventive measures had to be employed

in every case in which it was a possibility.

The clinical picture included extreme dyspnea, which was the most prominent feature, eventual cyanosis, fullness of the neck veins, hyperresonance of

the involved hemithorax with absence of breath sounds, and a shift of the heart

and mediastinum to the opposite side.

Management.—When tension pneumothorax was present, immediate treatment was required, though thoracotomy was not indicated unless there was

reason to suspect a wound of the trachea or of one of the large bronchi.
RESUSCITATION AND PREOPERATIYE PREPARATION 251

Oxygen was given by nasal catheter for cyanosis, persisting rapid pulse, and

restlessness caused by anoxia. As an emergency measure, a large-bore needle

(16-18) was inserted into an upper (preferably the second) anterior intercostal space, strapped in place, and connected to a water-seal bottle. If

tension still persisted after several hours, a catheter (16-18 F.) was substituted for the needle and was connected to a water-seal bottle (fig. 31).

FIGURE 31.—Water-seal

agement of tension pneumothorax. If

necessary, additional suction could be

produced.

The response to the measures described was usually prompt and striking.

Dyspnea and cyanosis disappeared. As decompression was accomplished, palpation demonstrated that the trachea had resumed its normal midline position

and was no longer displaced to the opposite side. In the occasional case in

which air continued to leak into the pleura! cavity in spite of these measures,

thoracotomy was undertaken, but usually only after a period of observation of

from 18 to 24 hours. In occasional instances, a large laceration of the trachea

or bronchus required earlier operation.

If a patient with a tension pneumothorax had to be transported before

decompression was accomplished, because of the tactical situation or for other

reasons, a needle still in situ was replaced by a catheter, and a flutter valve

replaced the water-seal bottle. A condom or the split finger of a rubber
252 THORACIC SURGERY

glove permitted the escape of fluid and air (fig. 32). Water-seal drainage

during evacuation was neither convenient nor safe.

Tension pneumothorax is discussed in greater detail under that heading

(vol. II, ch. IV).

FIGURE 32.—Management of tension pueumothorax. Needle

introduced through second interspace anteriorly, through cork,

with finger cot flutter valve in situ.

THORACENTESIS

Since a large hemothorax or hemopneumothorax could reduce the vital

capacity to dangerously low levels, thoracentesis was an important part of

resuscitation of the thoracic casualty. It was performed whenever any appreciable amount of blood or air was present, appreciable amount being defined as

an amount which could be detected at the dome of the diaphragm on physical

examination. With the intrapleural cavity emptied, the lung could reexpand,

and an immediate improvement occurred in the vital capacity. The military

experience did not bear out the anxiety felt in some quarters before the war

that thoracentesis immediately after wounding might cause a resumption of

bleeding from the injured pulmonary parenchyma (vol. II, eh. VI).

The amount of blood obtained gave some indication of the severity of the

intrathoracic damage and aided in an appraisal of the structures injured and

in the decision concerning the best method of treatment. It was also a sound

guide to the amount to be replaced by transfusion. If the injury had occurred

less than 12 hours earlier, and the blood was considered to be uncontaminated,

it was occasionally aspirated directly into a sterile Baxter donor bottle and

returned to the patient as an autotransfusion (p. 256). This practice was

contraindicated on even the suspicion of a thoracoabdominal injury.

Sterile aspiration sets were eventually standard equipment in all shock

tents. A 17-gage needle was used, preferably with a short, beveled point
RESUSCITATION AND PREOPERATIYE PREPARATION 253

rather than a sharp point, to avoid damaging the lung. The needle was connected -with a vacuum bottle or with a syringe with a 3-way valve to prevent

air from entering the chest while the blood was being aspirated. An assistant

clamped the tubing when the syringe was removed to be emptied. The vacuum

bottle was placed lower than the patient, usually on the floor. If standard

equipment was not available, a short piece of rubber tubing, with appropriate

adapters, could be used.

If the needle was introduced low in the axilla, it was possible to remove

almost all of the fluid from the chest without making any change in the

position of the patient. The site of preference for its insertion was the sixth

or seventh interspace in the posterior axillary line or the second anterior interspace in the midclavicular line.

In an uncomplicated hemothorax, no serious attempt was made to empty

the pleural cavity completely as part of the resuscitative regimen. At this

time, the purpose of the procedure was simply to expand the lung and relieve

pressure on the mediastinum. No rule could be laid down concerning the

amount of blood to be removed at any single aspiration, but it was seldom

necessary to discontinue the procedure because of the amount per se. From

1,200 to 1,500 cc. could usually be removed with impunity. The most reliable

guide was the status of the patient and the appearance of symptoms due to too

rapid attempts to expand the lung. If he complained of a tight feeling and

pain in the chest, dyspnea, or dizziness, aspiration was temporarily discontinued and resumed later.

Hemothorax is discussed in greater detail under that heading (vol. II,

ch. VI).

REPLACEMENT THERAPY

Special Considerations in Thoracic Wounds

Replacement therapy was an essential component of resuscitation in chest

wounds, but its use was hedged about by a number of qualifications and precautions which did not have to be considered in other types of wounds.

As in all other injuries, the clinical estimation of the need for fluid replacement was based upon the nature of the wound; the known loss of blood; the

condition of the patient, including the blood pressure and the pulse and respiratory rates; and the surgery which would be necessary. Facilities for hemoglobin and red blood cell determinations were always available, and later in

the war, the copper sulfate method for determination of the hematocrit and

plasma protein levels was introduced and proved very useful in regulating

fluid replacement.

In chest injuries, however, these observation could not be accepted without

qualification. Other circumstances had to be taken into consideration:

1. Deficient oxygenation, whether caused by an obstructed airway, pulmonary compression or contusion, or a cardiac wound, could, in itself, without

an excessive loss of blood, produce the typical clinical picture of shock with a
254 THORACIC SURGERY

low or unrecordable blood pressure and a rapid, feeble, irregular pulse. Faced

-with this picture, the inexperienced medical officer was apt to institute rapid

blood replacement, a procedure that could be fatal to a casualty with an already

unbalanced cardiorespiratory system.

2. Restitution of cardiorespiratory physiology reduced the amount of

fluid replacement necessary in thoracic wounds, but this improvement did not

mean that replacement therapy could be arbitrarily reduced in amount or

omitted entirely. At least a quarter of all thoracic injuries were thoracoabdominal, and half or more were associated with wounds in other parts of

the body. Thus shock that was not of thoracic origin or not wholly of thoracic

origin was a compelling entity in a large number of thoracic wounds. In such

cases, it was augmented and complicated by disturbances in cardiorespiratory

physiology, but even after they were corrected, it persisted and was an indication for replacement therapy.

With the correction of reversible pleuropulmonary changes, the resultant

increase in the pulmonary capillary area permitted more vigorous replacement

therapy, with a reduced degree of risk. It was still necessary, however, to

follow a precise resuscitative regimen in which the risk of pulmonary edema

was nicely balanced against the need for whole blood. Sound judgment was

required to insure that the casualty received the blood that he needed but at

the same time did not receive so much that his precarious, recently restored,

cardiorespiratory balance was endangered.

Large transfusions, rapidly administered, were not well tolerated by

casualties with damaged lungs and secondary cardiac disturbances:

1. They were particularly poorly tolerated when the injuries were the

result of blast. Flooding of these patients with large amounts of blood or

plasma could produce acute pulmonary edema, which might be an important

factor in the fatal outcome.

2. Casualties with partial or complete pneumothorax, who were suffering

from hypoxia caused by reduction in the vital capacity from such mechanical

causes as hemothorax and pneumothorax, might also develop pulmonary edema

by sudden overloading of the decreased pulmonary vascular tree.

3. The vascular bed in chest injuries was already reduced by partial collapse of the lung, and it could be further reduced by the extensive hematoma of

the pulmonary parenchyma present in some cases. The rapid introduction of

blood in such cases, with no time allowed for compensation, produced a further,

abrupt reduction in the vascidar bed.

There was never an indication for rapid transfusion in thoracic casualties

unless continued bleeding from a large vessel was occurring or there was knowledge of serious blood loss earlier. As has been pointed out several times, the

surgical time factor, after correction of the cardiorespiratory imbalance, was

not a matter of extreme importance in chest wounds.

Generally speaking, unless the casualty was obviously bled out, it was best

not to start any sort of intravenous therapy on a patient who was coughing and

whose chest showed gross rhonchi. After the airway had been cleared bv
RESUSCITATION AND PREOPERATIVE PREPARATION 255

aspiration, tlioracentesis performed, and pain relieved, so that normal respirations were possible, hypoxia promptly improved. Then the pulmonary vascular bed could better tolerate intravenous fluids in the necessary amounts. It

was a mistake to administer blood, especially in quantity, until failure to respond to these measures made it clear that blood loss was playing a major role

in the casualty's state of shock. The level of the blood pressure did not furnish

the absolute guidance in chest injuries that it did in other wounds, since eardiorespiratory imbalance might be more at fault than actual blood loss.

Plasma Transfusion

Plasma was sometimes administered to thoracic casualties before they

reached the clearing station, and in many instances it was lifesaving, particularly in Tunisia, where ambulance hauls were often long and trying. In a

report to the Surgeon, II Corps, after this campaign, Maj. Francis M. Findlay,

MC, and Capt. (later Maj.) Marion E. Black, MC, noted that it was impractical

to give plasma in U.S. Army ambulances, a serious defect in view of these circumstances. Some surgeons believed that if a patient needed plasma, he should

not be transported until it had been administered. Another suggested that

when long ambulance hauls were necessary, a halfway station should be established, in charge of a medical officer whose function it would be to check the

status of each casualty and remove from transit those in need of plasma. The

different circumstances in the campaigns in Sicily and Italy made these expedients unnecessary.

A tendency to give too much plasma in the aid and collecting stations was

sometimes noted, particularly early in the war, before the limitations of this

agent were understood. The administration of excessive amounts placed an

extra burden on the already impaired circulatory system of thoracic casualties

and sometimes resulted in decompensation, as well as in the development of the

wet lung syndrome. The overgenerous use of plasma in installations ahead of

the field hospital also made it difficult to give the necessary amounts of blood

when the field hospital was reached.

Techniques of Transfusion

Unless the patient was obviously exsanguinated, the most practical plan

was to introduce 500 cc, of blood at a moderately rapid rate and then slow the

rate of administration. How much more blood was necessary could then be

checked by laboratory determinations, though an experienced shock officer or

chest surgeon usually could settle the matter without this aid. If 1,500 or

2,000 cc. had to be given, the transfusion was allowed to run over a period of

hours.

Since most casualties with chest injuries had to be placed on the operating

table on one side or the other, much time was saved, as well as much stress for

the patient, if transfusion was started in one of the veins of the leg. This also
256 THORACIC SURGERY

simplified the procedure when a patient with multiple wounds had to be turned

to expose them. The needle could usually be introduced at the ankle, without

a cannula. If a cannula had to be used the site of preference was the saphenous

vein, just above the internal malleolus.

A needle in the antecubital fossa was likely to become dislodged as the

patient was moved. Then the anesthesiologist had to turn his attention from

the anesthesia to replacing the needle and restarting the blood. The use of a

leg vein was practical from another standpoint, that rapid administration of

blood might become necessary in the course of the operation.

Patients with chest wounds associated with multiple wounds of the extremities frequently needed prolonged intravenous replacement therapy and had no

available avenues of administration. Then other techniques were used, such

as sternal puncture or administration of the blood through the external jugular

vein or the corpus cavernosum of the penis.

Autotransfusion.—Early in the war, before the blood bank was established at Naples, it was a frequent practice, as already noted, to use for autotransfusion the blood which had been aspirated from the pleural cavity. This

practice was not followed in thoracoabclominal wounds, even if only the diaphragm had been injured.

While autotransfusion was frequently employed after the blood had been

in the chest up to 12 hours, most surgeons believed that from 4 to 6 hours was

a much safer limit. Severe reactions (chills, fever, and toxic manifestations)

could follow the use of blood aspirated from the chest, partly because of the

hemolysis of the red blood cells it contained and partly because of the presence

in it of pleural transudates high in protein; blood is an irritant to the pleura,

and its presence gives rise to a rapidly developing serous effusion with a high

protein content. Autotransfusion was seldom employed late in the war.

Blood secured from the chest was collected into a transfusion bottle or flask,

through several thicknesses of fine-mesh gauze. If the autotransfusion was

not to be performed immediately, which was the best plan, sodium citrate was

added to the blood. If the blood was used at once, it was administered through

the recipient tubing set with the stainless steel mesh filter incorporated in the

package containing the flask.

Intravenous Crystalloid Solutions

Intravenous crystalloid solutions were practically never employed in chest

injuries. There was no indication for their use except in the occasional case

in which dehydration was so extreme that it required immediate correction.

Banked Blood

During the African and Sicilian campaigns, large quantities of fresh whole

blood were made available from what amounted to a living blood bank of service troops. The men were classified as to blood type, and each donor on the list
RESUSCITATION AND PREOPERATIYE PREPARATION 257

was replaced by another as soon as he had given blood. Donors were secured

from the same source during the early fighting in Italy. In February 1944, a

blood bank was set up in Naples, and thereafter adequate supplies of fresh whole

blood were available from this source. Provision for blood was part of the

preparation of the Seventh U.S. Army for the invasion of southern France in

August 1944.

Blood flown from the United States was never sent to the Mediterranean

theater. The problem therefore did not arise, as it did in the European and

Pacific theaters, concerning the use of blood diluted with Alsever's fluid in chest

casualties. Fresh blood was desirable for thoracic casualties because of the

deterioration of red blood cells in the excessive fluid in blood preserved by this

method. This was a particularly important consideration when multiple transfusions were likely to be necessary.

EMPTYING OF THE STOMACH

Correct preoperative preparation included emptying of the stomach before

anesthesia, to avoid the risk of aspiration of gastric contents, which could lead

to serious pulmonary consequences (p. 292). This measure was desirable in

all wounded men and urgently necessary if food had been taken after wounding

or as recently as 2 hours or less before wounding. As a matter of fact, the

length of time since the patient had taken food was not a sound criterion of the

amount of material likely to be in the stomach. A large residue was often

present many hours after ingestion of food, possibly as the result of pylorospasm or of lessened gastric motility because of the nervous tension of combat.

An additional reason for inserting a Levin tube before operation in all

chest injuries was that in some cases, gastric dilatation was great enough to

enhance the respiratory difficulties already present.

RESUSCITATION IN THORACOABDOMINAL WOUNDS

In thoracoabdominal wounds, speed of resuscitation was essential because

speed of surgery was essential, just as in any abdominal wound. In these injuries there was always the possibility, if not the probability, that contamination of the peritoneum, as well as of the pleural cavity, was occurring and that

continued hemorrhage might threaten life. There was therefore no reason for

temporizing and delay after cardiorespiratory imbalance had been corrected,

replacement therapy begun, and the diagnosis established with reasonable certainty. Even when the response to adequate resuscitative measures was not

entirely satisfactory, delay in the shock tent did not, ideally, exceed 1 to 3 hours

at the maximum. In all thoracoabdominal wounds, the operation was itself an

essential part of the regimen of resuscitation.

Thoracoabdominal wounds are discussed in greater detail under that

heading (vol. II, ch. III).
25S THORACIC SURGERY

RESPONSE TO RESUSCITATION

Criteria of adequate resuscitation included:

1. Spontaneous cessation of hemorrhage or its control.

2. Establishment of a patent airway.

3. Stabilization of the chest wall and restoration of its integrity.

4. Effective cough.

5. Control of shock.

C. Establishment of an adequate cardiorespiratory balance.

7. Clearance of blood and air from the pleura! space.

8. Reexpansion of the lung.

After adequate resuscitation, the patient's status was reevaluated in the

light of these criteria. Not all of them were met in all cases, but, as a rule,

enough of them had been to make surgery safe. It was not necessary that completely normal conditions be reestablished before it was undertaken. When

the cardiorespiratory balance had been restored by correction of hemothorax,

pneumothorax, and stabilization of the chest wall, the systolic blood pressure

was likely to have reached 80 mm. Hg and to be tending upward, and surgery

could safely be undertaken.

If resuscitation had been adequate but the patient's status was still poor,

certain other possibilities had to be borne in mind in the patient whoso shock

was obviously not irreversible:

1. Leakage of air in large amounts from the trachea or bronchus.

2. Soiling of the pleura with esophageal or reflux gastric contents.

3. Continuing hemorrhage from an intercostal or mammary vessel, which

was not frequent (vol. II, ch. IV).

4. Cardiac tamponade, which was not common in military surgery (vol. II,

ch. II).

5. Intraperitoneal or intrapleural contamination from spillage of the contents of a hollow viscus. Gross contamination of the left pleural cavity by

large bowel contents produced as profound shock as was seen during the course

of the war. In such injuries, a response to resuscitative measures could be

expected only after the cause of the shock-producing mechanism had been

eliminated.

6. Intraperitoneal hemorrhage. Early surgical intervention was necessary

when, for instance, the spleen lay shattered in the left pleural cavity or the

right lobe of the liver continued to bleed. If the site of the wound of entry

in the chest, the location of retained metallic fragments, and the lack of response to shock therapy pointed to continuing hemorrhage, with or without

other intra-abdominal injuries, then the surgeon had to weigh the possibilities

and proceed with surgery in spite of the patient's continued shock. If fecal

contamination of the peritoneum or pleura had also occurred, the response to

resuscitation was slower than if only hemorrhage was a factor. If contamination had been serious and of long duration and if there had also been a massive

loss of blood, then the patient might not react at all.
RESUSCITATION AND PREOPERATIVE PREPARATION 259

Any of these conditions served as a sound indication for thoracotomy or

thoracolaparotomy. A satisfactory response to resuscitation could not be

expected while they remained unconnected.

Priority of surgery.—The combined effect of multiple injuries also seriously influenced the response to resuscitation. Furthermore, the frequency

with which other wounds of varying severity complicated intrathoracic wounds

often made the decision as to regional priority of management extremely important. There was general unanimity on this point: When wounds of the

thorax presented indications for early thoracotomy, this operation was always

done before other surgery. The single exception, which was not usual, was

severe intra-abclominal hemorrhage. Total equilibration of the cardiorespiratory mechanism enabled combined procedures of surprising magnitude to be

done safely.

PSYCHOLOGIC CONSIDERATIONS

Often during the stress of combat, when a hospital was filled to overflowing with battle casualties, there was a tendency, quite understandable under

the circumstances, to forget the casualty as an individual and consider him

only in terms of his injury. This was a particularly serious error in the management of patients with chest injuries. They were often apprehensive, and

the knowledge that they might be harboring foreign bodies in the chest often

caused them a great deal of concern. Ideal management, therefore, required

that they receive the maximum reassurance possible. Eelief of pain and improvement in respiration were probably the two factors that did most to improve the mental attitude of the severely wounded. Morale was high in the

forward hospitals of the Mediterranean theater because of the skill and esprit

de corps of the surgical staffs and because it was common knowledge among

the fighting men in the forward echelons that if they lived to reach a forward

hospital, they were almost certain to recover.

Reference

1. Haight, C.: Intratracheal Suction in the Management of Postoperative Pulmonary

Complications. Ann. Surg. 107 : 218-228, February 1038.
CHAPTER X

Anesthesia

Ernest A. Doud, M.D.

GENERAL CONSIDERATIONS

The excellent anesthesia provided for casualties with wounds of the chest

in World "War II was brought about by two developments between the two

World Wars. The first was the development of intratracheal positive pressure

absorption anesthesia. The second was improvement in the knowledge of

cardiorespiratory physiology (1).

Thoracic surgeons and anesthesiologists with adequate equipment were

dispersed from the forward areas of the combat zone back through the chain

of evacuation. This policy greatly reduced the fatalities from chest wounds

as well as their morbidity. It permitted the prompt and competent care of

nontransportable casualties by providing for surgery, when it was necessary, as

near the frontline as it was practical to provide hospital facilities.

The need for qualified anesthesiologists for the management of thoracic

injuries was recognized early in the war. It was also recognized that they must

take the responsibility for more than the administration of anesthesia. In

addition to relieving the surgeon of all concern for anesthesia, they assumed

the responsibility for shock therapy during operation, and, when it was practical, before operation. They also coped with the ever-present problems of

pulmonary secretions and accumulations of intratracheal blood by repeated

catheter aspiration during operation, and, if necessary, by bronchoscopy

immediately afterward.

The duties of the anesthesiologist and his relation to the surgeon are excellently stated in the final report of the 2d Auxiliary Surgical Group on forward

surgery:

* * * the anesthetist carries a large part of the responsibility in treating severely

wounded men. The more competent the anesthetist the less the burden on the surgeon.

With a well-qualified anesthetist at the head of the table the surgeon can give his undivided

attention to the operative procedure itself.

It was generally agreed that such an anesthetist could "support an inexperienced surgeon better than a brilliant surgeon [could] maintain an

inexpert anesthetist."

261
262 THORACIC SURGERY

EQUIPMENT

Satisfactory anesthesia depended upon adequate equipment. There were

many deficiencies early in the war, both in North Africa and in Sicily. Even

in the Sicilian campaign, some thoracic surgical teams of the 2d Auxiliary Surgical Group did not have anesthesia machines. Inductions had to be carried

out with open drop ether or ethyl chloride, or with Pentothal sodium (thiopental sodium), with oxygen administered by face mask or nasopharyngeal

catheter. In many instances, the entire intrathoracic procedure was carried

out with intravenous Pentothal sodium (p. 84).

FIGURE 33.—Improvised anesthesia apparatus used in Sicily by the 2d Auxiliary Surgical Group. The oxygen cylinder (a), oxygen flow regulator (b), and humidifier (c)

were standard hospital equipment. Other items improvised included the connection tubing

(d), ether vaporizer (e), breathing bag (f), soda-lime canister (g), and face mask (h).

There were numerous improvisations (fig. 33) in many of which ordnance

and engineering units assisted. Several types of ether vaporizers were devised.

Positive pressure was obtained by occluding the escape valves of masks through

which oxygen was administered and manually compressing the attached small

breathing bag. Neither nitrous oxide nor soda lime was available at this time.

Large volumes of oxygen were used to dilute the carbon dioxide.

After November 1943, these difficulties no longer existed. Several types

of excellent anesthesia machines were distributed, and there were ample supplies of oxygen, nitrous oxide, ether, Pentothal sodium, and socla lime. The

equipment and supplies were made available not only to hospitals but to the

mobile surgical teams. Thereafter, anesthesia left nothing to be desired, for by

this time the anesthesiologists had learned the necessary lessons of wartime

anesthesia by their experiences in the early campaigns.

PREOPERATIVE PREPARATION

The excellent results obtained in all types of combat injuries in World

War II could be attributed in large part to the excellent preparation of the
ANESTHESIA 263

casualties for both anesthesia and surgery. Originally, until thoracic surgical

teams were assigned to field hospitals, surgeons were responsible for triage;

resuscitation and preoperative preparation, including procuring blood for transfusion from neighboring service troops; and determination of the optimum

time for operation. When field hospitals were set up adjacent to clearing

stations, which was first clone in the campaign in Sicily, thoracic surgical

teams were assigned to them, and anesthesiologists took over the major part

of the responsibility for resuscitation. They employed, as necessary, replacement therapy, nasotracheal catheter suction, tracheal intubation, paravertebral

block, and whatever measures might be necessary (p. 241). They also assisted the surgeon in determining the optimum time for operation. This was

preferably after resuscitation was completed. If, however, the condition of the

casualty continued to deteriorate in spite of adequate therapy, whatever surgery

was indicated was performed at once.

Preoperative medication.—Preoperative medication was almost always

administered intravenously in the operating tent, to make certain of satisfactory absorption, so that whatever drug was used would have the optimum effects

at the desired time.

All patients, except those in deep shock, were given atropine sulfate (gr.

1/150 to 1/100). If sedation was thought necessary, morphine tartrate was

administered (gr. 1/8 to 1/4). It was always administered cautiously, for it

was not infrequently found that casualties with chest wounds had already received too much. Until this was realized, acute morphine intoxication was not

uncommon. When the circulation improved in response to resuscitative measures, the morphine previously administered to casualties in shock, who had

been exposed to cold and wet weather, was rapidly absorbed. In such circumstances, an additional dose of morphine could be dangerous (p. 244).

For this reason, intercostal or paravertebral nerve blocks with procaine

hydrochloride (ISTovocain) were frequently used in preoperative preparation

in preference to morphine. If the injuries involved only the chest wall, patients

who had been treated by nerve block during resuscitation could sometimes be

operated on with the addition of procaine infiltration analgesia. This method,

however, had a limited use, because the multiplicity of wounds restricted the

employment of both local and regional anesthesia.

TECHNIQUE

Induction.—Anesthesia was easily induced in some patients with ether and

oxygen or with open drop ether. In other cases, nitrous oxygen and oxygen

were used, with the gradual addition of ether. When it was advisable to eliminate possible excitement during induction, the most satisfactory combination

of drugs was the intravenous use of Pentothal sodium (table 13) in 2.5- to

5-percent solution and the topical use of cocaine in 4- to 10-percent solution,

with preliminary oxygenation.
264 THORACIC SURGERY

TABLE 13.—Distribution of anesthesia by type, and by type of hospital, Seventh U.S. Army,

1 November 1944-30 April 194-5

Type of anesthesia

Intravenous (Penthothal sodium)

Inhalation '

Combined intravenous and inhalation

Field blocks

Regional (miscellaneous)

Spinal

Sympathetic block

Total

Evacuation hospitals

Cases

22, 363

9, 762

3, 849

4, 904

558

383

319

42, 138

Percent

53.

23.

9.

11.

1.

100. 0

Field hospitals

Cases Percent

71

148

56

45

117

11

44

2, 492

2.

86.

2.

1.

4.

100.0

1 Endotracheal anesthesia was used 3,042 times in evacuation hospitals and 1,782 times in field hospitals, this being

31.2 percent and 83.0 percent, respectively, of the inhalation anesthetics given in those installations.

Anesthetic agents.—Ether was the principal anesthetic agent used in

most chest wounds. It was seldom used alone but was highly satisfactory

when combined with nitrous oxide and oxygen, or with Pentothal sodium,

or simply with oxygen.

Pentothal sodium with oxygen was used as the principal anesthetic agent

only when lack of equipment and supplies required it, which was seldom the

situation after the campaign in Sicily.

This agent had many advantages: It did not irritate the bronchial mucosa.

Respiratory movements were reduced to a minimum, and the surgeon therefore

did not suffer from interference by them. Controlled respiration was easily

effected with it. When it was used with ether, only small amounts of that

agent were required. On the other hand, Pentothal sodium gave rise to

occasional laryngospasm, and the postoperative respiratory depression that it

caused was likely to be prolonged. The chief reason for restricting its use to

selected patients and for using it only when other types of anesthesia were not

possible was its very small margin of safety. It was not a proper agent for

general use.

Positioning.—Unless there were contraindications, such as head injuries,

the modified Trendelenburg position was used during operation, for two reasons. The first was that it reduced the possibility of air embolism. The second

was that it was helpful in improving the condition of the casualty, particularly

the shocked casualty, during anesthesia.

Tracheal intubation.—The trachea was intubated routinely, to facilitate

positive pressure for pulmonary control and expansion without causing gastric

dilatation. Another purpose was to stabilize the mediastinum during intrathoracic surgery. A soft rubber catheter was passed through the tube, and

frequent tracheobronchial aspirations were carried out to protect the contralateral lung from gravitated material.
ANESTHESIA. 265

The tube used was the largest which would pass through the glottis without difficulty. Some anesthesiologists preferred a tube with an inflatable cuff,

in the belief that the cuff prevented fluid accumulations in the trachea from

escaping around the tube into the pharynx. Others preferred to pack the

pharynx with moistened gauze, in the belief that the packing prevented the

tube from acting as a wick to permit regurgitated material to be drawn into the

trachea. Still others preferred to place a mask over the tracheal tube, thus

producing a seal for attaining positive pressure.

Usually when the ether was used, and always when Pentothal sodium

was used, the respiratory exchange Avas increased by rhythmic manual compression of the breathing bag throughout the operation.

Opinion was divided as to whether intermittent positive pressure anesthesia or the apneic technique of controlled respiration was the preferred

method for maintaining anesthesia for surgery with open pneumothorax.

However it was attained, 2-3 mm. Hg pressure prevented mediastinal shift,

and 10-12 mm. Pig pressure was used to expand the lung for short periods every

20-30 minutes during operation, as well as when the wound was being closed.

Curare.—Curare was used intravenously by one surgical team during the

Kalian campaign to obtain abdominal relaxation and to facilitate tracheal

intubation (2). The drug, which was not on the approved list, was supplied

to the anesthesiologist of this team by the manufacturer and used by special

permission on a trial basis. Curare proved extremely useful in obtaining

abdominal relaxation, but it never came into widespread use, one reason being

that the supply was scanty.

ADJUNCT THERAPY DURING OPERATION

As accurate as possible an estimate of the blood lost was made as the operation progressed, and the estimated loss was replaced as it occurred, to prevent

the casualties, whose balance was always delicate, from slipping into shock.

The physical status of many patients improved during operation because of

(1) the increased efficiency of respiratory exchange following aspiration of

the trachea and administration of oxygen in high concentration, (2) the effects

of the Trendelenburg position, and (3) intravenous replacement therap}-,

usually in the form of whole blood transfusions.

The anesthesiologist was kept fully employed during operation with the

administration of the anesthetic; maintaining respirations; keeping the tracheobronchial tree free of fluid; constant evaluation of the patient's condition; and

the administration of intravenous fluids, sometimes under pressure, to increase

the rate of flow if the blood loss was particularly heavy.

BRONCHOSCOPY

Bronchoscopy was not routinely used at the end of thoracic operations,

chiefly because most anesthesiologists believed that increasing the depth of

anesthesia at this time would have deleterious effects. It was, however, used

053C811'—G2 19
266 THORACIC SURGERY

whenever necessary to make certain that respiratory passages were clear of

blood and mucus, as well as to determine the patency of the bronchi if too

great resistance was offered to pulmonary expansion. It always had to be borne

in mind that the uninjured lung had been in a dependent position during surgery. It was frequently necessary to clear the left stem bronchus, which was

likely to present special difficulties.

Bronchoscopy was sometimes necessary, before operation, to clear accumulations in the tracheobronchial tree after failure of attempts at blind nasotracheal suction. Circumstances sometimes made it wiser to delay suction

until the trachea! tube was inserted after rapid induction of anesthesia.

Oxygen was administered with a little positive pressure after each brief period

of suctioning. When the respiratory passages had been satisfactorily cleared,

anesthesia was continued and the operation proceeded with.

The chief risk of bronchoscopy, the vagovagal reflex, could be eliminated

by the administration of atropine before the procedure was undertaken. The

risk of omitting it is evident in the following case history:

Case 1.—This casualty, a 23-year-old soldier, was injured by a high explosive shell

fragment on 26 May 1944 at 0730 hours. He was admitted to a field hospital 4 hours after

injury, after having received morphine gr. y2 and 3 units of plasma. The blood pressure

was S4/50 mm. Hg and the pulse 120.

The wound of entry was over the eleventh rib, in the left posterior axillary line, and

was 4 cm. in diameter. The wound of exit was in the anterior axillary line and was 6 cm.

in diameter. Omentum had herniated through both wounds. The left chest was silent,

and haziness was evident throughout it by roentgenologic examination. The abdomen was

tender and rigid.

The patient received another unit of plasma and 1,400 cc. of blood before operation.

Preoperative medication consisted of morphine gr. % and scopolamine gr. 1/100. When

operation was begun, the blood pressure was 110/70 mm. Hg and the pulse 110.

Operation was begun at 1430 hours. The wounds of entry and exit were debrided, and

a large hematoma of the muscles was excised. Segments of the eighth, ninth, and tenth

ribs were found shattered; their rough edges were smoothed.

An intercostal incision was then made through the eighth interspace. The pleural

cavity contained 1,000 cc. of blood. Part of the stomach, the transverse colon, and the

spleen, covered by omentum, had herniated into the left chest through a huge rent in the

anterolateral portion of the diaphragm at its point of attachment to the chest wall. The

spleen was widely macerated, but the pedicle had not been injured, so bleeding was not

profuse. Splenectomy was performed and the damaged omentum resected. The tail of

the pancreas was found lacerated and was repaired with interrupted cotton sutures. A

3-cm. laceration of the serosa over the greater curvature of the diaphragm was closed with

some difficulty by two-layer imbricating cotton sutures. The phrenic nerve was paralyzed.

The chest was irrigated with 2,000 cc. of physiologic salt solution. The wound was dusted

with 5 gin. of sulfanilamide powder and closed in layers. Mobilization of muscles was necessary to secure adequate closure. A heavy dressing of gauze and wide adhesive was

applied to stabilize the chest. Replacement therapy during the operation, which took 2

hours and 15 minutes, consisted of 500 cc. of blood.

The bronchoscope was then introduced, without difficulty. Although the patient had

previously been in excellent condition, he became cyanotic and pulseless just as the procedure was being terminated. The immediate insertion of an intratracheal tube and the

use of artificial respiration were without effect. The heart was not heard any time after

bronchoscopy was performed.
ANESTHESIA 26

An immediate post mortem examination showed the heart to be flabby and dilated, but

otherwise, except for the traumatic damage, no abnormalities were found.

Comment.—It was concluded that the patient died of a vagovagal reflex, which undoubtedly could have been prevented by atropinization before the bronchoscope was

introduced.

References

1. Graham, E. A.: A Brief Account of the Development of Thoracic Surgery and Some

of Its Consequences. Surg. Gynec. & Obst. 104: 241-250, February 1957.

2. Doud, E. A., and Shortz, G.: The Use of Curare for Abdominal Surgery in Seriously

Injured Patients. Anesthesiology 7: 522-525, September 1946.
CHAPTER XI

Initial Wound Surgery

LymanA. Brewer III, M.D.

GENERAL CONSIDERATIONS

Although it necessitates a certain amount of repetition, it seems worthwhile to begin the discussion of the forward surgery of thoracic casualties with

a restatement of the principles which governed their management in the division and army area. As pointed out in detail earlier (p. 199), the indications

for thoracotomy in forward hospitals remained in a state of flux from the

landings in North. Africa in November 1942 until they were clarified under the

direction of Col. Edward D. Churchill, MC, Consultant in Surgery to the Surgeon, Mediterranean Theater of Operations, U.S. Army, at a meeting of chest

surgeons in Marcianise, Italy, in March 1944. Experience satisfactorily arbitrated most of the differences of opinion that still existed, and the consulting

surgeon, by discussion as well as directive, effectually settled the remaining

issues. With the clarification of indications for thoracotomy, many fewer such

operations were performed, and results were correspondingly better.

Establishment of Policies

One of the chief arguments of the surgeons who believed thoracotomy was

frequently required in field and evacuation hospitals was that it was necessary

to prevent infection. Thoracic casualties, like all other casualties, sometimes

did die from infection, but infection was not the usual cause of the deaths that

occurred soon after wounding. Early deaths were practically always due to

disturbances of cardiorespiratory physiology.

In thoracic casualties, prevention of infection, however important it was

ultimately, was thus a secondary consideration immediately after wounding.

At this time, the chief attention was directed to the cardiorespiratory balance,

which, in most wounds of the thorax without abdominal involvement (thoracoabdominal wounds are discussed separately (vol. II, ch. Ill)), could be restored

to normal or close to normal by resuscitative measures alone. Respiration is

dependent upon lung expansion, and lung expansion is dependent upon an

intact thoracic cage. The object of the management of thoracic casualties in

forward hospitals was therefore the restoration of a functioning lung that was

fully expanded against a restored thoracic wall.

269
270 THORACIC SURGERY

Indications and contraindications for forward thoracotomy.—While

the general policy early in the Tunisian campaign and for some months afterward was to perform thoracotomy in forward hospitals on very liberal indications, experience rapidly accumulated to show that overzealous surgical

interference soon after wounding resulted in an increased morbidity and mortality. The mortality rate was lowest, and complications were fewest, when

forward surgeons performed major intrathoracic procedures only on specific

indications. These results were what might have been expected. Thoracotomy,

even when it was absolutely necessary, put an added burden on an already

damaged cardiorespiratory system. When he performed it unnecessarily, the

forward surgeon might unwittingly be administering the coup de grace to the

casualty.

At the meeting in Marcianise, in March 1944, it was decided that theater

policy thereafter should be to limit primary thoracotomy, whether by extension

of the wound or by a separate incision at a site of election, to the following

indications:

1. Continuing intrapleural hemorrhage not controlled by hemostasis in

the course of debriclement of the chest wall. This situation was uncommon.

2. Anatomic or clinical evidence of penetration of the diaphragm, which

was common.

3. Large intrapleural foreign bodies or other debris readily accessible by

simple extension of the wound. These were common.

4. Wounds of large bronchi or of the intrathoracic portion of the trachea,

which were uncommon.

5. Passage of a missile through, or its lodgment in, the mediastinum, with

reason to suspect visceral damage, particularly injury to the esophagus. These

injuries were not frequent.

The following conditions were not, in themselves, to be regarded as indications for thoracotomy either by extension of the wound or by a separate

incision:

1. Foreign bodies, whether metallic objects or fragments of bone, whether

they were in the lung or the pleural space.

2. Hemothorax. Evacuation of blood from the pleural cavity by suction

at the time of debridement of the chest wall wound was not considered a

thoracotomy.

3. Laceration or contusion of the lung in the absence of definite evidence

of continuing hemorrhage or leakage of air.

It was eventually found practical to base the management of a wound of

the chest on its size. Arbitrarily, a traumatic thoracotomy came to be defined

as a wound of the chest wall that, when debrided, resulted in a pleural defect

6 cm. or greater in one diameter or one that resulted in the destruction of three

or more ribs and all intervening structures. Actually, this definition covered

most sucking wounds: Since these wounds had to be sutured to make the pleural

cavity airtight, a wide debridement of the chest wall muscles was necessary in
INITIAL WOUND SURGERY 271

all of them. This sort of defect was most often caused by a fragment from a

high explosive shell, though it was sometimes caused by a bullet that struck the

thoracic cage tangentially or that emerged from the chest wall in such an

erratic manner as to produce a disproportionately large defect. The size of

the foreign body was not necessarily proportional to the size of the defect that it

caused.

From the surgeon's standpoint, the important consideration was that a

traumatic thoracotomy was not of his making. It was the result of wounding,

and the wound was of such a size as to permit any indicated intrapleural manipulations. The intrathoracic damage in many instances might not, of itself,

have required forward surgery. The surgeon simply took advantage of the

exposure provided by the wound to perform whatever intrathoracic surgery

might be necessary later.

Components of initial wound surgery.—Initial wound surgery, on the

basis of these indications and contraindications, was therefore to consist of:

1. Debridement of the chest wall, without inspection of, or operation on,

intrathoracic structures. This restriction did not preclude aspiration of blood

or air from the pleural cavity by means of thoracentesis or by the insertion of

a catheter through the pleural defect, irrigation of the chest cavity, and intrathoracic instillation of penicillin solution. Closure of the pleural defect by

approximation of the muscle and fascial planes was considered part of debridement, Closure of the pleura per se was often not possible; the pleura is so

delicate and so friable that it tears when suture is attempted.

2. Traumatic thoracotomy (thoracotomy through the wound), with debridement of the chest wall and inspection of, or operation on, intrathoracic

structures as indicated. If necessary, the traumatic wound was extended to

achieve this purpose.

3. Formal thoracotomy, with the incision at a site of election separate from

the wound as indicated.

Modifications of Policy

The policy of limiting surgery in field hospitals to nontransportable

thoracic casualties (p. 91) was, of course, flexible. It varied with local conditions, including such considerations as speed of evacuation, the terrain over

which evacuation was to be accomplished, the location of the evacuation hospital in relation to the field hospital, and the casualty load. Two other considerations were important, (1) the availability of anesthetic facilities and

personnel and (2) the relative competence of the personnel of the two installations. Even though it meant an increase in the timelag, the patient's interests

were usually better served if additional time were taken to transport him to a

hospital staffed and equipped for thoracic surgery.

Similarly, the surgeon doing chest surgery in a field or evacuation hospital

was expected to depart from the strict policies just outlined when there was

valid reason to do so. He could, for instance, go far toward relieving the load

on base hospitals if he removed accessible foreign bodies at debridement, though
272 THORACIC SURGERY

the presence of a foreign body was not, in itself, an indication for thoracotomy

in a forward hospital. If the surgeon who performed the initial wound surgery aspirated the blood in the pleural cavity, a large hemothorax, which might

later lead to infection or require decortication, would probably be avoided. The

forward surgeon, by the exercise of sound judgment and by taking advantage

of opportunities that presented themselves, could, while adhering to the general

principles laid down for his guidance, prevent increased morbidity, including

infectious complications, and make secondary surgery unnecessary.

DEBRIDEMENT

Debridement of all wounds of the external chest wall was mandatory,

though in the absence of definite indications for more radical forward surgery,

it could usually be postponed until an evacuation hospital was reached. No

wound was too small to require debridement, and failure to perform it adequately could result in extremely serious infections. The operation included

excision of all devitalized tissue, washing out of all dirt and foreign material

with sterile saline solution, and packing of the wound with sterile fine-mesh

gauze or roller bandage.

Chest surgeons who cared for casualties in base hospitals stated that it was

practically always necessary to perform delayed debridement on wounds that

had not been debrided originally because they were thought to be too small to

need it or because they had been caused by high-velocity missiles and were regarded as sterile. In such wounds, a subcutaneous area of tissue destruction

was invariably found, out of all proportion to the wound of entry, and direct

extension of the infection to the pleural space could also be demonstrated. If

the wound had been properly debrided, the fine-mesh gauze (ordinary bandage)

could be removed in from 7 to 10 days at the base hospital and secondary closure

of the wound performed.

Positioning

When only debridement of the chest wall was to be done, the location of the

wound influenced the decision as to positioning on the operating table. Patients

verging on shock were kept in the Trendelenburg position unless head wounds

contraindicated it. The same position was considered desirable whenever lung

tissue had been damaged or was to be cut across, on the theoretical assumption

that the risk of air embolism would thus be decreased.

If a posterolateral traumatic thoracotomy or formal thoracotomy was necessary, the patient was placed on the intact side, with the chest at a right angle

to the table (fig. 34). A small rolled blanket or bath towel was placed under

the axilla to prevent pressure on the axillary nerves. Eestricting pads were

avoided, as was pressure beneath the costal margin on the underside^of the chest,

next to the table, so that there would be no compression of the underdiaphrao-m.

Freedom of movement of the underdiaphragm was important during a thoracotomy that collapsed the uppermost lung. The thigh and leg nearer the table
INITIAL WOUND SURGERY 273

were flexed, to help stabilize the patient. The other thigh and leg were extended, and the foot was fixed to the end of the table. Rolled blankets or sandbags were used to support the anterior chest. Satisfactory positioning on the

table was completed by passing a broad adhesive strapping from the lower edge

of the table across the hips, between the crest of the ilium and the greater

trochanter of the femur, and thence down to be fixed to the opposite side of the

table.

FJGUKE 3-1.—Position on operating table for posterolateral thoraeotomy. A. Adhesive strap over hips to hold patient to table. B. Fixation of position by sandbags, used

in Held and evacuation hospitals when regular operating tables were not available.

C. Rolled towel or small pillow in underlying axilla, to prevent injury to brachial plexus.

D. Pillow under head. E. Pillow between legs. F. Site of posterolateral incision.

Steps of the Operation

The cardinal principle of debridement was that it be thorough. Failure

to perform adequate debridement introduced the risk of pleura! infection and

could lead to empyema. The wound was often grossly contaminated by dirt

and bits of clothing. Large masses of muscle were often so badly contused as

to be nonviable. Bone fragments were numerous, and accessible foreign bodies

were frequent.

A nice balance between radical and conservative surgery was always attempted. The wound track was excised down to the pleural opening, but only

devitalized tissue was excised. Only loose fragments of bone were removed;

as much as possible of the ribs, periosteum, and intercostal structures was preserved. Too radical removal of the bony structures might be followed after

operation by instability of the chest wall and paradoxical motion. Eib fractures that had not penetrated the pleura were not disturbed except to smooth

6536S1V—02- -20
27-i THORACIC SCRCEKY

FIGURE 35.—Debridement of chest wound in field hospital.

the sharp, rough edges of the stumps with a rib-cutter. If only the inner or

the outer table of a fractured rib was displaced, the intact half was left in situ,

on the ground that half a rib furnished more support to the chest wall than no

rib at all. Periosteum was saved at all costs; it was used to bridge defects, for

the bone regenerating from it prevented paradoxical movement of the chest

wall. Only accessible foreign bodies were removed. All damaged intercostal

bundles were ligated anteriorly and posteriorly, whether or not free bleedingwas occurring. Care was taken not to include intact intercostal nerves in the

ligated bundles. Intercostal structures were not resected unless the}' were

actually damaged, since their excision would have enlarged the defect.

A simple debridement of the chest wall (fig. 35) included removal of

damaged muscle tissue; removal of accessible foreign bodies and debris; and

removal of fragments of the scapula, clavicle, superficial portions of the sternum, and superficial rib fragments. The pleura was not disturbed by any of

these procedures. Once the debridement had become extensive enough to

include the undersurface of the ribs and the pleura, then a traumatic thoracotomy had been performed, and the resulting open pneumothorax required

positive pressure anesthesia and introduced other problems and risks. It was

unwise to undertake a debridement of any considerable extent without facilities for intratracheal anesthesia.

When debridement was performed according to the technique and limitations just described, it was found that no other forward surgery was necessary
INITIAL WOUND SURGERY 2(0

in three-quarters or more of all chest injuries. Whatever other surgery was

indicated could be safely performed later at a fixed hospital in the base.

Aspiration of the pleural cavity.—All but the most insignificant wounds

of the chest caused a pleural defect large enough to admit a No. 15 or No. 18

French catheter. In most cases, however, diligent aspiration of the chest with

a needle was just as effective in the removal of retained blood as was the use of

a catheter, and, being simpler, was preferable. When a catheter was used, a

suction machine was attached to it. If aspiration was adequate at operation,

postoperative aspiration was seldom necessary for any length of time and was

frequently not necessary at all.

In some cases in which the blood had clotted and could not be satisfactorily

removed by thoracentesis, a catheter was inserted through the pleural defect

and worked back and forth to break up the clots. When as much material as

possible had been removed by this method, the pleural space was irrigated

with from 1,000 to 2,000 cc. of physiologic salt solution, which was then aspirated through the catheter with the aid of the suction machine, A hole cut

in the catheter near the proximal end permitted digital control of the degree

of suction applied.

Closure of the Wound

Whether initial wound surgery was limited to debridement or included

some intrathoracic procedure, careful closure of the chest wall was equally

important. It was essential that the muscle layer be closed, for two reasons:

1. The muscles furnish strength and support to the chest wall, which the

skin and pleura do not.

2. It was imperative that any leakage of air into the pleural cavity be

prevented. If the leak was small, a tension pneumothorax might result. If it

was large, a sucking wound might develop.

While closure of the pleura was not always feasible, it was desirable whenever possible; an intact and well-healed pleura furnished an efficient barrier

against the spread of infection from muscle layers to the pleural cavity. The

risk of empyema was always reduced when the muscle layer of the chest wall

was firmly closed and when the pleura, if possible, was also closed.

There were several techniques of closure:

1. Under ideal circumstances, it was a simple matter to reapproximate

the muscle layers in tiers with interrupted sutures of either fine cotton or silk

for all layers. Catgut was used for the pleura. The skin wound and subcutaneous tissues were closed later in a base hospital or chest center, by delayed

primary wound closure.

2. Under less ideal, and more usual, circumstances, considerable skill and

ingenuity might be required to effect adequate closure without tension. It was

essential that tension be avoided. It was almost invariably followed by infection, and even a minor infection could rapidly result in an infected blowing

wound and total empyema.
THORAC10 SIjRGERY

FIGURE 30.—Techniques of closure of sucking wound. A. Mobilization of latissimus

dorsi flap to cover defect of sucking wound. B. Latissimus dorsi flap tightly sutured to

edges of defect of sucking wound.

o. "Whenever possible, closure was ell'ectecl with intercostal structures, but

extracostal muscle sometimes had to be employed (fig. 36). If the desired

results could be accomplished by undermining and mobilizing adjacent muscle,

closure offered no great difficulties, but the available muscle structures were

usually insufficient for this purpose. In these circumstances, muscle flaps had

to be swung into place. Ample muscle was available posteriorly, but near the

spine, muscles are not so plentiful on the thoracic cage, and it was frequently

necessary to use a flap of the erector spinalis to close the defect (fig. 37).

Anteriorly, only the pectoral muscles are available (figs. 38 and 39), and if for

any reason they could not be employed, closure had to be effected with subcutaneous fascia and skin.

In planning a muscle flap, it was always necessary to calculate a length 50

percent greater than the distance from its base to the far side of the defect.

The additional length was necessary to compensate for the retraction that

inevitably occurred when the flap was cut and that would have introduced the

dangerous factor of tension, which had to be avoided. The deep fascia of

the flap was used for closure of the first layer of the wound. Closure of the

other layers was effected by imbrication of the split edge of the flap and of

the muscles adjacent to the defect.

4. Pericostal sutures as the sole method of closure were abandoned for

other techniques (fig. 40) early in the war, because of the poor results (fig.

4f). The ribs were approximated while the intercostal bundle was being

sutured. The Lambotte bonediolding forceps or a large towel clip proved

excellent rib-approximators. Catgut sutures were sometimes used to approximate separated ribs and reduce the size of the costal opening.
INITIAL WOUND SURGERY

FiGXJiiK 37.—Closure of wound with swinging flap of erector spinalis. A. Location of

defect in lower posterior chest wall. B. Details of technique. Sutures placed in erector

spinalis flap. C. Flap sutured in place. (Note substitution of erector spinalis for

paraspinalis.)

Relaxing incisions at a distance from the wound were often a great help

in closure. Extensive dissection and freeing- up of the subcutaneous tissue

were also helpful.

5. The use of skin and fascia to effect closure was always an undesirable

improvisation, since it left an unstable and unsupported chest wall. When

this technique was used, pressure dressings were necessary to strengthen the

wall. Usually a plastic procedure, with a fascial graft or prosthesis, had to

be employed later, at the base hospital or in the Zone of Interior, to re-create

a stable thoracic cage and prevent herniation of the lung.
278 THORACIC SURGERY

5 th

FIGURE 38.—Closure of anterior wound complicated by sternal defect with pectoral

muscles. A. Location of sternal defect. P.. Schematic showing of relation of pectoral

muscle to sternal defect. C. Detail of coverage, showing developed pectoral flap.

6. The diaphragm was occasionally employed to close certain strategically

located defects in the lower thoracic cage. It was also sometimes paralyzed

by crushing the phrenic nerve, in the belief that it was helpful to decrease the

size of the hemithorax and thus lessen the strain on a large wound during the

immediate postoperative period. Neither method was generally popular.

The skin wound was usually left open, to be closed a few days later in

a general hospital at the base. In many instances, primary suture at initial

wound surgery would have been entirely safe. It was never possible, however,

to determine the potential virulence of a latent infection which might be

present in the wound at the time of initial debridement, and the infectious

complications that arose in some cases in which primary closure was done

more than offset any gains accomplished by this technique. It was with good

reason that delayed primary wound closure became theater policy.

Dressing.—The dressing was of great importance in wounds of the chest

wall. Maximum support was provided by the liberal use of wide Ace ban-
INITIAL WOrXI) SURGERY 279

fvS

FIGURE 39.—Closure of large anterolateral sucking wound. A. Wound after debridement. B. Schematic showing of development of pectoralis major flap. C. Closure of wound

with pedicled flap of pectoralis major.

dages or of adhesive applied up to, or beyond, the midline, both anteriorly

and posteriorly. The skin was first painted with tincture of benzoin or some

other adherent, to provide good traction and to prevent the blistering

likely to occur when an adhesive dressing was applied tightly without this

precaution.
280 THORACIC SURGERY

A properly applied supportive dressing, put on -without tension, reduced

paradoxical motion of the chest; kept the muscles of the thoracic cage in

physiologic approximation; and, by reducing pain, made the patient willing

to cough and thus aided in the expectoration of material from the tracheobronchial tree.

FIGUEE 40.—Technique of approximating ribs and securing airtight

closure of interspace without use of

pericostal sutures. Care had to be

taken to avoid crushing intercostal

nerves.

FIGLTKE 41.—Section of rib 2 weeks

after catgut suture had been placed

around it.
INITIAL WOUND SURGERY 281

Local Chemotherapy

The practice of using local sulfonamide therapy at operation was rather

general when the war began. From 5 to 10 gm. of crystalline sulfonamide

was used in the pleural cavity and in the wound, depending upon the contamination found at operation. This was a matter of individual practice,

not a theater recommendation, and the policy was gradually discontinued

because its tendency to cause increased and often troublesome fluid production

more than offset any possible bacteriostatic effect. It was also found that

sulfonamide powder at times caused granulomas of the wound and delayed

healing.

A few surgeons considered local sulfonamide therapy of great value. A

number considered it harmful. The majority believed that whether it was

used or not made no difference at all. Its general use never reached prewar

expectations. Even before penicillin became available, there was a growing

belief that systemic chemotherapy was all that was necessary, and it was also

believed that the sulfonamides might play some part in renal shutdown

(lower nephron ncphrosis), which was occurring with disturbing frequenc_y

in association with profound shock.

After penicillin was introduced, it became the rather general practice to

instill it into the pleural cavity at the end of any intrathoracic operation, in

25,000- to 50,000-unit amounts, in 25 cc. of physiologic salt solution. If the

infection was severe or mixed, sulfanilamide was sometimes used with penicillin. Later, this practice was also discontinued. There was never any conclusive proof of its efficacy, and most surgeons came to believe that as much

was probably accomplished by systemic penicillin, in full doses. Neither local

nor systemic chemotherapy nor antibiotic therapy was regarded as a substitute

for extensive and thorough debridement and other sound surgical practices.

TRAUMATIC THORACOTOMY

In traumatic thoracotomy, as the term implies, the wound itself and the

debridement that was a necessary part of its management provided the entrance into the pleural cavity.

In a formally planned thoracotomy, the incision was sometimes made

through an extension of the original wound if the latter was so located that

the necessary surgery could be carried out through it. If there was considerable damage to the ribs, the incision could be made through the bed of a

resected rib. In the absence of costal damage, an intercostal incision was

used. The location of the incision depended upon only one consideration,

gaining the maximum exposure for the necessary manipulations. The traumatic wound was therefore not used unless, with only slight extension, it

offered satisfactory exposure.
282 THORACIC SURGERY

If there was need for access to a part of the chest not readily available

through an enlargement of the original incision, there was no hesitancy, after

debridement had been performed, in making an elective incision that would

give the desired access. If, for instaiice, a bullet entered the upper right

chest and finally lodged in the lower lobe of the right lung, the wound of

entrance was closed, and a formal intercostal thoracotomy was done at the

level that would be optimum for examination of the entire right lung as well

as for removal of the foreign bodv.

Anterior thoracotomy was discarded early in the Mediterranean experience. An incision in the thin tissues of the anterior chest wall frequently

broke clown, and the exposure was not so good as that secured by other

incisions. By the end of the war, an anterior incision was seldom used except

in traumatic thoracotomies and in an occasional cardiac wound in which it

gave the necessary exposure. If it was used, an intercostal incision was

preferred to lib resection, which inflicted further damage on the thoracic wall

and with which closure was not as satisfactory. If an intercostal incision

was used, the introduction of two rib-spreading Army-type retractors, with

slow spread of the ribs, produced excellent relaxation of the chest wall and

adequate exposure without rib fracture. Some surgeons carried out intercostal block with procaine hydrochloride (Novocain) before spreading the

ribs. Proponents of these techniques believed that they hastened recovery and

greatly reduced postoperative pain.

ELECTIVE THORACOTOMY

In the Mediterranean theater, the policy was to employ a posterolateral

approach for practically all elective thoracotomies (fig. 42). It permitted

satisfactory access to most of the chest structures and closure with it was

seldom difficult.

A technique developed by Maj. Thomas IT. Burford, MC, and suggested

by Col. Frank B. Berry, MC, utilized a shortened posterolateral incision

through the intercostal bundle, without costal section or resection (figs. 43 and

44). As experience accumulated, it became apparent that section of the serratus

anterior was not necessary; simply reflecting it served the purpose equally well.

In more than 200 thoracic injuries in which it was used, this technique provided

entirely adequate exposure for the management of all types of wounds that

required thoracotomy. Thoracolaparotomy, extensive decortication, lobectomy,

and complete hilar dissection were accomplished through it.

A wound of the anterior superior chest presented a particularly difficult

problem if it was necessary to expose the large vessels in the superior mediastinum and at the base of the neck. The mediastinal portion of the procedure
INITIAL WOUND SURGERY 283

FIGURE 42.—Exposure of thoracic cavity with rib-spreader in posterolateral

thoracotomy. A. Rib-spreader. B. Rib-spreader in situ, with gentle spreading of

ribs, showing: Erector spinae muscle group (a), spinous processes (b), divided

latissimus dorsi, serratus anterior, and intercostal muscles (c), scapula (d), right

upper pulmonary lobe (e), right middle pulmonary lobe (f), and right lower

pulmonary lobe (g).
284 THORACIC SURGKRY

FIGUEE 43.—Burford technique of traumatic thoracotomy. using shortened

posterolateral incision. A. Serratus anterior muscle. B. External intercostal muscle. C. Cut edge of latissimus dorsi muscle. (Note method of

reflecting serratus anterior muscle. Thorax is entered through intercostal

bundle.)

could be managed quite well intrathoracieal]y except that the exact point of

injury was frequently not determined before operation. It -was therefore

necessary to provide exposure of both the cervical and the mediastinal portions

of the vessels. This was best accomplished by a curving anterior incision, which

permitted access to the base of the neck, the clavicle, and the sternum unilaterally (fig. 45). After the clavicle had been sectioned, with Gigli's wire

saw if it was available, a portion of the manubrium, with the sternoclavicular

joint, could be reflected outward. All the major vascular structures could thus

be exposed, and. if the pleura had not shared in the damage, the operation could

be done extrapleurally.

Details of the management of wounds of the lung (vol. II, ch. I), foreign

bodies (vol. II, ch. VII), cardiac wounds (vol. II, ch. II), and other special injuries are described under the appropriate headings.

Closure was effected by the same general principles described for debridement (p. 275).
INITIAL WOUND SURGERY 285

4

13

EiGUEE 44.—Burforcl technique of traumatic thoracotoray. Closure without perieostal

sutures. A. Lambotte rib clamp in place, approximating ribs. B. Closure of intercostal

bundle, with removal of clamp.
286 THORACIC SURGERY

FIGURE 43.—Exposure of large vessel in superior mediastinum and at base of neck by

modified Harken technique. A. Curving anterior incision exposing base of neck, clavicle,

and lateral half of sternum. B. Schematic showing of section of manubrium and lateral

retraction of flap. C. Exposure of major vessels showing superior vena cava (a), left

innominate vein (b), and arch of the aorta (c).

SPECIAL TECHNICAL CONSIDERATIONS

Lavage of the pleural cavity.—After intrathoracic procedures had been

completed, all blood, blood clots, and other detritus -were removed from the

pleural space. As a rule, most of it could be removed by the suction tip. A

certain amount, however, was likely to escape detection by this method, and the

surgeons of the 2d Auxiliary Surgical Group early came to believe that thorough lavage with physiologic salt solution at body temperature was a more

satisfactory plan. From 1,500 to 2,000 cc. of solution were introduced, but the

amount of fluid used was not important. What mattered was that lavage be

continued until the fluid returned clear and it could be assumed that all blood

and blood clots that could be removed had been washed off the pleural lining.

The thoracic surgeons of the 2d Auxiliary Surgical Group had used this

technique in civilian practice, and they believed that when it was employed,

the postoperative effusion was reduced in amount and convalescence was

smoother. The use of gauze sponges, even soaked in physiologic salt solution,
INITIAL WOUND SURGERY 287

to remove blood and blood clots from the delicate pleural surfaces was less satisfactory. The use of ganze, however gently it was employed, was certain to

produce some degree of trauma, add to the amount of postoperative pleural

exudation, and predispose to the formation of pleural adhesions when the lung

and thoracic wall came into apposition.

A few surgeons did not accept this point of view and omitted Iavage after

thoracotomy, on the ground that a small amount of blood left in the pleura

after aspiration would not serve as a pleural irritant. This concept was contrary to the concept prevalent as far back as World War I. Yates (2), in the

history of the U.S. Army Medical Department in that war, cited Delrez' and

Middleton's demonstration that blood in. contact with the serosal membrane in

the chest (and in the joints) is so irritating that it can provoke a seronbrinous

serositis. In Yates' own opinion, any irritation of the pleural serosa provoked

a very rapid serous effusion accompanied by hemothorax, the amount of fluid

thus formed soon exceeding the amount of blood originally present. In view

of Yates' sound approach to the problem of hemothorax, it is difficult to understand his further statement that Iavage of the pleural cavity was a temptation

to be resisted, as healing after it was poor. Very few of the thoracic surgeons

in the Mediterranean theater shared this point of view.1

Nerve block.—While a few thoracic surgeons advocated and practiced

crushing of the phrenic nerve at thoracotomy, to prevent postoperative pain,

the majority believed that this was a certain way to induce paresthesis and

anesthesia, which could be considerably more troublesome than pain.

As their experience increased, however, thoracic surgeons routinely performed intercostal nerve block at operation, going at least two nerves above

and two below- the site of injury. The decrease, or complete elimination, of

pain after operation permitted the patient to breathe deeply and cough freely,

and this prophylactic measure prevented many postoperative complications.

A few surgeons preferred to perform intercostal nerve block by the paravertebral technique.

Manual reexpansion of the lung.—Frequently, while the anesthesiologist

was using positive pressure to expand the lung after intrathoracic surgery

had been concluded (p. 264), it was observed that the lateral portion of the

lower lobe did not expand as readily as the remainder of the lung. When the

patient was lying on his side, partial collapse of the lung allowed a foldingover of this portion onto the diaphragmatic surface of the lower lobe. When

the infolded portion was pulled out and unfolded manually, aeration promptly

became satisfactory. The temporary manual blocking of an upper lobe bronchus, for example, sometimes allowed most satisfactory expansion of a lower

lobe that was slow to expand.

iAs a matter of historical record, mention should be made of the animal experiments, on dogs

and goats, carried out at the University of Chicago, to determine the effect on blood plasma proteins

of filling the pleural space with plasma after loss of varying amounts of lung. The experiments were

carried out by Adams and Thornton, whose final report was made to the Committee on Medical Research. Office of Scientific Research and Development, 2S Sept. 194:1 (2).
288 THORACIC SURGERY

Drainage.—In the early months of fighting in the Mediterranean theater,

drainage was instituted routinely in lacerations of the lung, abrasions of the

parietal pleura, or contamination of the pleural cavity. This was in line with

the established medicomilitary policy that all thoracic wounds should be

drained intercostally. An intercostal tube, however, seldom functioned more

than 48 hours, and if there was fluid in the chest, aspiration then had to be

employed. As the war progressed, the policy of routine drainage was replaced

by the use or omission of drains according to the indications of the individual

case. The decision depended not only upon the type of wound but also upon

the location of the hospital, the adequacy of nursing care in it, and the surgeon's personal experience in chest surgery. If there was any question of

pulmonary lacerations or pleural soiling, drainage was always instituted.

If drainage was omitted, great pains were taken to secure complete reexpansion of the lung at the time of closure; apposition of the lung with the

thoracic cage was of paramount importance. The following technique was

usually employed:

As pleural closure was begun, the anesthesiologist gently increased the

intrabronchial pressure to between +5 and +10 cm. H20. A No. 22 F.

catheter, with at least two openings in the tip, was inserted through an opening between the sutures and was so placed as to lie in the uppermost portion of

the chest. An air vent had previously been made in the catheter near the

proximal end, to prevent undue suction which might damage the lung. Most

thoracic surgeons did not consider it necessary to use a suction machine attached

to the catheter. Attachment of the catheter to a tube with its end in a basin

under water allowed all the air to bubble out. The catheter could thus be

removed, and the sutures in the chest wall at the site of insertion of the catheter

coidd be quickly tied.

By the time pleural closure was completed, the anesthesiologist had increased the intrabronchial pressure to between +15 and +20 cm. H20. At the

same time, the degree of suction was increased by digital occlusion of the hole

in the catheter. The positive pressure created by the anesthesiologist and the

negative pressure created by suction on the catheter usually resulted in good

expansion, and when the sutures in the muscle layer were tied, the chest became

airtight. After these sutures had been tied, a suture was placed around the

catheter by the assistant, and it was slowly withdrawn. Then this suture was

tied.

If drainage was to be employed, these precautions were not necessary,

since any residual air or fluid would be expelled through the drains. It was a

wise precaution, however, for the anesthesiologist to expand the lung at least

once just before the wound was closed, to be certain that expansion was possible.

When drainage was considered necessary, it was preferably accomplished

with two outlets (fig. 46). The first outlet was either a large rubber catheter

(No. 28 or No. 30 F.), with two openings cut on each side, or standard issue

red rubber tubing, 14 inch in diameter, with a %6-inch wall (Catalog No.

3878000). The end was beveled, and three or four holes were cut in the distal
INITIAL WOUND SURGERY 289

2y2 inches. A drainage tube of this size allowed for the escape of thick, bloody

fluid. The second drainage tube, a smaller catheter, preferably of the mushroom type, was placed anteriorly in the second intercostal space to allow the

escape of trapped air.

The lower catheter was not placed any farther posteriorly than the posterior axillary line or more dependency than the ninth intercostal space. Drainage through the seventh or eighth intercostal space was usually practical, since

the absolute dependency essential for drainage in empyema was not necessary

as a postoperative measure in an uninfected wound.

FIGURE 46.—Sites of drainage and techniques of placement of intercostal drainage

tubes. External portion of tubes connected to

water-seal bottles. A. Small de Pezzer catheter, with end cut out, in second interspace.

B. Tube tacked to parietal pleura. 0. Diaphragm. D. Fenestrated rubber tubing inserted into pleural cavity through eighth

interspace in posterior axillary line.

The lower catheter was inserted throuo-h a small stab incision made at right

angles through the selected intercostal space after the skin had been drawn

sharply upward. The distal 2y2 inches of the tube were pulled into the pleural

cavity before the skin was released. With this maneuver, the intrapleural portion of the tube tended to lie slightly angulated and upward. When the tube

was removed later, there was no opportunity for air to enter. In persons with a

thin chest wall, the use of a loose stitch, to be tied when the tube was removed,

prevented ingress of air.

After the tube had been introduced, it was pushed into contact with the

parietal pleura. The tip of the beveled portion was then tacked down with a

fine suture. If this was not convenient, the catheter could be held in place by

looping a suture over it and tying the suture over a small gauze bolster outside

of the skin. Whatever technique was used, the object was to make certain that

the intrathoracic portion of the tube lay flat and unkinkecl along the parietal

pleura.
290 THORACIC SURGERY

The smaller drainage tube, which was placed in an upper anterior intercostal space, served as an air vent. It was thought that reexpansion was more

rapid and more certain when it was used.

If penicillin had been instilled into the chest, the posterior drain was

clamped off for from 6 to 8 hours. Water-seal drainage w~as employed.

Wangensteen suction was occasionally used to help remove the fluid and hasten

reexpansion of the lung.

CATHETER SUCTION AND BRONCHOSCOPY IMMEDIATELY

AFTER OPERATION

Though the bronchial tree was kept as dry as possible by the anesthesiologist, by suction during operation, aspiration was repeated before and during

removal of the endotracheal tube. By this time, the patient was usually beginning to react and was likely to cough, from the tracheal stimulation caused

by the manipulations. He thus aided in the removal of material beyond the

reach of the catheter.

Whether bronchoscopy was necessary routinely at the conclusion of operation remained a matter of dispute until the end of the war:

Those who advocated routine bronchoscopy doubted that even repeated

tracheal aspiration through a catheter passed through the endotracheal tube

would completely clear the airway of blood and mucus. They regarded catheter

aspiration as a blind procedure at best, in which it was impossible to be certain

that both main stem bronchi had been adequately aspirated. They pointed out

that at times it was difficult to pass a catheter into the left main bronchus, so

that large amounts of material were frequently brought up through the bronchoscope after apparently satisfactory catheter aspiration (p. 291). They

considered bronchoscopy as particularly necessary if there had been gross blood

or clots in the tracheobronchial tree during operation.

Opponents of routine bronchoscopy took the position that when a competent anesthesiologist thought that he had cleared the air passages by catheter

suction, no significant amount of blood or other material w

Tas likely to be

brought up by bronchoscopy. This group of chest surgeons preferred to reserve

this procedure for patients with excessive tracheobronchial bleeding and for

the few cases in which resistance offered to pulmonary reexpansion raised

doubts concerning the patency of the bronchi.

Both groups, of course, advocated immediate bronchoscopy if the stomach

had not been properly emptied before operation and the patient vomited. As

experience was gained in treating war casualties, it was seldom indeed that a

patient was placed on the operating table without prior evacuation of the

stomach with a Levin tube.

The persistence of audible moisture through the Magill tube or the failure

of complete and prompt pulmonary reexpansion after catheter aspiration was

also a positive indication for bronchoscopy.
INITIAL WOUND SURGERY 291

One objection advanced to routine bronehoscopy was that it required

prolongation of the operation and deepening- of the anesthetic level. The

advocates of the procedure claimed that this argument was not valid because

an alert anesthesiologist could so gage the depth of anesthesia that it need not

be increased. It was necessary that the jaws be kept separated until the endotracheal tube was removed, and only 2 or 3 minutes were needed from that

point to the completion of aspiration by bronehoscopy. Furthermore, deep

anesthesia was not required or desirable for this procedure. The patient was

kept sufficiently relaxed to permit easy introduction of the bronchoscope, and

yet near enough consciousness to be stimulated by its passage, so that he would

begin to cough.

If the position of the patient on the table permitted, bronehoscopy could be

carried out while the wound was being closed or other wounds were being

debrided.

There was one risk attached to bronehoscopy in this inbetween stage of

anesthesia, the so-called vagovagal reflex, which was practically always associated with hypoxia. It was a general practice in civilian surgery to administer

atropine (gr. 1/100 or 1/75) just before bronehoscopy was undertaken because

this drug effectively blocks this reflex. This was not the routine practice in

the early days of the Mediterranean theater, but after two deaths from this

cause (p. 266), the policy was promptly instituted and became routine in all

hospitals of the theater. These two deaths, the only ones in 436 patients in the

2d Auxiliary Surgical Group experience treated by bronehoscopy immediately

after operation, represented a negligible risk, which might possibly have been

eliminated by the use of atropine. Against these fatalities were the many

deaths from postoperative complications probably prevented by bronehoscopy.

Failure of catheter suction was a factor of supreme importance in several

cases in which recovery was complicated, and it was known to be directly responsible for atleast one death:

Case 1.—A 41-year-old staff sergeant, who was somewhat overweight and barrelchested, sustained a large posterior sucking wound of the right chest, with multiple rib

fractures, 13 November 1944 at 0003 hours. Debridement was done at 2100 hours the same

day. The operation was difficult and took 2% hours. The pulse rate gradually increased

during the operation, and there were several periods of cyanosis, which were relieved only

by positive pressure anesthesia. Frequent aspirations through the endotracheal catheter

produced only small amounts of bloody mucus. The patient died on the operating table,

at the end of the operation, while bronehoscopy was being performed. The left stem

bronchus was filled with blood and tenacious fluid, and the left lung was completely

atelectatic. The right stem bronchus was relatively free of fluid.

Comment.—This death could probably have been prevented had the essential pathologic

process been recognized during operation by the surgeon and anesthesiologist and had

bronehoscopy been employed without delay. It is also possible that the blocking of the left

stem bronchus existed before surgery and that preoperative bronehoscopy would have

insured successful anesthesia and surgery. It was consistently more difficult, as this case

shows, to aspirate fluid from the left stem bronchus than from the other bronchi.
292 THORACIC SURGERT

COMPLICATIONS DURING SURGERY

Aspiration of vomitus.—Aspiration of gastric contents during operation

was an uncommon occurrence because vomiting was uncommon: Emptying

of the stomach in the shock tent, as already pointed out, was part of the

preoperative routine, and after it had been completed, the gastric tube was

usually left in situ.

When vomitus was aspirated, immediate action was necessary. Fatal

bronchial obstruction could develop, especially if food particles were present

in the vomitus, and fatal asphyxia could supervene rapidly. Gastric contents

are extremely irritating to the respiratory tract, and their presence excited an

immediate, severe exudative chemical bronchitis and bronchiolitis. Without

their prompt removal, a fulminating pneumonitis developed.

If vomiting occurred before the patient had completely reacted from the

anesthetic, so that his cooperation could not be secured, no time was wasted

in attempts to make him cough. Bronchoscopy was performed immediately

because it permitted visualization of the bronchi and facilitated the removal

of particulate matter. An intravenous injection of atropine was given (gr.

1/100) if no atropine had been given within the hour, to minimize the possibility of vagovagal reflex.

Cardiac standstill.—Cardiac standstill was an infrequent complication

of surgery in World War II. Prolonged hypoxia and shock before surgery,

inadequate preoperative preparation, obstruction of the airway, poor ventilation, and blood loss during surgery were all important in its development. As

experience was gained, casualties were brought to surgery in better condition

and carried through operation in a better physiologic state; cardiac standstill

became extremely uncommon. Probably the most important factor in reducing

the risk of cardiac arrest was careful preoperative preparation (p. 237).

POSTOPERATIVE MANAGEMENT

The military experience amply corroborated the long established view

that nowhere in surgery is proper postoperative care more essential to a good

end result than in chest surgery. The functional level to which the patient

was restored, as well as the number and extent of postoperative complica! ions

and later sequelae with which base surgeons were required to contend was

dependent, in large measure, upon the efficacy of postoperative management.

Immediate Measures

It was routine, in seriously wounded patients and in those in less than

satisfactory condition, to continue transfusion during operation as well as

afterward.

Patients in poor condition at the end of operation were frequently left

on the table for an hour or more while additional blood was administered and

oxygen was given by the intratracheal tube. Boothby-Lovelace-Bulbulian mask,
INITIAL WOUND SURGERY 293

or nasal catheter. It helped to prevent the anoxia that was the greatest hazard

at this time.

There were three principal objectives of immediate postoperative care:

1. To bring the lung into apposition with the chest wall as rapidly as possible. This goal, which was essential to restore normal intrathoracic physiology and prevent empyema, was usually achieved by the use of positive pressure

by the time the wound was closed.

2. To relieve pain, so that the patient would be able to maintain optimum

respi ratory excursions and to cough effectively.

3. To maintain a clear airway, to prevent pulmonary complications from

retention of secretions.

When these requisites were fulfilled bj^ the adoption of special measures

to accomplish them, convalescence was usually as smooth as the intrinsic nature

of the injury permitted.

Relief of pain.—It was imperative that the patient move the chest wall

after operation. His respirations had to be full and deep, and he had to cough

and raise the secretions collected in the tracheobronchial tree. Both of these

acts were attended with pain unless intercostal nerve block had been performed

at operation (p. 246). Then this problem did not arise. If pain recurred,

it could be controlled by repetition of the nerve block, which could be done

without moving the patient from his bed. The effect of a single injection

usually lasted for 2-1 hours or more, and the procedure could be repeated as

often as necessary. When a patient could cough without pain, as lie could

when the intercostal nerves were blocked, he could usually clear his bronchi

satisfactorily by his own efforts.

The effects of nerve block were longer lasting than the effects of morphine

would have been. Morphine was contraindicated in these circumstances. As

pointed out elsewhere (p. 246), it had undesirable effects in thoracic injuries

and even more undesirable consequences after operation.

Clearance of the tracheobronchial tree.—Patients were turned at regular intervals after operation until they could move themselves. Ward attendants periodically urged them to cough, in order to evacuate secretions.

They helped them to sit up, and they supported the chest manually during

attempts to cough. In these ways, the importance of coughing was stressed

and the patients' cooperation was secured.

An increase of bronchopuhnonary secretions was usual immediately after

operation. If there was a preexisting bronchitis, as there frequently was during the late fall and winter, the secretions were likely to be semipurulent or

purulent. If coughing was not effective and fluid was retained, the signs, in

addition to a frequent, ineffectual cough, were rattling respirations, dyspnea,

and sometimes cyanosis, which was a late manifestation. If the bell of a

stethoscope was placed over the patient's mouth and his respirations listened

to, it was easy to recognize the presence of retained tracheobronchial secretions.

When these signs appeared, an intratracheal catheter was introduced at

once, and aspiration was performed at regular intervals. The expulsive effort
294 THORACIC SURGERY

which resulted from its introduction forced small plugs of material out into

the larger bronchi, whence they could be removed by suction.

If catheter suction was not successful, bronchoscopic aspiration was

considered to be necessary. Whenever there was doubt as to the need for

bronchoscopy, the doubt was interpreted as an indication for its use. It was

particularly indicated if the amounts of fluid in the tracheobronchial tree were

excessive and if the patient had only partly reacted from anesthesia and the

muscles of his neck and jaw had become stiff and rigid. Although bronchoscopy

was a more complex technique than catheter suction, it could be performed

without moving the patient from his bed.

Thoracentesis.—As already mentioned, surgeons who did not drain the

pleural space after forward surgery were in the minority, though a few with

wide experience preferred to rely on thoracentesis. When drainage was omitted,

reexpansion of the lung was maintained by the continued use of thoracentesis

as long as 100 cc. or more of fluid or air was obtained by this procedure. Close

postoperative observation was necessary in these cases. Some patients required

no postoperative aspiration, while others required it for several clays or even

a week or more.

The objective of both groups of surgeons—those who used drainage and

those who did not—was to obtain a dry pleura and a reexpanded lung as quickly

as possible. When the techniques of drainage and thoracentesis were employed

correctly, there was no discernible difference in the results accomplished.

Management of drainage tubes.—Drainage tubes were milked at least

once or twice daily to maintain their patency, but major adjustments and irrigations through them were avoided as increasing the risk of infection. The

tubes were removed as soon as they had ceased to function, which was usually

within 48 hours after operation.

It was a strict rule that no patient be evacuated with an intercostal catheter

in situ. It was learned early in the war that water-seal drainage was not only

unsatisfactory but dangerous during evacuation, whether the bottle was connected to a needle or to a catheter.

General Routine of Management

The remainder of the postoperative routine was, in general, much the saure

as after any serious chest operation:

Replacement therapy.—The indications for the administration of blood,

plasma, or both were the same as during resuscitation. Plasma protein and

hematocrit determinations frequently revealed surprisingly low levels, even in

patients who had had large amounts of blood administered before and during

operation. Even in these circumstances, great care was taken not to overload

the cardiovascular system, particularly in blast injuries, in which pulmonary

edema was readily precipitated. It was desirable to keep the fluid intake by all

routes at 2,500 cc. each 24 hours, so that the urinary output would be at least

1,000 cc. during this period. This output was regarded as the essential mini-
INITIAL WOUND SURGERY 295

mum when sulfadiazine was being given. The general policy was to give electrolytes in as small quantities as would be adequate.

Precautions against thrombosis and embolism.—Thrombosis and embolism were not frequent complications in chest wounds, though they could

occur, just as in any other wound. They Avere sometimes present as a complication of associated wounds.

The usual precautions against embolism were employed routinely. The

patient's position was changed frequently. Fowler's position, which tends to

cause some obstruction to the return flow of blood from the extremities, was

not maintained for long periods. Simple exercises for the feet, legs, and thighs

were begun the day after operation if local injuries did not contraindicate

them. The lower extremities were examined daily, with a careful search for

Homans' sign on each examination.

Roentgenologic examinations.—Clinical observations during the postoperative period were supplemented by roentgenograms to demonstrate pulmonary reexpansion and the presence of air and fluid in the chest. Anteroposterior and lateral films were usually taken on the fourth or fifth day after

operation, with the patient in a sitting position. They were taken at other

times as necessary, but always within 48 hours of the time the patient was to be

evacuated.

CHEMOTHERAPY AND PENICILLIN THERAPY

The Sulfonamides

Before penicillin became available in the spring of 1944, sodium sulfadiazine (1 gm. every 4 hours) was given as long as fever persisted and until the

pleural space was free of fluid. To meet these requirements, it usually had

to be given for from 10 to 14 days. Special precautions for the use of the

sulfonamides were detailed in a medical circular issued by the Office of the

Surgeon, Fifth U.S. Army, in January 1944 (3). In this circular, attention

was called to the fact that most patients observed up to this time with anuria

going on to lower nephron nephrosis had received sulfadiazine intravenously

in 5-o-m. doses. Precautions were laid down for its local use (not more than

10 gm.), and for withholding intravenous sodium sulfadiazine therapy until

24 hours after operation, after the patient had reacted from anesthesia and

shock. Then the dose was not to exceed 2.5 gm. every 12 hours. Sulfonamide

therapy was to be promptly discontinued if the 24-hour urinary output was less

than 1,000 cc. or if gross or microscopic hematuria developed. Fluid intake was

to be adequate to insure a minimum urinary output of 1,500 cc.

Since lower nephron nephrosis continued to occur in spite of these precautions, it is doubtful that sulfonamide therapy played any major role in its

development. This theory was borne out by the later studies of the Board for

the Study of the Severely Wounded, which produced no evidence to show that

the sulfonamides played any part in the renal dysfunction (4-).
296 THORACIC SURGERY

Studies on shock in the Mediterranean theater by Maj. (later Lt. Col.)

John D. Stewart, MC, and his associates (5), indicated that sulfonamide levels

in the blood were "erratic and uncertain." These observers warned that this

"unpredictability" should be kept in mind in any appraisal of the presumed

benefits of routine sulfonamide therapy in severely wounded men. Sulfonamide therapy must be controlled by blood determinations, they warned, if both

overdosage and ineffective levels were to be avoided.

The early favorable results achieved in combat-incurred wounds in the

Mediterranean theater led the uncritical to attribute them to chemotherapy.

Accurate statistical data and control studies do not exist, but careful observation of large series of wounds convinced impartial observers that favorable

results were chiefly due to early, adequate debridement, with chemotherapy

of little real influence. As the war progressed, it became increasingly evident

that the local or systemic use of the sulfonamides did not greatly improve the

results accomplished by careful attention to surgical principles.

There was no evidence that the incidence of empyema was significantly

less when either local or systemic sulfonamide therapy was employed, though

established infections were thought to run a shorter course when the necessary

surgery was thus supplemented.

Penicillin

By the spring of 1044, penicillin, which had originally been used only for

selected cases, had become available in sufficient cmantities to be used in all

wounds. The routine was to begin using it as soon as the wounded man reached

the battalion aid or clearing station, in the amount of 20,000 units intramuscularly every 3 hours. If it had been omitted in these installations, it was

begun as soon as the field or evacuation hospital was reached. It was then

continued in this amount after operation, the duration of therapy depending

upon the surgeon's decision. Usually, it was given for from 7 to 10 days. If

contamination was severe or infection was evident, 50,000 units was sometimes

given intravenously in the shock ward and another 25,000 intramuscularly

before routine administration was begun.

A few surgeons advocated instillation of penicillin (25,000 units in 25

cc. of physiologic salt solution) after all aspirations of the chest, but this was

not an accepted practice.

As experience increased, it became evident that penicillin, like the sulfonamides, was not of great value, and perhaps was not even necessary if

debridement had been complete. The opinion also spread that the principal

benefit derived from irrigation of the pleura! cavity before wound closure was

not due to any chemical or antibacterial agent used in the fluid but was due,

instead, to the mechanical cleansing thus achieved.

On the other hand, penicillin was of definite value in controlling infection

when, for any reason, the removal of all devitalized tissue was impractical

or would have resulted in excessive mutilation. Wounds around the shoulder
INITIAL WOUND SURGERY 297

are an illustration. Penicillin was also of very great value in surgery at the

base.

Lack of followup studies makes it impossible to draw any conclusions as

to the absolute and relative effects of these various policies. The case fatality

rate among teams of the 2d Auxiliary Surgical Group for the second half of

1944, after penicillin had come into general use, was considerably lower than

for the first half (25 percent against 34.9 percent) and was still lower in 1945

(20 percent). Penicillin may have played a part in this reduction. It is

more likely, however, that the reduced mortality reflects the increased experience of the surgeons in the theater in the management of thoracic and thoracoabdominal wounds: their greater appreciation of the implications and possible

complications of chest wounds; improvements in anesthesia; and improvements

in preoperative and postoperative care, especially the liberal use of whole

blood.

References

j. Yates, John L.: Wounds of the Chest. In The Medical Department of the United

States Army in the World War. Washington: Government Printing Office, 1927. vol. XI,

pt. 1, pp. 342-442.

2. Adams, W. E., and Thornton, T. F.: The Use of Plasma for Pilling the Pleural Space

After Loss of Varying Amounts of Lung. Thoracic Surgery Report No. 1, Committee on

Medical Research, Office of Seientiüc Research and Development, 28 Sept. 1943.

3. Medical Circular No. 1, Office of the Surgeon, Headquarters, Fifth U.S. Army, 21

Jan. 1944.

4. Medical Department, United States Army. Surgery in World War II. The Physiologic Effects of Wounds. Washington: U.S. Government Printing Office, 1952.

5. Memorandum, Lt. Col. John D. Stewart, MC, to Surgeon, MTOUSA (Thru, CO.,

2d Medical Laboratory and Surgeon, Fifth U.S. Army, APO 464), 2 Jan. 1945, subject:

Observation on the Severely Wounded in Forward Field Hospitals of the Fifth Army, With

Special Reference to Wound Shock.

C5S6811—62 21
CHAPTER XII

Reparative Surgery

Thomas H. Burford, M.D.

GENERAL CONSIDERATIONS

The reparative phase of the management of thoracic wounds was considered to have begun as soon as initial wound surgery had been completed in

a forward hospital and the patient was sufficiently stabilized after it to be

safely transportable to a fixed hospital. A large experience with these wounds

in MTOUSA (Mediterranean (formerly North African) Theater of Operations. U.S. Army), showed that most thoracic casualties could be safely transported to fixed hospitals in the base within a week after initial wound surgery,

regardless of the type of operation that had been done in the forward hospital.

As the war progressed, two policies widened the scope, and increased the

effectiveness, of reparative surgery. One was the deployment of general hospitals in close support of the Fifth U.S. Army as it moved up the Italian

Peninsula. The other was the use of air evacuation, which was first employed

in North Africa. These two policies made it possible to institute reparative

surgery at a time of maximum benefit for both casualty and theater manpower.

The earlier a casualty underwent reparative surgery, the greater were his

chances of prompt recovery and the better the outlook for his return to duty

within the theater holding period.

The reparative phase of wound surgery, which was developed originally

in the Mediterranean theater, furnished another illustration of the intelligent

integration of the administrative and professional functions that, together,

produced effective continuity of medical care. The procedures of reparative

surgery were based on principles designed to prevent or minimize infection

and to assure as rapid anatomic and functional restoration to normal as the

nature of the wound permitted. Progress in the reparative phase of management of chest injuries was not less significant than was the progress achieved

in their initial management,

Mission of Fixed Hospitals and Thoracic Surgery Centers

When policies in the Mediterranean theater were stabilized, casualties with

chest injuries who required more than simple wound closure were usually cared

for in chest centers. The mission of general and station hospitals and of

thoracic surgery centers in base areas has been outlined in detail under those

various headings (p. 97).

299
300 THORACIC SURGERY

Specifically, the procedures of reparative surgery for chest wounds carried

out in fixed hospitals in the base were:

1. Delayed primary closure1of wounds not completely closed at the time

of forward surgery.

•2. The management of hemothorax, including its complications of clotting,

organization, and infection.

3. The management of posttraumatic (hemothoracic) empyema.

i. The performance of pulmonary deeortication for organizing hemothorax or hemothoracic empyema.

.">. The precise localization of intrathoracic foreign bodies, with their

removal on strict indications.

6. The management of complications of thoracoabdominal wounds.

7. The management of other complications related to the chest wound.

Except for delayed primary wound closure, all of these procedures are

discussed in detail in the second volume of the thoracic surgery series.

DELAYED PRIMARY WOUND CLOSURE

The dangers of primary closure of battle-incurred wounds of the chest

were as great as those of primary closure of other wounds. Since there was

no basic difference between soft-tissue wounds elsewhere in the body and

wounds of the chest wall or the soft-tissue component of intrathoracic wounds,

the policies evolved for the management of soft-tissue wounds elsewhere in

the body were entirely applicable to chest wounds and were employed for them.

Indications and contraindications.—As pointed out elsewhere (p. 140).

the entire program of delayed primary wound closure in World War II

reflected a complete departure from the elaborate bacteriologic concepts and

practices by which this technique was employed in World War I. The shift

was from emphasis on the flora of the wound, as demonstrated by microscopic

and cultural methods, to the gross surgical pathology of the wound, as determined by clinical inspection alone. When the program of delayed primary

wound closure was fully developed, the procedure was as follows:

1

In tlio Mediterranean theater, the division of the surgery of combat-incurred wounds into

initial wound surgery, reparative surgery, and reconstructive surgery was conceived by Col. Edward

D. Churchill. MC, Consultant in Surgery, OfTice of the Surgeon, Headquarters, MTOUSA, who also

introduced the term ''delayed primary wound closure" to describe the final step in the closure of

combat-incurred wounds. By the spring of 1944, it had become the general practice, at initial wound

surgery for thoracic wounds as for other soft-tissue wounds, to leave the skin and subcutaneous

tissues open, for later suture in hospitals to the rear. Many surgeons in the theater objected to the

nomenclature, on the ground that to employ the words "delayed" and "primary" in juxtaposition was

a contradiction in both term and concept. The nomenclature, nonetheless, came into general use in

the Mediterranean theater and was adopted by some, though not by all, surgeons in the European

theater. It might he added that many surgeons objected, with equal vigor, to the use of the term

"secondary closure" for suture of the skin and subcutaneous layers of the wound, on the ground that

it implied a previous attempt, which had not been made, to close these layers.
REPARATI VE SURGERY 301

1. A clean -wound, in which there was no evidence of infection and in

which there was no devitalized sloughing tissue, was considered fit for immediate closure. In most hospitals, the condition of the wound was determined

by inspection in the operating room, when the dressings were removed for

the first time. In a few hospitals, as already mentioned, it was the practice,

when the patient was first examined, to elevate the outer dressing and inspect

the wound through the fine-mesh gauze immediately over it. The dressing

was then replaced, and the gauze was removed with the dressing in the operating room.

2. A wound that was indurated or showed any other evidence of infection

was treated for from 24 to 72 hours before closure by dressings soaked in warm

physiologic salt solution.

3. A wound that harbored necrotic tissue or otherwise showed that debridement had been inadequate was treated by redebridement before wound closure,

or, if conditions justified it, closure was delayed for several additional days.

In the early months of the war, it was repeatedly necessary to redebride wounds

in base hospitals because initial debridement had been inadequate or had been

omitted. Failure to debride a wound simply because it was small or had been

made by a high-velocity missile was found to be an invitation both to wound

infection and to pleural infection. Even later in the war when penicillin was

available, a subcutaneous area of tissue destruction out of all proportion to

the size of the wound of entry was invariably found in these wounds, and

many tiin.es, direct extension of the infection to tire pleural space could be

demonstrated.

Timing.—When delayed primary wound closure was first used in the Mediterranean theater, the timelag between wounding and closure was often from

15 to 21 days. This was too long. At the end of this period, scar tissue had

frequently developed, and excision of the wound was necessary to effect satisfactory closure.

As time passed, initial debridement became more effective, and the advantages of earlier wound closure were increasingly appreciated. The timelag

was successively reduced, first to from 7 to 10 days and later to from 5 to 6

days. When closure was accomplished within these time limits, suture approximation was frequently all that was necessary.

Results.—The policy of delayed primary closure of wounds that had been

properly debrided in forward hospitals was attended with generally good results. At the 53d Station Hospital, Bizerte, for instance, there were 125 primary unions in the, first 144 chest injuries treated by this technique. The

average- time from wounding to final closure was 14 clays. While no controlled

studies were carried out, an analysis of roughly comparable groups of injuries

indicated that approximately 7 weeks' time was saved in wound healing when

delayed primary wound closure was employed. The use or omission of local

sulfanilamide therapy did not alter results to any significant degree. There

were 8 failures in 15 closures undertaken on 3 patients (5 closures on each
302 THORACIC SURGERY

patient), which suggested to the surgeons that not more than 3 closures

should be attempted at a single sitting unless there was a complete change of

gloves and instruments.

There were 111 primary unions in 118 wound closures carried out at the

21st General Hospital, Bou Hanifia, Algeria. The explanation of the seven

failures was as follows:

1. Incomplete debridement, with foreign bodies and small bits of neerotic

muscle left in situ to serve as sources of infection.

2. Unrecognized infection present at the time of closure.

3. Undue delay in closing the wound, thus permitting scar tissue to form.

4. Closure under tension, chiefly due to insufficient undermining of the

wound edges before closure. In two or three of these cases, the use of small

split-thickness skin grafts would have been wiser. This was another technique

which often saved weeks of healing time.

As the figures in these 144 cases show, once the indications and contraindications for delayed primary wound closure had been established, primary

healing was the rule. The technique had a number of other advantages:

1. Whatever other reparative procedures were necessary could be carried

out in a solidly healed chest wall, which was found to be an essential protection

against wound infection and subjacent pleural contamination.

2. The use of this technique materially increased the number of reparative

procedures that could be completed within the period of the theater holdingpolicy.

3. This technique permitted turnover of hospital beds at a rate previously

unobtainable, and the patients were in generally better condition when they

were evacuated to a reconditioning center or to the Zone of Interior for

further treatment.

Chemotherapy and antibiotic therapy.—The excellent results secured in

the first cases of delayed primary wound closure led some uncritical observers

to ascribe them to the use of the sulfonamides. The later results were sometimes ascribed, equally uncritically, to the use of penicillin. It would have been

desirable, from a research standpoint, to run control series, in which these

agents were withheld from alternate patients whose wounds were serious

enough to require them, but this was obviously unthinkable. There was no

doubt, however, in the minds of experienced surgeons, that the value of both

chemotherapy and antibiotic therapy was far less than the value of adequate

debridement. In their opinion, it was that procedure that made delayed primary wound closure so successful.

REPLACEMENT THERAPY

In spite of vigorous transfusion therapy in forward areas, the majority of

thoracic casualties arrived in base hospitals witli hematocrit values well below

normal. It was the practice to give daily transfusions of from 500 to 1,000

cc. of blood until a hematocrit value of at least 40 was reached. This often
KEPAEATIVE SURGERY 303

required several transfusions. In one group of 648 casualties, 1,047 transfusions

of 500 cc. each were required, an average of 800 cc. per patient.

If major reparative surgery was performed, the need for whole blood was

greatly increased. The amount required varied with the magnitude of the

procedure. Thoracotomy for the removal of an intrathoracic foreign body

usually required, in the absence of complications, no more than 1,500 cc, including the amounts administered before, during, and after operation. A

difficult, time-consuming thoracotomy usually required at least 2,500 cc, and

as much as 4,000 cc. was necessary in many cases.

REPARATIVE SURGERY AND THE LEARNING CURVE

An evaluation of reparative surgery is made somewhat difficult by the fact,

to which attention has already been called, that in the first months of the war,

conditions were listed as irreversible complications that later were recognized

merely as indications for surgical attack. The recorded incidence of complications at this time was further affected by the tactical situation: Patients who

were safely transportable could not be held in general hospitals for longer

than 3 weeks. For these reasons, the incidence of complications in these first

months of fighting in North Africa seems smaller than it actually was. The

peak incidence of complications that required therapy was during the Sicilian

and the early Italian campaigns. At this time, the incidence was 52 percent,

as shown by an analysis of 870 thoracic wounds collected from seven general

hospitals, four of which at times operated as thoracic centers. By the end of

the war, the incidence had declined to 15 percent,

This highly favorable trend meant that, as the war progressed, more and

more men with chest injuries were making uneventful recoveries from their

wounds. Less and less major surgery was required in fixed hospitals because

of the improved quality of forward surgery. Clarification of the indications

for thoracotomy in forward hospitals (p. 200), improved methods of resuscitation, and the introduction of penicillin all played their part in the decrease of

intrathoracic complications that required surgery in base hospitals. The improvement must, in the main, be credited to the so-called learning curve, already

commented upon, which implied that both forward and base surgeons increased in experience and skill as the war progressed.
CHAPTER XIII

Reconditioning and Rehabilitation

Dwight E. Harken, M.D., B. Noland Carter, M.D., and

Michael E. DeBakey, M.D.

GENERAL CONSIDERATIONS

Policies of hospitalization differ in civilian and military medical practice,

A civilian is hospitalized for only part of the time that he is under medical

treatment or observation. It is the rule rather than the exception for a surgical

patient to be discharged from a civilian hospital early in the postoperative

period to complete his convalescence at home. Moreover, he can return to work

promptly, at least, on a part-time basis, if physical endurance is not a prerequisite.

The military casualty who sustains a wound can be returned to duty

promptly -within the army area, and occasionally within the division area,

if his wound is slight. For psychologic reasons, if for no other reasons, this is

the wisest policy. If his wound is of any consequence, he must remain in some

hospital until he is physically fit for duty or until he is separated from service

after maximum benefits have been obtained from hospitalization. There is no

assignment in the army, either on combat duty or limited service, for a soldier

who can work only part of the time. This state of affairs necessarily prolongs

the period of hospitalization for the wounded soldier.

These generalizations applied to all casualties in World War II. Thoracic

casualties originally suffered under an additional handicap, the generally

pessimistic outlook of the medical officers and others who cared for them.

There was an unfortunate tendency to consider most of them as potential chest

cripples, in the same category as the victims of empyema in World War I.

As long as they were viewed from this standpoint, the results of treatment were

less satisfactory than they should have been, for efforts at reconditioning and

rehabilitation were lacking in vigor and enthusiasm if, indeed, any attempts at

all were made. When it began to be evident that a wiser concept of chest

wounds (p. 198), supplemented by new techniques of resuscitation, anesthesia,

and surgery, was producing prompt and excellent results, a spirit of positive

optimism began to pervade the thoracic services, involving patients as well as

their surgeons and other attendants.

When it was practical, it was an excellent plan to maintain a separate

medical thoracic section in close proximitj' to the surgical section in general

305

653G81T—62 22
306 THORACIC SURGERY

hospitals on the base or in thoracic surgery centers. When bed space was

available and interested internists were willing to assume the responsibility,

the patient could be transferred to the medical section as soon as surgical care

was no longer necessary, usually within 7 or 8 days. Nutritional deficiencies,

anemia, and similar conditions were corrected under the care of the internist,

and psychiatric and other care was provided as necessary.

The exercises to be described shortly were begun as soon as possible after

operation, often within 24 hours. The program of early ambulation and

exercise was correlated with early participation in work details. At the same

time, ambulation was expanded into group exercises and then into hikes of

increasing length. Bicycle exercises in bed were expanded, as soon as possible,

into bicycle rides through the neighboring countryside. A full program of

recreation was planned. The idea was to divorce the patient from his wounding

and his surgical experience as promptly and completely as possible, so that he

would be reconditioned mentally as well as physically for return to duty,

preferably in the oversea theater.

Functional Studies

Facilities for bronchospirometric tests of thoracic casualties were not

provided in the Mediterranean Theater of Operations, U.S. Army, and were not

available in most hospitals in other theaters. Theoretically, these studies would

have been desirable. They are, however, time-consuming, and it is doubtful

that if facilities had been available, the time could have been taken to make

them. They would have provided an objective criterion to indicate when a

patient was ready for military duty, particularly if they had been performed

serially. Most thoracic surgeons believed that clinical evaluation was quite as

satisfactory in determining the activity level or the duty status.

At one chest center, serial fluoroscopic examination proved an efficient and

fairly objective method of determining respiratory function. Examination of

the normal chest showed that the parenchymal markings followed, in a general

way, the ascent and descent of the diaphragm and, to a lesser degree, the upward and outward inspiratory lift of the ribs. The ribs moved in a pattern

characteristically out of phase with the parenchymal markings (bronchial and

vascular).

After injury, if progress was unsatisfactory and the chest became fused,

fluoroscopic examination showed narrowing of the intercostal spaces, poor

excursion of the costal cage, and immobility of the diaphragm, with a resulting

reduction in respiratory efficiency. Even when such gross abnormalities were

not present, pleural adhesions often greatly depressed parenchymal function.

Often the only manifestation of the reduction was that the vascular and

bronchial markings moved in phase with the movements of the costal cage

instead of, as in the normal chest, out of phase with them.
RECONDITIONING AND REHABILITATION :]()"

Personnel

In whatever hospital chest casualties were treated, whether overseas or in

the Zone of Interior, trained and interested personnel were essential to the

success of the reconditioning program. Members of the Army Nurse Corps,

male and female physiotherapists, and trained technicians were responsible for

the constant attention to minute details and for the individual handling which

these patients required. Their attitude was in large measure a reflection of

the importance that medical officers who cared for the patients attached to the

program.

Individual attention was mandatory, particularly after wounding, to assure

the proper frame of mind on the part of the casualty. During wartime, the

normal desire to recover completely and promptly was not always strong in the

wounded soldier. Unless this negativistic tendency was counteracted promptly,

the chest disability could easily become fixed, and the more prolonged the fixation, the more refractory it was to treatment. For this reason, individual

attention by trained and enthusiastic personnel was necessary to institute and

supervise chest exercises from the earliest feasible moment.

Some chest centers made a practice of using as assistants in the program

certain carefully selected chest casualties who had recovered. It was a stimulating and encouraging object lesson for newly admitted patients to see another

patient, with the same wounds they had suffered, looking fit and well and

performing without difficulty the exercises they were being required to undertake.

Whatever the method, it was imperative that some member of the staff of

the unit to which the casualty was admitted or transferred be aware of the

importance of these exercises. It was the responsibility of whoever was in

charge of the program to see that all patients were performing the exercises

and that all were performing them correctly. It was also imperative that

someone stand guard against the patient's fixation on his wound when he began

to suffer from the dyspnea and tachycardia inevitable at the beginning of a

rigorous training program. If specific remedial breathing exercises were not

instituted and continued as indicated, the classical thoracic deformity would

either occur or recur in serious chest wounds, and the casualty would be well

on the way to becoming a chest cripple like his predecessors of World War I.

GENERAL POLICIES

Chest exercises were of two kinds:

1. The basic calisthenic program which eventually became part of the

reconditioning of all wounded patients, regardless of the nature of their

wounds (fig. 47), supplemented, for chest casualties, by special breathing

exercises and exercises for the shoulder girdle.

2. The special exercises necessary to correct chest deformities that had

already occurred.
308 THORACIC SURGERY

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RECONDITIONING AND REHABILITATION 309

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General (Preventive) Exercises

"Whenever it was practical, it was a wise plan to train chest patients in

breathing exercises and in special exercises for the shoulder girdle before

operation. This eliminated the difficulty of instructing them in the required

movements when postoperative discomfort might limit their cooperation.

As a rule, breathing exercises were started as soon after operation as the

patient was oriented. In some chest centers, all patients, in addition to the

special exercises required for their special injuries, practiced breathing exercises for 5 or 10 minutes of every hour during the day and until bedtime.

The nurse and the wardmaster were responsible for seeing that the schedule

was followed.

More vigorous exercises were usually possible by the second or third postoperative da}r

. When this program was enforced, the respiratory excursion

was frequently full and unimpaired by the time the soft-tissue wound was

healed. Whether or not results were entirely satisfactory, the classical chest

deformity was seldom part of the picture.

Corrective Exercises

Corrective chest exercises were designed to undo the sequelae of chest

injuries in which deformity had been permitted to become established. Their

rationale was as follows:

1. At the time of injury (operation), the chest wall becomes painful on

motion, and the patient splints it voluntarily. Normally, both the voluntary

and involuntary breathing mechanisms are symmetrical. When, however, the

wounded side is splinted to avoid discomfort, it is divorced from the respiratory

act. After a short time, the automatic neuromuscular mechanism is interrupted,

and it frequently does not return spontaneously. In many injuries, immobilization that is first of voluntary, and then of neuromuscular, origin is mechanically reinforced and maintained by adhesions that have formed between the

parietal and visceral pleura. The parietes and the lung are sometimes solidly

incai'ceratecl by the dense fibrous cortices.

When the pathologic process has progressed to this point, the classical

chest deformity is likely to be present (appendix A, p. 341). The head is held

laterally toward the injured side. The shoulder on the involved side slides

downward and inward and moves medial to the vertical line from the anterior

superior iliac spine. The chest wall is held in a position of full expiration.

At the same time, the spine assumes a position of scoliosis and the pelvis is

tilted toward the unaffected side.

When a casualty with a chest wound had been permitted to reach the state

described, his condition could be corrected only by special exercises in which

he received personal instruction.

Both in the European Theater of Operations, U.S. Army, and in the Zone

of Interior, great stress was put upon elaborate special respiratory exercises.
RECONDITIONING AND REHABILITATION 311

The programs employed at the chest centers at the 160th General Hospital,

Stowell Park, England, and at Baxter General Hospital, Spokane, Wash., were

highly developed and extremely effective.

DEVELOPMENT OF PROGRAM, MEDITERRANEAN THEATER

In the Mediterranean theater, even in the early days of the fighting, the

importance of deep breathing was emphasized to all patients. Practically all

bed patients were able to participate in breathing exercises led by a corpsman

especially trained in calling out orders.

Intelligent physiotherapy was also employed to great advantage in the

early recovery phase. It was directed primarily toward early restoration of

shoulder motion (fig. 48) and reestablishment of normal posture. It was found,

however, that unless both medical officer and physiotherapist were alert to

the progress of the individual patients, there was a tendency to continue this

type of treatment far beyond the period of actual benefit. This overloaded

the physical therapy department, needlessly prolonged hospitalization, and

had an extremely bad psychologic effect on the soldier himself.

Shoulder girdle exercises were instituted in all patients with wounds or

surgical incisions involving the muscles in this region. Patients without abdominal extension of their injuries also were trained in exercises tensing the

abdominal wall. Flexing the leg and thigh muscles was added to the exercises

after one or two instances of femoral thrombophlebitis had occurred.

With the single exception of those with cardiac wounds, patients who had

had major chest surgery could be safely and comfortably out of bed within 24

hours after operation. Early ambulation had both physiologic and psychologic

advantages. The wasting and atrophy of disuse were avoided. The dangers of

pulmonary emboli were greatly reduced. The nutritional state often improved

dramatically because the appetite improved and food intake increased. Empyema cavities which had remained stationary in size as long as the patients

remained bedridden decreased in size when they became ambulatory.

Chest wounds were peculiarly well adapted to the program of early ambulation. With pain controlled by intercostal nerve block with procaine hydrochloride, the patient had no temptation to fight against movement or to practice protective splinting on the injured side (immobilizing it in total expiration

and relaxing the accessory muscles of respiration).

Ambulatory patients were sent on daily walks, and were encouraged to

participate in recreational activities. Some of them worked about the wards.

In the Mediterranean theater, blow bottles were found of little value, and

no special attempts were made to teach the differential breathing exercises

popular in the European theater. They were not thought necessary when a

proper routine was followed immediately after surgery. In refractory cases,

in which patients were received on the service with the shoulder girdle

frozen, treatment consisted of heat, massage, and active and passive motion

instituted under the direction of physiotherapists.
312 THORACIC SURGERY

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THE PROGRAM IN THE EUROPEAN THEATER1

The reconditioning program employed at the 160th General Hospital chest

center was under the direction of Maj. (later Lt, Col.) Dwight E. Harken,

MC, and Capt. Joseph P. Lynch, MC. It was modified from the voluntary

respiratory exercises which British thoracic surgeons had been employing for

a number of years. The program at this center was chiefly based upon the

routine employed by Mr. A. Tudor Edwards, under whom Major Harken had

received part of his training (p. 115), and his physical therapy staff, particularly Miss Winifred Linton and Miss Jocelyn M. "YV. Eeed (.1).

Rationale of Exercises

These exercises were designed to teach the patient voluntary, unilateral,

segmental, controlled breathing, on the theory that breathing is an activity that

the human race has permitted to become almost entirely automatic, voluntary,

and bilateral. By recapturing the ability to expand the affected side, it was

possible to restore it to the functional level of the unaffected side. Calisthenics

and the breathing exercises usually practiced, in the opinion of British chest

surgeons, simply developed the unaffected side, to the further detriment of

the injured side. They considered it neither practical nor desirable for the

patient to undertake such, activities until the lung on the affected side was fully

expanded and the vital capacity correspondingly increased.

The purpose of these exercises was twofold:

1. To reestablish the lost neuromuscular arc from the motor cortex to the

chest wall and diaphragm. Until this had been accomplished, it was futile

to urge the patient to use the injured side of his chest.

2. To mobilize the chest wall and diaphragm, which were restricted locally

by incarcerating cortices and adhesions. Accomplishment of this objective

ultimately freed the pleura and allowed normal air and vascular exchange

in the lung.

Procedure

As soon as possible after he reached the center, the patient was seen by a

member of the thoracic reconditioning staff. Special records were made of his

weight, chest expansion, function of thoracic cage, chest deformities, general

status, and similar data. These records were used later for comparative

purposes.

The patient was given a mimeographed sheet of instructions, which described the thoracic deformity, stated the principles of its correction, and detailed the manner of performing the specific remedial breathing exercises

(appendix A, p. 341). At the same time, all of these matters were clearly explained to him in the simplest possible words. If he was ambulatory, the

1 The reconditioning program at the IGOth General Hospital chest center is presented as perhaps

the most carefully worked out and supervised in the European theater.
RECONDITIONING AND REHABILITATION 31;")

nature of his deformity was demonstrated to him in the large mirror with

Avhich each ward was provided.

After the patient had been familiarized with his disability and deformity,

he was shown how to lie correctly in bed. The tilted pelvis was returned to

normal position, so that the weight was distributed equally on both buttocks.

The shoulders were squared, and the head was shifted to the midline.

The next undertaking was the restoration of motor cortex control over

the muscles of respiration. As already pointed out, man does not normally

exercise voluntary control over the independent respiratory activity of separate

sides of the chest, much less control particular segments within one hemithorax

or the other. Yet, this was precisely what was necessary for the recovery

of chest casualties, to prevent their becoming permanent chest cripples. The

establishment of voluntary motor control over the injured hemithorax and

its fused, sunken segments was the foundation of success in remedial breathing exercises. Equally important was voluntary motor control over the excursions of the diaphragm, in order to accomplish its remobilization.

The problem was essentially the education of the motor cortex, or, more

properly, the education of the whole neuromuscular mechanism, in order to

achieve voluntary control of areas that are not normally under the voluntary

domain and that in the fused chest had also been dropped from the normal

involuntary sphere.

Restoration of the mobility of the diaphragm was more difficult than

restoration of the mobility of the chest wall, for three reasons:

1. It was impossible for the patient to see the results he was achieving.

2. The costophrenic adhesions, or, more correctly, the parietophrenic

adhesions were often very dense and were slow to yield to the diaphragmatic

pull.

3. The patient sometimes had great difficulty in comprehending the concept

of abdominal breathing and more often than not would move the abdominal

wall in a manner precisely opposite to the proper pattern.

The first step in the patient's reeducation in voluntary breathing was to

make him find, or become aware of, the involved and immobile portion of his

chest,2This was accomplished by having him place his hand over the affected

area, institute gentle pressure, and exaggerate any existing respiratory excursions or initiate them if none were present. It usually required intense concentration for the patient to become conscious of specific areas of his chest.

The manner in which the pressure was delivered was also important.

During the inspiratory effort, the pressure from the hand was just firm enough

to establish an afferent pathway whereby he could become conscious of the area.

During the expiratory phase, the pressure was much firmer, representing an

exasperated substitute for normal. When expiration was deepest, a gentle

extra thrust, sharply released, would give the chest wall a spring or recoil that

initiated the inspiratory phase of the act. Most often, it was this recoil that

Illustrations for these exercises are in the material given to each patient (appendix A, p. 341).
316 THORACIC SURGERY

the patient picked up and continued in his conscious effort to move the lagging

area of the chest wall.

The key to the solution of problems connected with the diaphragm was to

explain to the patient that on inspiration the chest wall increases the volume

of the thoracic cavity, and therefore of the lungs, by opening like bellows, while

the floor of the thoracic cavity (that is, the diaphragm) similarly increases the

thoracic volume by dropping downward like a piston. After many trials, it

was found that the comparison with a piston was the most effective description.

When it was used, the patients quickly realized that the abdominal muscles

must relax and be forced out by the descending piston and that, conversely,

these muscles could force the piston upward into the thoracic cavity if they

were contracted and the abdomen was pushed in. Progress in diaphragmatic

breathing could best be assessed by fiuoroscopic examination at 5-day intervals.

THE PROGRAM IN THE ZONE OF INTERIOR

Development of Program

At the Baxter General Hospital chest center, the program of reconditioning of thoracic casualties was developed to meet a specific need.3 Many patients

were admitted to the hospital who were in good condition after adequate and

appropriate medical and surgical treatment overseas. Some patients, however

were found to have a persistent disability, which took the form of a constant

complaint of inordinate dyspnea upon even moderate exertion. They simply

had to drop out of whatever activity they were engaged in, sit down, and puff.

Physical examination of these patients showed that the side of the chest

involved in the previous injury (or occasionally the previous disease) was

restricted in its movement or fixed in the position of expiration. The ribs wore

in close approximation in the dependent position, and the diaphragm was

elevated. On fiuoroscopic examination, there was little movement of the affected

rib cage or the diaphragm, even during an episode of dyspnea.

The explanation of these findings was that in the course of prolonged bed

rest after wounding (or illness), with voluntary or involuntary limitation of

thoracic motion on the affected side, a number of pathologic changes had

occurred. The muscles of respiration had become markedly atrophic. Fibrous

thickening had developed in the parietal pleura, intrathoracic fascia, and intercostal structures, with considerable fibrous obliteration of the pleural space

The diaphragm on the affected side had become seriously involved in the

process, and as a result, the respiratory muscles motivatino-'the mechanism of

breathing had lost their strength. In addition to this handicap, these muscles

had another burden imposed upon them, that of moving the ribs and the

diaphragm (the bellows of the respiratory apparatus), which were fixed Infibrous adhesions.

■■■ TIi,. rccon.litionins program at the Baxter General Hospital ehest center is presented as perhaps

the n.ost earetully worked out and supervised in the Zone of Interior.
RECONDITIONING AND REHABILITATION 317

Casual inspection of these patients, and even careful study of their roentgenograms, gave no hint of the severity of their disability. That became

apparent only when the severe dyspnea produced by moderate exertion was

observed. Apparently, the increased metabolism caused by exercise resulted

in an accumulation of carbon dioxide in sufficient amounts to activate the

respiratory center. The oxygen levels remained adequate, as indicated by

the absence of cyanosis and the normal coloration of the peripheral circulatingblood.

A number of studies would have been desirable, including determination

of the vital capacity; determination of the oxygen and carbon dioxide blood

levels: selective spirometry of the tracheobronchial tree; and studies of samples

of tidal air for comparison of the relative nitrogen, oxygen, and carbon dioxide

levels of the affected and unaffected hemithoraces. Facilities for these investigations were not available.

In the absence of this fundamental information, the best plan seemed to be

to devise a program of exercises which, by specific direction toward that end,

would rapidly redevelop the muscles of respiration without imposing a total

physical contribution upon the entire body. It also seemed important that

these exercises be so planned that they could be continued for long periods

without the development of dyspnea, which would discourage further activity;

it had been observed that the breathlessness or sense of breathlessness associated

with the false dyspnea of carbon dioxide accumulation discouraged further

activity and thus helped to maintain the process which was causing it.

The program at Baxter General Hospital was under the general direction

of Maj. Thomas B. Wiper, MC, assisted by Map James T. Lang, CAC, Capt.

Leslie T. Wood, Inf., Capt, David Blair McClosky, AC, and T. Sgt, Benolcl

Cook {2). An important collaborator was Captain McClosky, a former concert

singer, who had suffered a loss of respiratory capacity and experienced a sense

of breathlessness after surgical treatment of postpneumonic empyema.

A letter of greeting from the commanding officer of Baxter General Hospital to all thoracic casualties (appendix B, p. 345) made them cognizant at

once of the importance attached to the exercise program.

Indications for Exercises

The exercises that were part of the reconditioning program for chest

casualties were taught to the following groups of patients:

1. Those with dyspnea on exertion, as just described.

2. Those with stabilized empyema in which there was delay in reexpansion

of the lung after adequate drainage.

3. Those with stabilized lung abscesses in which there was delayed obliteration of the space left after adequate drainage.

4. Those with small residual heinothoraces in which the space did not

provide sufficient room for surgical decortication.
318 THORACIC SURGERY

5. Those with structural deformities of the thoracic cage resulting- from

multiple rib fractures caused by crushing- injuries.

6. Those to be submitted to elective thoracotomy, so that they would be

prepared to begin these remedial exercises immediately after recovery from

anesthesia. This group of patients was transferred to the convalescent ward

as soon as possible, so that they might take part in the additional exercises

instituted for all casualties who had advanced to this status.

Routine of Exercises

The exercises employed at this chest center were devised to strengthen

all the muscles of respiration and to mobilize the ribs, lung, adherent pleura!

surfaces, and diaphragm. Mobilization of these lixed structures was accomplished by the pull of selective muscle groups upon the rib cage and by

exercises which utilized the principle of Yalsalva"s maneuver.

The exercises were graded and phased as follows:

1. For the first 8 to 10 days after operation, exercises consisted of deep

breathing; active movements of abduction, adduction, flexion, and extension

of the arms: and active abduction and adduction of the scapula (figs. 49 and

50). The physiotherapist, in addition to supervising these active movements

of the respiratory muscles and muscles of the shoulder girdle, which were

designed to prevent atrophy and fixation, also worked to improve the posture

of tlw patient in bed. Selected patients also received diathermy, radiant heat,

and massage according to their special needs.

It was found at this center that the immediate postoperative reconditioning of chest casualties could be most satisfactorily conducted under the direction of female physiotherapists who had been indoctrinated with the basic

philosophy of the reconditioning program and who understood the anatomy

of the muscles which participate in the respiratory act.

At the end of this period, the patients were rcclassified and moved to a

prcconvalescent ward. Here, they came under the direction of male instructors

in the physical reconditioning section.

2. Between the 10th and 15th days after operation, 11 basic thoracic

exercises were conducted twice daily, for 15 minutes at a time (figs. 51-01).

3. Between the 15th and 20th days after operation, the exercise periods

were increased to 20 minutes twice daily, and each, exercise was repeated S times.

4. Between the 20th and 23d clays after operation, the exercises were

conducted for 25 minutes twice daily and "Tarzan" exercises were added to

the list (fig. 02).

5. Between the 23d and 20th days after operation, the exercises listed were

conducted for 30 minutes twice daily.

6. Between the 20th and 30th days after operation, the exercises were

carried out for 40 minutes twice daily, and supplementary exercises (figs. 03,

04, and 05) were added for warmup purposes. Other exercises, including

wooclchopping and swimming, were added at the discretion of the instructor!

All exercises were carried out with emphasis on deep breathing.
RECONDITIONING AND REHABILITATION :-U0

I

FIGT;KE 49.—Individually prescribed exercises for early postoperative period,

Baxter General Hospital chest center (2).

ISAM! Si

' -IIP

*, "*-*'.

/ I-

'A ;i

*

in. it.n

FIGIRI: r>0.—Mild thoracic exercises 7-14 days after operation (2).
320 THORACIC SURGEU*

Ü^gr*,, iffszzL "'• 'N*

I • BREAKING CHAINS

POSITION

:

,|WS Body erect, feet comfortably

spread.

Elbows extended horizontally at

side.

Hends loosely clenched, palms

down in -front of shoulders.

Tense hands and arms . . . inhale vigorously.

MOVEMENT

1. Pull elbows back hard as though trying to

break a chain held between hands.

INHALING DEEPLY AND RAISING

DIAPHRAGM

2. Relax to starting position and exhale vigoi

ousiy.

3. Repeat with S to 10 repetitions of 4 count

Cadence—slow

Draw arms and shoulders backwards . . .

elevate the chest.

JUiiiiii i Recover fa starting position and exhale

vigorously , . . puff!

PURPOSE

1. Increases anterior posterior diameter of chest.

2. Increases.transverse diameter of chest.

3. Produces rotation and elevation of the ribs.

4. Expands the lungs.

5. Produces movement of pleura! surfaces.

mm» it

FIGURE 51.-—Basic thoracic exercises. 1. Breaking chains (2).
RECONDITIONING AND REHABILITATION 321

ELBOW EXERCISE Ü

laiw

POSITION

Arms at sides, bent at the elbows with forearms and palms

in supinafing position, fingers

loosely clenched.

The shoulders and neck are relaxed.

To begin the exercise, the

weight of the body is

slumped on one foot.

WEIGHT FORWARD

il!^ h&iflift''.'I

■■mmm

Eibowrs relaxed and af fhe sides . .

elevate cfiesf.

inhale deeply . .

r

fll

PURPOSE

!. Increases transverse diameter of

chest.

2. Produces rotation and elevation

of fhe ribs.

3. Expends the lungs.

4. Produces movement of pleura!

surfaces.

5. Mobilizes and strengthens shoulder muscles.

*jg$0m$$k3W&&&&^

Neck and shoulder muscles, relaxed . . .

diaphragm drawn in . . . ribs elevafed.

FIGURE 52.-—Basic thoracic exercises. 2. Elbow exercise (2).
322 THORACIC SURGERY

ARM EXERCISE J{

MOVEMENT

Inhale and reach for fhc sky . . tense hands and arms

and force downward.

POSITION

Body erect,.-feet comfortably spread.

Arms m front, palms restinc on thighs.

As patient inhales, the arms slowly move forward and up over the head. (As

the arms reach the overhead'position, the breath should be fully drawn In art6

the Sower abdominal muscles fairly flat.)

While the breath is being held, simultaneously, the hands are clenched, elbows

bent, and the arms are drawn down tightly against the sides of the chest.

The shoulders, in the meantime, arc pressed down and slightly back.

At the same time the muscles of the upper abdominal area are forcibly drawn in.

v. The patient retains the air as long as possible while doing a series of pumping

IiNriALC movements with the shoulders and arms.

(This can be supplemented by rotating arms and shoulders forward and backward, alternately elevating and compressing the chest.!

Note; Bo '-UTG while drawing the arm:, down that they arc neither front nor

back, hut directly at the sides. /

PURPOSE

!. Increases anterior posterior diameter ol ch

2. Increases transfer e diameter of chest.

3. Produces rotation ör,6 elevation of the ribs

4. Expands tne tunas

C. Produces movemo it o!' pleu'"al surfaces.

6. Mobilizes end sire iqthens shouJdos muscles. EXHALE

FiGL'iiE 153.—Basic thoracic exercises. 3. Arm exercise (2).
RECONDITIONING AND REHABILITATION 09c

1 • RIB STRETCHER

POSITION

8ody erect, feet comfortably spread.

MOVEMENT

1. During deep Inhalation, the arm OH THE INJURED SiDE of the body is raised slowly sideward and upward with the palm of the hand out. Head and eyes follow the hand upward.

2. While raising the arm to the outward position, rise up on the toes of foot on normal side.

IT IS IMPORTANT that hip on injured side be kept tn line with the foot on ihai side.

3. When the arm has reached the ultimate position and breath is in, this position h held with

arm and fingers straining upward and outward, simultaneously, the injured side of the chest

ts made to follow the hand.

PURPOSE

1. Mobilizes ribs and intercostal substance on side of injury.

2. Increases intercostal interval by rotation and elevation of ribs.

3. Increases chest capacity of damaged hemithorax.

4. Mobilizes and strengthens shoulder muscles.

5. Produces movement of adherent pleura.

"Wafch ih& chest iaHow ihn hcmti!'

STRETCH | N

INHALE

FIGURE 54.—Basic thoracic exercises. 4. Rib stretcher (2).
m THORACIC «l'RO-KRY

^^^mi

r

—.3^. ...»

Weight on forward foot . . . inhale . . . let i

the elbows ojif.

MOVEMENT

1. INHALE DEEPLY, at the same time rock backward from original

position to an erect position, simultaneously the muscles of the lower

region of the abdomen are drawn up and the elbows and hands arcmoved directly out from the sides, putting tension upon the ImaglINHALE nary string pulling the ribs outward.

2. The patient then EXHALES VIGOROUSLY and recovers to starting

position.

3. Patient must imagine that attached to bis elbows is a string which In

turn is attached to the ribs.

Note: It is important that the shoulders do not rise with

this exercise, nor should there be undue tension of

the neck muscles.

EXHALE

FIGURE ~>i.—Continued
BECOXDITIOXTXU AND REHABILITATION ,'yj.a

. . ... •. -•" •; <&* '

__ .'"'Z^'U*'^ iSlwM. A ..ta

[

«siai

This is a slight variation of exercise No. 4 but is much more vigorous.

• AGAINST THE WALL £»

POSITION

Body erect, <eet comfortably spread.

Hand or« normal side against the wall at an even weight with shoulder.

Foot or, normal side about 18 inches from the wall.

MOVEMENT

1. Initial movement is same as in Exercise No. 4.

2, The hand on the wall presses against the wall as the arm rises and as the breath cc

Counter pressure (toward the wall) is applied with the leg on the injured side.

Note: This motion will tend to take all the weight off the foot nearest the wall.

PURPOSE

1. Mobilizes ribs and intercostal substance on side of injury.

2. Increases intercostal interval by rotation and elevation of ribs.

3. Increases chest capacity of damaged hernithorax.

4. Mobilizes and strengthens shoulder muscles.

5. Produces movement of adherent pleura.

EIGUEE 55.—Basic thoracic exercises. 5. Against the-wall (2).
326 THORACIC SURGERY

ii • CLASPED HANDS

POSITION

Body erect, feet comfortably

spread.

Hands clasped.

J Elbow of arm an normal side

against the side of lower

rib.

ELBOW PRESSURE

®ÄP

FSbow against normal side . . .

pressure of opposite hand

against hand on normal side.

MOVEMENT

i. As a full breath Is taken, pressure is made by the elbow against the ribs on the healthy side.

2. The shoulder of the affected side Is bent toward the front and the opposite shoulder.

3. Pressure of breath should be felt in fhe back and sides of affected ribs. Concentration must

be made there and assisting pressure applied.

Note: It Is important to keep both feet firmly on floor, knees straight and hips in fixed

position to avoid rotation of lower extremities. /T5

PURPOSE -

1. Mobilizes ribs and intercostal substance on side of injury.

2. Increases Intercostal Interval by rotation and elevation of ribs.

3. Increases chest capacity of damaged hemifhorax.

4. Mobilizes and strengthens shoulder muscles.

5. Produces movement of adherent pleura. SIDE TWIST

Start with hand comfortably in front . . . twisting injured side and

shoulder fa ihe opposite side.

yimmmsfffimmm*?

'*mmmmmmmmm»mmmm

FIGUKE 56.—Basic thoracic exercises. 6. Clasped hands (2).
RECONDITIONING AND REHABILITATION 327

HAND ON 7

CHEST

POSITION

Body erect, feet comfortably

spread.

Hands interlocked, palm of the

hand on the normal side of

fhe chest pressed against the

side of the lower ribs.

Elbow of the affected side

should be held slightly away

from the chest.

Cfasp ftauds, press

agöifisf normol side.

:iffiü3jjv::

Ills'

W'

MOVEMENT

!. Inhale deeply, apply

more pressure \o the

hands, place the foot

on the injured side

one full step directly

forward, at fhe same

time twisting shoulder

forward and toward

the opposite side.

2. EXHALE VIGOROUSLY an6 relax to

starting position.

Inhale . . . step forward . . . twist injured side forward and upward.

PURPOSE

L Mobilizes ribs and intercostal substance on side of injury.

2, increases intercostal interval by rotation and elevation of ribs.

3, Increases chest capacity of damaged homilhorax.

4. Mobilizes and strengthens shoulder muscles,

5. Produces movement of adherent .pleura.

FiGUKE 57.—Basic thoracic exercises. 7. Hand on chest (2).
?>-2H THORACIC SCKOERY

tt**

mm

Inhale from crouch position . . . rock on

POSITION

Feet well spread, hands on knee

Bodv In football crouch.

««yv&fr.

HAND ON KNEE

INHALE

MOVEMENT

!. Inhale deeply, press hands against knees and rock forward on the balls of the feet.

2, Flatten the stomach

posterior portion of

3. Lower head and neck

enure exercise is done

A. Exhale and

PURPOSE

relax TO

muscles and concentrate the breath enfireh

the lungs and upper back.

and strive to hump the back as much as pcssi;

in one movement,

starting position.

To force the air into the posterior portions of the lung by humping the back and tensing the abdominal muscles. ON TCES

FIGVKF. öS.—Basic thoracic exercises. 8. Hand on knee (2).
RECONDITIONING AND REHABILITATION 329

HAND ON FOOT !>

Stretch out and up . . . fill f/ie lungs . . . bob to

the left foot and then to the right . . . while

holding breath.

*%

POSITION

Body erect, feet in

side-straddle.

4

mmm ;-j$

FIGURE 59.—Basic thoracic exercises. 9. Hand on foot (2).

653681v—G2-
330 THORACIC SURGERY

Infra/e vigorously . . . keep chest expanded . . . then inhale and exhale slowly

using the diaphragm only.

FULL CHEST 10 POSITION

Body erect, feet

comfort a bly

spread. MOVEMENT

f. Inhale deeply.

2. Expand chest as far as possible.

3- Exhale ai first slowly and then more rapidly as technique for control of the diaphragm and

abdominal muscles is learned.

Note: It is important to keep the chest expanded and the ribs raised throughout this

exercise. Avoid letting chest drop as In normal breathing.

PURPOSE

1. Increases anterior, posterior and transverse diameter of the chest.

2. Strengthens abdominal and diaphragmatic muscles.

3. Particularly useful in mobilizing an elevated, adherent diaphragm, previously fixed to chest wall by disease or injury.

DIAPHRAGM BREATHING

DEPRESS AND RELAX

FIGURE 60.—Basic thoracic exercises. 10. Full chest (2).
RECONDITIONING AND REHABILITATION 331

1 I • DISAPPEARING STOMACH

• :

- r:

INHALE

POSITION

Body erect, feet comfortably spread.

DIAPHRAGM DRAWN IN

AND OUT ALTERNATELY

MOVEMENT

1. Inhale deeply raising arms forward to the overhead position,

2. Exhale vigorously at the same time lowering arms forward

to starling position. Bend body forward from waist, completely deflating lungs.

3. Close valve in throat, resume erect position at the same time

drawing diaphragm in as far as possible.

4. Alternately draw in and relax diaphragm. This exercise

causes great action in abdominal and diaphragmatic sections.

PURPOSE

1. Strengthens abdominal and diaphragmatic musculature.

2. Mobilizes adherent diaphragm,

3. Produces increased thoracic space by elevation and rotation of ribs.

4. Strengthens all respiratory muscles.

5. Mobilizes and strengthens shoulder muscles.

Stimulates normal func-

\ t'mn of the diaphragm . .

\ increases chest capacity.

FIGURE 61.—Basic thoracic exercises. 11. Disappearing stomach (2).
00,1 .1.1-' THORACIC SURGERY

^

>

\

VJ - . - .. :

I *»'

"3

A.-."*

IS '—.—_.. TARZAN 12 G

POSITION

Body erect, feet slightly

spread.

INHALE EXHALE

MOVEMENT

1. Inhale deeply, relax neck muscles, allow mouth to open.

2. With forceful use of diaphragm, yell on the vowel "A" keeping the chest raised, but using

only a violent lift of the muscles of the upper abdominal area to give the sound its impetus.

PURPOSE

!. Strengthens diaphragm.

2. Mobilizes adherent diaphragm.

3. Produces Increased thoracic space.

4. Teaches controlled respiration.

FicuitK 02.—Basic thoracic exercises. 12. Tarzan exercise (.2).
RECONDITIONING AND REHABILITATION 6-JO

SUPPLEMENTARY EXERCISES

i«*iW* ¥iSft%*1

HIGH JUMPER

POSITION

Feet in side straddle position, knees well bent.

Body In crouched position.

Arms extended, palms up.

MOVEMENT

}. Inhale deeply, extend body to erect position at the same lime extend arms well overhead.

2. Exhale and forcefully flex arms to position parallel with shoulders.

3. Inhale deeply and assume completed position of step No. One.

4. Repeat step No. Two.

5. Repeat stop No. One.

6.. Exhale vigorously and relax to starting position.

PURPOSE

!. Strengthens and mobilizes shoulder muscles.

2. Increases chest capacity by rotation and elevation of ribs.

3. Forcibly reduce chest capacity and thereby

4. Produce movement of pleura! surfaces and mobilization of diaphragm.

Fieri**: {>?>.—Supplementary exercises. High jumper {2).
334 THORACIC SURGERY

\

•SHOULDER SWiNG

POSITION

Feet side straddle, knees straight.

Hips in a fixed position.

Body bent forward ai waist, arms raised sideward.

MOVEMENT

1. Swing left arm and shoulder vigorously as

far to the right as possible.

2. Alternately swing right arm and shoulder

to the left in like manner.

Two movements with each arm constitute

one repetition.

Note: St is important to keep knees and

hips In fixed position to create a

twisting motion of the thoracic

cage as well as to wärm up the

shoulder and arm muscles.

PURPOSE

1. Strengthens and mobilizes shoulder muscles.

2. Mobilizes ribs by elevation an6 rotation

pull exerted by shoulder muscles.

POSITION

Erect, ^ee^ together.

Arms sideward, palms up.

MOVEMENT

1. Inhale, raise left leg forward with knee

straight until foot is approximately the

height of the shoulder, and at the same

time swing arms forward, touching foot

with hands. The right knee may be somewhat bent. During this kicking movement

exhale vigorously.

2. Inhale and recover to starting position.

3. Repeat count one with right foot.

A. Recover to starting position.

PURPOSE

1. To Increase chest capacity by mobilizing

ribs.

2. To mobilize diaphragm by compression

from increased Infra abdominal pressure.

. FRONT KICK

W

FIGURE 64.—Supplementary exercises. Shoulder swing (2).
RECONDITIONING AND REHABILITATION 335

Hold ffte breath , . . bend away dov/n . . , bob vigorously.

INHALE 4 BOBBING MOVEMENTS TO EACH SIDE

MOVEMENT

1. Inhale deeply, raise arms forward fo overhead position and draw In diaphragm.

2. Bend at the waist in a bobbing movement and alternately touch the left side of the [eft foot

with fingers of the right hand four successive times,

3. Reverse and touch right side of right foot with the right hand four successive times.

This movement is repeated until patient is forced to expel the air.

PURPOSE

1. Valsalva type exercise for mobilization of diaphragm and shoulder girdle muscles, through alternate compression and expansion of the hernithorax.

2. The bobbing action of the body causes a piston-fike action of the diaphragm forcing air

deep into the chest cavity.

FIGURE 65.—Supplementary exercises. Bobbing movements to each side (2).
o o 1> THORACIC SURGERY

For Your Own

Progress Notes

MEASURING UP

FiciriiK (>(>.—Pago used li.v patients 1o record their own progress (2).

7. After the 30th postoperative day, the reconditioning program lasted for

an hour and a half twice a day. The first 45 minutes were devoted to the

12 thoracic exercises and the supplementary warmup exercises. The second

45 minutes were devoted to sports and games and were entirely recreational,

though in the selection of activities those were stressed that would encourage

continued stretching of the thoracic cage.

While the program outlined was the routine generally followed, the

patient's progress from one phase to another depended entirely upon his individual performance, of which he kept his own records (tig. 66). All activities

were conducted in small groups and were closely supervised by physical instructors (fig. 67).

About 45 days after operation, most patients were in suitable condition to be

transferred to the Army Air Forces Reconditioning and Convalescent Regional

Hospital, Fort George Wright, Wash. Here the remedial thoracic exercises

M-ere continued under supervision while the patients participated in the general

physical reconditioning program directed by The Surgeon General.
RECONDITIONING AND REHABILITATION 337

1 mmm

ff«':.

ander propr:

S'jparvh'ior.

$

f\l>

»!

Ji 2i

' ' >*'-.«• ,.

,1 f •?

*t, « * <

FIGUKF, G7.—Group exercises under supervision (:<

cr>:-iG8i'-—02 24
338 THORACIC SURGERY

Results of Program j&

1

-

At the Baxter General Hospital chest center, it was noted that occasional

patients who had made what seemed to be a complete surgical recovery from

posttraumatic or postpneumonic empyema presented manifestations indicative

of reactivation of the inflammatory disease when they began their reconditioning routine. The residual status of the disease had not been revealed by either

physical or roentgenologic examination. The patients had arrived from other

hospitals in apparently good condition, with their wounds well healed and no

physical evidence of disability. When recurrent empyema manifested itself

in this fashion, patients were referred to the surgical ward for operation, after

proper preparation for it.

Another group of patients who had sustained some loss of substance of the

thoracic wall as the result of either initial trauma or the extensive debridement

required by it reacted to the exercise program by herniation of the lung through

the defect. Those patients were also referred to the surgical section, for plastic

reconstruction of the chest wall.

The exercise program thus unwittingly served as a valuable method of

detecting physical fitness and of bringing to light promptly any residual defect

or disability which might require further surgery.

It needed no more than simple clinical observation of the comparative

progress of patients given breathing and other exercises with those not given

them to prove that this program was one of the most valuable additions to the

care of thoracic casualties. Patients not given these exercises complained of

chest pain, dyspnea, and other disabilities, and also presented deformities of

the chest wall. Early ambulation and the early use of these exercises generally

eliminated this sequence. Patients consistently found that their exercise and

activity tolerances increased as their respiratory function improved. It was

exceptional, unless there were complications, that a patient submitted to

thoracotomy for the removal of foreign bodies or for decortication was not able

to participate in all but the most rigorous physical exertion within a month

after operation. Gain in weight and strength and response to therapy for

anemia, as well as the general well-being, always paralleled the increase in

respiratory function.

The condition of thoracic casualties on discharge from the chest center

was generally gratifying. Once it was explained to them, they readily realized

the importance of their cooperation in these exercises in their own immediate

rehabilitation and future health. As a result, these patients, like most other

thoracic casualties of World War II, faced the world well and fit, and not as

chest cripples.

References

1. Reed, J. M. W.: Post-Operative Breathing and Other Exercises. In Pye's Surgical

Handicraft: A Manual of Surgical Manipulations, Minor Surgery, and Other Matters

Connected with the "Work of Surgical Dressers, House Surgeons, and Practitioners, edited

by II. Bailey. Ed. 14. Bristol: John Wright & Sons, Ltd., 1944.
RECONDITIONING AND REHABILITATION 339

2. Thoracic Remedial Exercises as Developed and Presented at Baxter General Hospital, Spokane, Wash. Medical Research and Development, Thomas B. Wiper, Major, MC;

Physical Reconditioning Research and Development, James T. Lang, Major, CAC; Leslie

T. Wood, Captain, Inf.; David B. McClosky, Captain, AC; and Renold Cook, Technical

Sergeant; 1045.
APPENDIX A

Thoracic Surgical Unit for 803d and 15th Hospital Centers

160th General Hospital

INSTRUCTIONS FOR THE PATIENT

In the past, people who have had injuries or diseases of the chest have been left deformed. You have had such an injury. You can look in the mirror and see this deformity.

Your injured side does not move, when breathing, as well as your good side. In severe

cases, the head and neck are shifted to the injured side—the shoulder on that side is lower—

the chest is sunken, there is curvature of the spine, and the hips are tilted. This deformity

of the head, nock, shoulder, chest, spine, and hips, labels a man as a "chest cripple" (fig. 1).

When the chest does not expand, the lung does not move; and when the lung does not

move it becomes diseased.

There is no reason to have "chest cripples" because we now know how to prevent (his

tragedy with SPECIFIC REMEDIAL BREATHING EXERCISES and proper calisthenics.

The use of breathing exercises for 10 minutes in every hour is a small price to pay for

health.

SOLEIER, AVE'YE TRIED TO CONVINCE YOU ; YOU HAVE TO BE CONVINCED

BEFORE YOU'LL TRY; AND YOU HAVE TO TRY IN ORDER TO GET RESULTS.

FOLLOW INSTRUCTIONS AND LOOK AT YOUR CHEST IN THE MIRROR AND

YOV'LL BE CONVINCED.

SOLDIER, IT'S YOUR CHEST, YOUR BODY, YOUR HEALTH, AND YOUR LIFE!

Specific Remedial Breathing Exercises

There are three main types of breathing exercises, (a) lower chest (fig. 2) ; (b) upper

chest (fig. 2) ; and (c) diaphragmatic (fig. 3). You should become so expert with these

that you will be able to breathe with your injured side alone—without moving your normal

side. You will even do better than this before long—you will be able to breathe with the

upper or lower part of the injured side, as you like. This sounds like a circus act, and

certainly you didn't know that a person could train himself to breathe with one or the

other side of his chest—much less part of one side—but you can if you concentrate and

persist.

Do each of the three types of exercises six times with a few seconds' rest between each

group of six. If you do not rest a few seconds, you will get dizzy. Take in as much air as

possible, and force out as much as you can each time. After 6 lower chest, 6 upper chest,

and 6 diaphragmatic exercises, run through them again, and again and AGAIN for 10

minutes. DO THIS EVERY HOUR,

341
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APPENDIX A 343

FIGUBE 2.—Loiver chest. Place your hand flat

on the lower chest wall of your Injured side.

The finger tips should come just to the rib margin. Rest your hand lightly on the surface as

you take in air slowly through your nose (inhale) . Press firmly to help force air out through

the mouth as you exhale. Take in as much air

as possible then push out as much as you can.

CONCENTRATE ON MOVING THE ONE SIDE.

YOUR HAND HELPS LOCALIZE THE AREA

THAT YOU ARE TRYING TO USE. WATCH

YOUR HAND MOVE AND CONCENTRATE AS

THE CHEST PUSHES IT OUT ON INSPIRATION AND AS YOUR HAND PUSHES THE

CHEST IN ON EXPIRATION.

FIGURE 2.—Continued. Upper chest. Same

principle as lower chest exercise but the hand

from the opposite side is used. The fingers fall

just below the collar bone. It is more difficult

to gain upper chest control, but as you can see

in the mirror, this is an especially important

area as it is generally badly sunken.

UPPER CHEST

CALISTHENICS

You will have a period of calisthenics every day, and these are very important too, but

do not confuse your breathing exercises with calisthenics. Your calisthenics will straighten

your spine, set your head straight on your shoulders, put your hips back in line and get you

so that you can raise your arms above your head. Soon you will not look like a human

question mark—or a feeble old man carrying a bucket of lead.

* * *

CONCENTRATE—PERSIST—CARRY YOURSELF STRAIGHT—WATCH YOUR

PROGRESS IN THE MIRROR

IT'S YOUR CHEST—YOUR BODY—YOUR HEALTH—YOUR LIFE—

YOU OUGHT TO CARE

Dwight E. Harken

Major, MC

Consultant in Thoracic Surgery

803d and 15th Hospital Centers
THORACIC SURGERY

BREATHING OUT (EXHALING) WITH THE DIAPHRAGM

BREATHING IN (INHALING) WITH THE DIAPHRAGM

FIGURE 3.—Diaphragmatic. The idea of diaphragmatic breathing is difficult to get over

because you cannot see it work. The diaphragm is the partition between the organs in your

abdomen and chest. This big sheetlike muscular partition is fastened to the lower rib

margins, and when it moves up into the chest—like a piston—it forces air out of the lungs.

If you push- in with your hands on your abdomen and bloio out air through your mouth-, you

are making tlie diaphragm force air up and out of the lungs. When you take in a very deep

breath you must relax the pressure on your belly wall (and let it swell out)—this means

that you are making the piston move downward and sucking in air through the nose. Again,

to make it clearer: push in on the telly and push air out through the mouth—then—breathe

in, through the nose and push the belly out.
APPENDIX B

Army Service Forces

NINTH SERVICE COMMAND

BAXTER GENERAL HOSPITAL

SPOKANE, WASHINGTON

Subject: Thoracic Therapy Exercises

To : The Patients of Baxter General Hospital

Greetings to all patients who have been brought to us by the hazards of war for the

curative measures that may be applied to you. We consider that the opportunity to help

you is a high houor. While you are with us, your welfare in all respects will be our

sacred trust. No skill or facility will be spared to assure that when our efforts in your

behalf have been completed you will leave in the best condition, knowing that nothing

has been omitted which could be done.

To obtain the optimal results, we want you to know that you will have a large part

of the task of restoring yourself to normal health. To accomplish the maximum benefit

in the shortest time, there are two simple rules : namely, to embrace all helpful measures

fully and discard all retarding influences. As in so many of life's activities, we profit

from opportunities in proportion to what we put into them. And so it is in recovery from

wounds or disease, your intelligent cooperation will repay you manyfold. This booklet

deals with reconditioning measures designed for your special type of disability. The

processes set forth have been carefully worked out by experts in the field, are basically

and scientifically sound, and have been proven in thousands of cases to accomplish their

intended purpose.

At Baxter, we have highly skilled specialists selected from the medical profession of

the entire country and assigned here for the purpose of earing for the types of injury

and disease of which yours is one. Associated with them and assisting them in their

work are a host of professional and technical specialists in related fields of action, all

human, like you and me, intensely interested and enthusiastic and nothing makes them

happier than successful progress and recovery of the patients whom they have so earnestly

and conscientiously labored to cure. Their sense of satisfaction and happiness over

successful recovery is scarcely exceeded by the patient's.

(Signed) A. B. ilcKie

Colonel, MC

Commanding

345
INDEX

Abdomen:

examination of, 230

exploration of, through diaphragm, 145

Abdominal breathing, 315

Abdominal exercises, 311

Abdominal findings, 233-234

Abdominal pain, 232

in chest wounds, 233-234

Abdominal tenderness, in chest wounds, 232,

233-234

Abdominal wounds, S3,138,142,143, 220

case fatality rates in, 60, 61

experience of auxiliary surgical groups

with, 130

mangement of—

by thoracic surgeons, 93, 106-107, 129

in evacuation hospitals, 96

nontransportability in , 15

Abradantur, 3

Abrasions of pleura, 288

Abscess formation about detached rib fragments, 139

Absorptive function of alveoli, 247

Ace bandage, 278-279

Acidulated drinks, in hemothorax, 6

Actinomycosis, 175

Acute gastric dilatation, 143, 144, 233, 235,

257, 290

ADAMS, Gapt. ARTHUR J., 83

ADAMS, AV. E., 2S7n

Adaptabilty of auxiliary surgical group

teams, 108

Adhesions in thoracoabdominal wounds,

20S, 209

Adhesive strapping, in crushing injuries, 142

Adjunct therapy, 141, 176-177,192

during operation, 265

in empyema, 151

See also Plasma; Replacement therapy;

Transfusions; etc.

Adjutant General, 69,169

Administration of hospital centers, 133

Administrative considerations, in—

auxiliary surgical group teams, 105-106

auxiliary surgical groups, 102-103

British experience, 31-32

Administration considerations—Continued

convalescent hospitals, 172-173

thoracotomy of necessity, 11

European theater, 113-160

field hospitals, 93, 94-95

Mediterranean theater, 73-111

Zone of Interior, 161-1S1

Administrative Memorandum No. 62, Office

of the Chief Surgeon, ETOUSA, 3 May

1944—133

Advantages, of—

thoracic surgery centers, 137

thoracotomy of necessity, 11

Agincourt, Battle of, 3

Air embolism, 264, 272

Air evacuation, 191, 195, 205-206, 299

from frontlines, 103

in Mediterranean theater, 79

to "united Kingdom from Continent, 132,

135, 137,147

Airlift of blood, from Zone of Interior, 128,

141,257

Air-raid casualties (British), 32, 116, 121

retained foreign bodies in, 42

Air replacement, 144,190,191,195

early British use of, 34

in World War 1,12

Airway, maintenance of patency of, 214

after operation, 293-294

See also Tracheobronchial tree.

Algeria, 105

Algiers, 105

Allied experience, in AArorld AA7ar I, 8-10

Allied medical conference, after World AArar

1,14-10

Alsever's solution, 128, 257

Alveoli, absorptive function of, 247

Ambulance:

administration of plasma in, 255

evacuation by, 7S, 103, 218

Ambulatory casualties, 218

American Association for Thoracic Surgery,

26, 28, 164,181

American Board of Thoracic Surgery, Inc.,

164,1S1

Amphibious landings, 106, 109, 195

i Unless otherwise specified, all entries in this index refer to injuries and diseases of the chest

and their management in World War II.

347
348 THORACIC SURGERY

Anaerobic infection, in World War I, 10, Anoxemia. 191

IG, 23 Anoxia, 233, 239, 242, 245

Analysis, of— after operation, 293

British air-raid casualties, 121 cerebral damage in, 232

British experience, 116 cyanosis, as indication of, 243

surgical results, 74 during anesthesia, 192

Anatomic definition of chest wounds, 59, 66 effects of morphine in, 244

Anatomic distribution of wounds, in battle- in flail chest, 249

field deaths, 06 in sucking wounds, 249

Anatomic incidence of wounds, of heart, 44 in tension pneumothorax, 251

ANDERSON, JMaj. J., 38 with dyspnea. 242

Anemia— Anterior-superior chest wounds, 2S2-2S4

after operation, 300 Anterior thoracotomy, 282

as contraindication to air evacuation, 200 Antibiotic therapy after operation, 295-297

Anesthesia, S3, 125, 144, 107-172, 201-207, in decortication, 20

271. 297, 305 in delayed primary wound closure, 302

after phrenic crushing, 2S7 Antipersonnel bombs. 107

after U.S. Civil War. 7 Antisepsis, after U.S. Civil War, 7

at 160th General Hospital chest center, Anuria, after sulfonamide therapy, 295

149-150 Anzio beachhead, 90,100, 200, 207

at Walter Reed General Hospital chest air evacuation from, 79

center, 178 auxiliary surgical group teams on, 100

development of, between World Wars. equipment on, 87

29, 31 management of casualties on, 70

equipment for, 194, 262 Aorta :

in World War I, 14 cent act of foreign body with, 45

evacuation of stomach before, 257, 292 erosion from, into esophagus, 149

for decortication, 9, 26 Apennines, mule evacuation in, 7S, 218

for lobeetomy, 170 Apex cardiac impulse, 230

for rib-resection drainage of empvema, 150 Apneic technique of controlled respiration,

German facilities for, 37 265

in blast injuries, 145 Apprehension, 259

in evacuation hospitals, in Mediterranean Argonne, 15

theater, 93 ARISTOTLE, 42

in field hospitals, 93 Arm, wounds of, 143, 220-221

in World War I, 13,16 Armies, surgeons of, in ETOUSA, 113

intrathoracic pressure during, 14 Armies :

techniques of, 263-265 Third U.S. Army, 130

training in, in European theater, 103, 121- meeting of Army surgeons of, 119

122,140-147 Fifth U.S. Army, 8, 35, 66, 73, 82, S7, 90,

Anesthesiologists, 118,119 104. 105, 108, 198, 199, 203, 211, 295,

duties of, at operation, 265 299

in European theater, 119 auxiliary surgical group teams in, 108,

on thoracic surgery teams, 100,107 109

postoperative bronchoscopy by, 290-291 case fatality rates in. 8. 61

qualifications of, 201 Consultant in Surgery in. 73

Anesthetic agents, 119, 192, 264 incidence of chest wounds in, 61

supplies of, 84, 202 medical conferences, 83

Anesthetic machines, 127 Seventh U.S. Army, 74. 79, 104, 105n, 129,

for auxiliary surgical group teams, in 137. 199. 211, 257

European theater, 127 auxiliary surgical group teams in, 104,

in Mediterranean theater, SO, 87, S9 108, 109, 130

shortages of. in Sicily, SO blood bank in. 90

Anglo-American Consultants Conference. 125 case of fatality rates in. 7-8
INDEX 349

Annies—Continued

Seventh U.S. Army—Continued

incidence in, 61

policies of evacuation, 77. 137

Ninth U.S. Army, 130

Fifteenth U.S. Army, 120

Armistice, World War I, 13

Army area :

field equipment, 127

medical care in, 187

medical depots, 127

urgent surgery in, 188

Army Medical Museum, 147

Army Medical Research and Development

Board, 244n

Army Medical Society, ETOUSA, 125

Army Nurse Corps, 307

ARREST, Col. R. T., 91

Arrows, as wounding agents, 3

Arteriospasm, 246

Artificial pneumothorax. See Air replacement.

Artillery shells, 107

Asepsis—

after U.S. Civil War, 7

in German hospitals, 36

Aseptic surgery, modern concept of, 7

Asphyxia, 105

as cause of death, in World War I, 9

from aspiration of vomitus, 202

Aspirating needles, 127

Aspirating wounds. /See Sucking wounds.

Aspiration:

after operation, in World War I, 12

at debridement, 275

before evacuation, 139

effect of inadequacy of, 33

failure of, in massive clotted hemothorax,

138

German use of, in hemothorax, 37

in basilar empyema, 151

in cardiac tamponade, 210

in empyema, 18-19, 28

during acute pneumonic stage, 21

in hemothorax, 138, 144, 1.50, 190, 193, 195,

200, 201

in civilian injuries, 28

in World War 1,11, 23

in pneumonia, 257, 292

in resuscitation, 33

in tension pneumothorax, 142, 144

of gastric contents, 257, 292

of trachea,85

Aspiration—Continued

of traeheobronchial tree, 200

after operation, 200

See also Thoracentesis.

Aspiration-instillation technique, 206

Assignment, of—

casualties to thoracic surgery centers,

169-170

professional personnel, 73, 1.88

thoracic surgeons, 1.63, 164

Assistant surgeons, on thoracic surgery

teams, 106

Associated wounds, 143, 186, 242

emergency care of, 215

priority of, 140-141

replacement therapy in. 254

See also Multiple wounds.

Association of Thoracic Surgeons of Great

Britain and Ireland, 125

Atelectasis, 6, 144, 191, 106, 247

as complication of wet lung, 32

in bullet wounds, 57

in hemothorax, 34, 3S

Atropine sulfate:

in prevention of vagovagal reflex, 266-207,

291, 292

in wet lung, 247

instruction in use of, S2

preoperative administration of, 263

reduction of vagal reflexes by, 192

Autotransfusion, 191, 252, 256

ACER. ,T., 13

Auricles, wounds of, 44

Auscultation, 230

Autoclaves, in Mediterranean theater, SO

Automatic neuromuseular mechanism, 310

Autopsy studies, in World War 1,13

Auxiliary surgical group(s) :

administrative considerations in, 102-103

concept of, 102-103

in European theater, 12S-131

in Mediterranean theater, 102-100

shock teams of, 239

statistics of, 120-131

teams:

adaptability of, 108

administrative considerations of. 105-

106

equipment of, 127

in evacuation hospitals, 05, 96-90

in field hospitals. 74-75, 02-94

in Mediterranean theater, 74, 91

in North Africa, 193

in Sicily, 106
THORACIC SURGERY

Auxiliary surgical group(s)—Continued

teams—continued

organization of, 104—108

records of, 108-109

transportation for, 87, 88

triage function of, 203

Auxiliary surgical group (s) :

1st—104, 115,124,129-130, 146

2d—89, 130,194, 199, 204, 200, 261, 262, 286,

291, 297

assignments of, 105-106, 109

case fatality rates for, 63

function of teams of, 105-106

records of, 105n, 108-109

statistics for, 63

teams of, in Sicilian invasion, 91

thoracic surgeons of, 79, 83

thoracic surgery teams of, 83, 102

3d—129,130

assignment of, 104-105

teams of, in Sicilian invasion, 91

4th—130, 174

5th—104,130-131

Axillary artery:

litigation of, 132

wounds of, 6

Back:

examination of, 230

wounds of, in World War I, 7

Bacteriologic concept of delayed primary

wound closure, 300-301

Bacteriologic controls in wound closure, in

World War I, 15

Bacteriology, of—

empyema, 157

hemothorax, 34

postdecortication empyema, 15S

BAIXANCE, C, 43

Barbiturates, 192

Base hospitals:

care of casualties in, at Anzio, 76

indications for surgery in, in World War

1,10

management of hemothorax in, 9S

reparative surgery in, 299-303

segregation of wounds in, 129

Basic instrument set, 89

for auxiliary surgical group teams, 127

Basic remedial exercises, 307, 310

Basilar empyema, 151

BASTIAXEIXI, R., 12

Bastogne, 130

Battalion aid stations, 76,188,196

case fatality rates in, in World War I, 9

emergency care in, 187, 216

litter carries to, in Mediterranean theater,

78

penicillin therapy in, 296

plasma administration in, 255

triage in, 202

Battalion surgeons, 213

Battle of France, 32

Battle of the Bulge, 126,130

Battlefield:

administration of morphine on, 244

deaths, 61, 64-67, 221

emergency care on, 1S6, 187, 213

evacuation, 3

triage, 3

Beach clearing stations, 130

BEACH, Lt. Col. P. D., 174

BECK, C. S., 44

BECKMAFT, E., 25

Bed capacity of—

evacuation hospitals, 95-96

field hospitals, 203

BEEBE, G. W., 59, 74

BEECIIEE, Lt. Col. H. K., 83, 244n

Belgium, service of 3d Auxiliary Surgical

Group in, 130

BELL, Capt. R. D., IS, 20

BELSEY, R., 82

BERET, Col. F. B., 12, 22n, 73, 199, 211, 282

Beta hemolytic streptococcic empyema, in

AVorld War I, 21-22

Beta hemolytic streptococcus, 10, IS, 19

BETTS, Lt. Col. R. II., 199

BIGGEE, I. A., 44, 163

Bilateral injuries, as indication for surgery,

in World War I, 16

Bile leakage, in wounds of liver, 39

BIPP, 15

Bismuth paste, in etiology of chronic empyema, 22

Bizerte, 97, 100, 199, 207

BLACK, Maj. M. E., 87, 255

BLADES, Col. B., 101, 162, 16G, 167, 178, 180

Blades-Kent technique of lobectomy, 153

BLAKE, CAPT. W. B., 174

Blast effects of missiles, 220

Blast injuries, 101, 232

diagnosis of, 142

historical note on, 45-46

incidence of, 45

in etiology of wet lung, 247

in World War I, 45
INDEX 351

Blast injuries—Continued.

management of, 143,145

pathologic process in, 45

pulmonary edema in, 294

replacement therapy in, 254

Blast lung, 102

BLESSE, Brig. Gen. F. A., 197

Blinded casualties, 170

Block of phrenic nerve, at operation, 14

Blood:

airlift of, to European theater, 128, 141,

257

as pleural irritant, 287

Sec also Replacement therapy; Transfusion ; etc.

Blood banks, establishment of, 29

between World Wars, 31

in European theater, 12S

in Fifth U.S. Army, 90, 256-257

in Seventh U.S. Army, 90

Blood donors :

in North Africa, 194

noncombat personel as, 90

Blood levels, in sulfonamide therapy, 296

Blood loss :

at operation, 265

as cause of cardiac standstill, 292

dyspnea due to, 232

unconsciousness in, 232

Blood oxygenation, effect of wet lung on, 247

Blood pressure:

elevation of, in anoxia, 239

in shock, 242

initial determination of, 219

replacement therapy on basis of, 255

Blood program, 12S

Blood replacement, 141,195, 200, 297

after thoracentesis, 252

in cardiac wounds, 210

in clearing stations, 218

in hemorrhage, 143, 204

in North Africa, 194

in thoracoabdominal wounds, 20S

precautions in, 90,128

with banked blood, 256-257

Blood substitutes, 28,192

Blood vessels, lacerations of, by rib fragments, 139

Blow bottles, 311

Blowing wound. Sec Sucking wound.

Board for the Study of the Severely

Wounded, 295

Boat ambulances, 76

Body armor, 67, 69

in Trojan War, 3

BOLAND, F. K., 51

Bologna, 100

BOLYEA, Lt. Alison, 174

Bone (rib) fragments, 201, 270

as indication for surgery, in World War I,

10,16

dangers of, 145

in lung, 139

in pleural cavity, 139

management of, in German casualties, 37

removal of, at debridement, 273-274

Boothby-Lovelace-Bulbulian mask, 84, SS,

244, 293

Bou Hanifla, 98

Bovie unit, 84,150

BOWDITCH, H. L., 19

BOWLBY, Maj. Gen. Sir Anthony A., 14, 38

Bradshaw Lecture 1920—43

Breathing exercises, 14, 31,144

after operation, 311

in hemothorax, 34,150

in prevention of infection, 33

in World War 1,14

BREWER, Lt. Col. L. A. Ill, S3, 85, 100, 10S,

198,199

British air-raid casualties, 32, 43,116,121

British Army, Consultant in Thoracic

Surgery to, 125

British Army consultants, 123

British casualty clearing stations, 109

British chest centers, 146,193

British chest injuries, in World War I, 7

British combat casualties, 32-35

British combat experience, 126-127

British Emergency Medical Service, 31, 82,

119, 125

British equipment, 31, 84,126

British Expeditionary Forces, in World

War I, 9

British experience, 30-35

administrative consideration of, 31-32

in cardiac wounds, 44-45

in foreign bodies, 42

in hemothorax, 33-35

in North Africa, 193

in World War I, S-9

British general hospitals, 109

British history, of World War I, 38, 43

British hospitals, training of U.S. personnel

in, 81-82, 115, 119-120

British Journal of Surgery, 44
352 THORACIC SURGERY

British museums, specimens of lung wounds, Bronchus (i)—Continued

4 wounds of, 200, 250, 270

British sources, supply of equipment from, as indication for forward surgery, 204

126,127 BRTJXSCHWIG, HIEROKYMTJS, 3

British special chest units, 31-32 Brussels, 125

British thoracic surgeons, 114,115, 120 Bulge, Battle of, 126

British thoracic surgery centers, 125 Bullet wounds:

British "turning out" of clot, 27, 34-35 effect of velocity in, 59

British use of remedial breathing exercises, hemothorax in, 33

314 in civilian practice, 2S

British "War Office, 31, 43 incidence of, 54

Brompton Hospital, 115 infection after, 10

Bronchial adenoma, 175 pathologic process in, 51, 55-58

Bronchial aspiration, 144 Bullets, development of, 7

Bronchial fistula, 205 BUKIIANK, Maj. B., 83,100,102

Bronchial obstruction, 143 BuKFoni), Maj. T. H., 27, 35, 98, 100, 102, 108,

as cause of atelectasis, 247 110, 199, 282

from aspiration of vomitus, 202 Burma, 32

Bronchial parenchymal markings, 300 BUKKSTEIX, Maj. C, 146

Bronchial secretions : Buttocks, wounds of, 124

increase of, after strapping, 245-240

reduction of, by atropine, 192 Cadaveric surgery, 166

Bronchial tear, in sucking wounds, 250 Camp Funston, 22n

See also Tracheobronchial tree. Camp Lee, IS, 20, 21

Bronchiestasis. 175 Cannon, first use of, 3

Bronehiolitis. 292 CASTXOX, Lt. Col. ^y. B., 15

Bronchitis. 293 Capillary permeability, 242

antecedent to wet lung, 247 Carbon dioxide, 192

as comnlicatjon of wet lung, 32 effect of excess of, on blood pressure, 239

from aspiration of vomitus, 292 in activation of respiratory center, 317

Bronchocutaneous fistula, 15S level of blood, 317

Bronchography. 172 level of tidal air, 317

Bronehopleural fistula, 139,15S, 170, 270 Carcinoma of lung, 175

after deeortieation, 20, 152 Cardia, transdiaphragmatic approach in

as contraindication to air evacuation, 200 wounds of, 40

Bronchopulnionary drainage, in wet lung, Cardiac arrest (standstill), 191, 292

247 Cardiac dilatation, in air-raid casualties, 32

Bronchoscopy, 172,191 Cardiac disturbances, in sucking wounds,

after aspiration of vomitus, 292 249

after operation, 205-207, 290-291, 294 Cardiac shift, in tension pneumothorax, 250

at 4Sth General Hospital chest center, 132 Cardiac surgery, between World Wars, 44

in bronchial obstruction, 142n, 143 Cardiac tamponade, 30, 210, 25S

in forward hospitals, 220 aspiration of, 190

in thoracic surgery centers, 171 effect of, in shock, 242

in wet lung. 192, 205, 248, 201, 200 management of, 191

in air-raid casualties, 32 »S'ee also Heart; Pericardium.

training in, 103 Cardiocirculatory reflexes, during anesBronehospirometry, 300 thesia, 149

Bronchus (i) : Cardiorespiratory balance, restoration of,

aspiration of, S5 140, 25S

bullet wounds of, 50 Cardiorespiratory disturbances, 144, 213,

closure of, 191 233, 237-238, 241-242

lacerations of, 251, 258 as cause of death, 269
INDEX 35E

Cardiorespiratory disturbances—Continued C;

correction of. 142, 243, 254-255, 259

before evacuation, 192, 206 C.

in bullet wounds, 56

in clotted homothorax. 151

relation of, to sbock, 237

replacement therapy in, 254—255

Cardiorrhaphy, 181, 210

Cardiovascular damage from high-velocity

missiles, 50

Cardiovascular reflexes, during anesthesia,

150

Care of casualties—

in transit, 135-136

on Anzio, 76

CAEREL, A., 44

Carrel-Dakin technique, in World War I,

15

Carriers of hcmolytic streptococcus, 22n

CAKTEE, Col.B.N., 102

Case fatality rates, S, 29, 60-04

in abdominal wounds, 61

in cardiac surgery, between World Wars, 0:

44

in Crimean War, 4

in decortication, 25-27 C;

in empyema, 35 C;

in World War I, IS, 21-22 Ci

in field hospitals, 131

in forward hospitals, 63

in foreign bodies in heart, 45 Ci

in French Army, in World War I, 9 C;

in open drainage, in World War I, 21

in poor-risk casualties, 13

in relation to surgical timing, in World

War I. 12

in relation to wounding agents, 54. 5S C;

in surgery for chronic empyema, 22-23

in thoracic surgery centers, 102 C:

in thoracoahdominal wounds, 61

in thoracoahdominal wounds (British), 3S

in U.S. Civil War, 5, 6

in wet lung, 247 C:

in wounds of heart, in World War I, 7,

43, 44, CO C

influence of anesthesia on, 201

in World War 1,13 C:

influence of penicillin on, 297

influence of field hospitals on, 61

of 2d Auxiliary Surgical Group, 63

of 100th General Hospital chest center,

148-140

relation of, to transportability, 207 G

»See ulno Mortality ; Statistics.

ase-findiiigs by preinduction roentgenograms, 177

use histories:

adequate resuscitation, 240-241

cerebral hemorrhage, 159

chylothorax, 152

combined empyema-liver abscess, 154

decortication for empyema, 25, 242

extrapleural transdiaphragmatic drainage, 15S

failure of postoperative catheter evacuation of chest, 291

foreign body in pericardium. 45

inadequate resuscitation in shock, 240

pulmonary-mediasfinal abscess, 159

retained foreign body, 41

rib-resection drainage for hemntlioracic

empyema, 147

thoracoabdominnl wounds. 159

vagovagal reflex after bronchoscopy. 200-

207

venesection in Crimean War, 4

nselond—

in European theater, 115

on Anzio beachhead. 70

aserta. 82, 83, 198

ussino-Minturno sector, 240

iisualties:

arrival of, in Zone of Interior. 170

evaluation of, 237

fi Mieter administration of oxygen, 293

itheter aspiration in—

bronchial obstruction, 142n

wet lung, 192, 205, 248, 254-255. 201. 203,

200

in air-raid casualties, 32

iitlietei- drainage, 271, 2SS-290

in tension pneumothorax, 250, 251

fitheter evacuation of—

chest at operation, 275

traclieobronchial tree after operation, 290-

291, 293

iitheter management of pressure pneumothorax, 195. 190, 200

atheter technique of reexpanding lung,

288

nuses of death,in—

cardiac wounds, 44, 45

empyema in World War I, 21

pneumonectomy, 175-176

thoracoabdominal injuries, 3S

War War I, 9, IS

auses of failure in delayed primary wound

closure, 302
354 THORACIC SURGERY

Censorship of medical journals, in Zone of

Interior, 121

Cerebral anemia, 242

Cerebral anoxia, 176, 244, 245

damage from, 232, 238

signs of, 243

Cerebral concussion, 232

Cerebrospinal meningitis, 22n

Cervical region, woimds of, 143

Cervical veins, intension pneumothorax, 250

Changes of position after operation, 205

Charity Hospital of Louisiana at New Orleans, 54

Chemical bronchitis, 292

Chemical decortication, 26

Chemotherapy, 192, 193

evaluation of, 296

in blast injuries, 145

in decortication, 26

in thoracoabdominal wounds, 268

Chest, anatomic definition of, 59, 66

Chest centers. See Thoracic surgery centers.

Chest cripples, 9, 305, 307, 33S

after World War I, 9, 98,101,101, 305, 307

Chest, vulnerability of, to wounding, 59-60

Chest wall:

anesthesia for wounds of, 192

closure, 191

debridement of, 274

defects of, 175

deformities of, 144

hemoptysis, in wounds of, 232

hemorrhage of, 195,196

infections of, 191

prevention of dysfunction of, 98

stabilization of, 142, 145, 243, 246, 24S-249,

25S

tuberculous abscess of, 24

wounds of, 103, 132, 141, 242

Chest wounds, classification of, 141-142

Chief complaint, 231

Chief Surgeon, AEF, in World War 1,13

Chief Surgical Consultant, AEF, in World

War 1,13,14

Chiefs of thoracic surgery sections, 118

China, 164

China-Burma-India theater, 164,174

Chloroform anesthesia, in World War 1,16

Chronic empyema, 191

British management of, in World War I,

31

.etiology of, 22

fibrosis of lung in, 25-26

in World War I, 19, 22-23

Chronic empyema—Continued

pathologic process in, 25-26

prevention of, by initial wound surgery,

103

Chronic spontaneous penumothorax, 176

Chronicity of empyema, after World War I,

9

Chronicity of infections, in World War I,

161-162

Chronology of wet lung, 247

CHURCHILL, Col. E. D., 16, 27. 29, 59, 66, 73,

82, S3. 98, 101, 104, 105, 163, 164, 165. 197,

199, 201, 269, 300n

Sec also Consultant(s).

Chylothorax, 152

Circular letter (s), 101, 125

ETOUSA, 122, 123-124, 139

MTOUSA. 17, 209-210

preparation of, 74

Circular Letter—

No. 22, Office of Chief Surgeon, ETOUSA,

23 Feb. 1943—121

No. 23, Office of Chief Surgeon, ETOUSA,

17 Mar. 1945—124, 13S

No. 32, Office of Chief Surgeon, ETOUSA,

6 Apr. 1945—132

No. 39, Office of Chief Surgeon, ETOUSA,

5 May 1945—137

No. 71, Office of Chief Surgeon, ETOUSA,

15 May 1944—123-124, 137

No. 81, Office of Chief Surgeon, ETOUSA,

10 June 1944—124,131

No. 101, Office of Chief Surgeon, ETOUSA,

30 July 1944—123, 124, 137

No. 174, Office of Chief Surgeon. ETOUSA,

2S Nov. 1943—120

No. 8, Office of Surgeon, MTOUSA, 10

Mar. 1945—202

No. 13, Office of Surgeon, NATOUSA, 15

May 1943—195

No. 16, Office of Surgeon, NATOUSA, 9

June 1943—195

No. 20, Office of Surgeon, NATOUSA, 22

June 1943—195-196

No. 46, Office of Surgeon, NATOUSA, 29

Aug. 1944—201, 211

No. 1, Office of Surgeon, Fifth U.S. Army,

21 Jan. 1944—295

No. 4, Office of Surgeon, Fifth U.S. Army,

7 Apr. 1944—203

No. 2, Office of Surgeon, Seventh U.S.

Army, 18 July 1944—211

No. 17, Office of Surgeon. Seventh U.S.

Army. 30 Dec. 1944—211
INDEX 600

Circular Letter—Continued

No. 3, Offlee of Surgeon, II Corps, 7 Aug.

1943—19G-197

Circulating blood volume, reduction of, 241

Circulatory system, disturbances of, 8

Cirencester, Gloucester, 115, 131, 146

Civilian experience, 51,122, 185,187-188

Civilian hospitals, policies in, 305

Civilian injuries, 51, 54, 187-1SS

liemothorax in, 28

wounding agents in, 51

Civilian management of empyema, before

World War I, IS, 19

Civilian surgeons, 17, 51, 85

training of, 74

Civilian thoracic surgery centers :

breathing exercises in, 14

in 1942—1C2

Civilian-type lesions, 175-176,178

Classification, 51, 141-142

by surgical risk, 206-207

of casualties for transportation, 135

of surgical procedures, 300

of thoracic surgeons, 164

Clavicle:

fracture of, 274

surgical access to, 284

Clearing platoons :

attached to evacuation hospitals, 96

serving as holding hospitals, 96

Clearing stations, 76, 187,188,196, 263

administration of morphine in, 244, 245

ambulance transportation to, 7S

auxiliary surgical group teams in, 109

care of nontransportable casualties in, 75

equipment in North Africa, 87

evacuation of casualties from, 95

in North Africa, 106, 194

indoctrination in, 203

mission of, 91

penicillin therapy in, 296

surgery in, in North Africa, 106

resuscitation in, 238

triage in, 76, 92, 202, 216-218

CLERF, L. H., 166

Clerical help, 147

Cleveland, 166

Clinical concept of delayed primary wound

closure, 300-301

Clinical evaluation, as basis of disposition,

110

Clinical picture, 231-234

in morphine overdosage, 245

in shock, 242. 253-254

Clinical picture—Continued

in tension penumothorax, 250

in wet lung, 247,293

Clinical policies at Walter Keed General

Hospital chest center, 179-180

See also Signs ; Symptoms.

Closed drainage, 157, 200

in empyema, during acute pneumonia

stage, 21

in World War I, 28, 37

in hemothoracic empyema, in World War

1,23

in tension pneuothorax, 144

in thorcoabdominal wounds, 145

in World War I, 12

See also Waterseal drainage.

Closed pneumothorax, 191

Clostridium welchii, 157

Closure:

after normal thoracotomy, 284

in World War I, 9, 10

of bronchus, 191

of chest wall, 132,191

of diaphragm, 145, 208

of open pneumothorax, 142

of parietal pleura, in World War 1,11

of pentrating wounds, 4

of pleural cavity, at debridement, 200

of sucking wounds, 33, 139, 213-214

of wounds, 271

at debridement, 275-2S0

Clothing, effect of, on vulnerability to

wounding, 60

Clotted hemothorax, 33, 136, 130, 151, 191

at 155th General Hospital chest center,

15S

decortication for, 9S

in thoracoabdominal wounds, 38

in World War I, 9

management of, 144

Management of (British), 34-35

return to duty after, 97

Cocaine, 263

block of phrenic nerve, 11

Cocainization, of larynx, 150

Codeine, 192

COHEN, Lt. M. B., 18

Coleman stove, 89

Collapse in blast injuries, 143

Collapse of lung—

after pleural drainage, 12

in open pneumothorax, 144

Collapse operations, for chronic empyema. 2S
356 THORACIC SURGERY

Collecting stations, 188, 106

ambulance transportation to, 78

emergency measures in, 210

plasma administration in, 255

triage in, 202

Collection of statistics, 74

COTJ.TS, Maj. J. U, 41. 125

Colon:

transciiaphragmatic approach to wounds

of, 40

wounds of, 200

Colostomy, 200

Columbia University, 165

Combat casualties:

arrival of, in Zone of Interior, 100

management of at Kennedy General Hospital chest center, 174-175

Combat, effect of, on vulnerability to wounding, CO

Combat zone :

deaths in,100

surgery in,100

Command circulars, 74

Commerey, 132

Comminuted rib fractures:

as indication for surgery, in World War I,

1(5

exploration in, 145

Committee on Medical Research, Office of

Scientific Research and Development, 287

Committee on Surgery, National Research

Council, 165

Communications Zone:

function of consultants in, 113

medical care in, 187

Company aidmen, 76, 78

Compensated respiration, 140

Competitive activities, in rehabilitation, 160

Complications, 191, 207. 300

after traumatic thoracotomy, 201

as cause of death, in thoracic surgery centers. 110

incidence of, 20, 303

in Crimean War, 4

in penetrating wounds, 51

in perforating wounds, 51

in shell fragment wounds, 58

of air-raid injuries, 32

of civilian injuries, 51, 54

of thoi-acoabclomin.il wounds, 136, 300

prevention of, in fixed hospitals, 08

Components of—

diagnosis, 220

initial wound surgery, 271

Components of—Continued

resuscitation. 33, 241-250

thoracic surgery teams, 106-107

Composition of—

field hospital staff, 02-04

Professional Services Division, Office of

Chief Surgeon, ETOUSA, 113

Compresses, before delayed primary wound

closure, 140

Compression injuries. Sec Crushing injuries.

Concept of—

auxiliary surgical groups, 102-103

chest wounds, 198, 305

in World War I. 19S

delayed primary wound closure, 300-301

empyema, after World War I, 2S

field hospitals, 01-02

management :

of chronic empyema. in World War I,

23-24

of pneumothorax, in World War I, 20-21

of pumonary hematoma, in World War

I. 11

of shock. 241-242

thoracic physiology, in World War I, 10-

20

thoracic surgery, in European theater, 114

thoracic surgery, in World War I, 8, 9,

17-1S

wet lung. 246-248

Confederate Manual, 6

Confederate surgeons, 6

Conferences—

at thoracic surgery centers. 174, 17S

in Mediterranean theater, 74, S2-83

Congenital diaphragmatic hernia, 132

Congress Central Mediterranean Force Army

Surgeons, 83

Consultant(s) :

functions of, 115-117

in ETOUSA, 113-117,122,131

in MTOUSA. 73-74

in Office of The Surgeon General, 161-102,

165.167,172

in surgery:

Fifth U.S. Army, 87,110

XATOUSA, 107

Seventh U.S. Army, 211

in thoracic surgery, to British Army, 125

in U.S. Army of Occupation, 117

Consultant system, 186

Consultants, meetings of, 110,132, 135
INDEX

Consultation practices, in thoracic surgery

centers. 172

Content of courses—

in anesthesia, 122

in thoracic surgery, 160

Content of National Research Council "Manual." 190-192

Continent:

evacuation from, to chest centers in

United Kingdom Base, 147

invasion of, 12:!. 120, 12S

thoracic surgery after invasion of, 115

thoracic surgery centers on, 101, 131-132,

130-137, 13S

Contract surgeons, 1GS

Contraindications to—

air replacement, 12

bronehoscopy after operation, 205-266

closed drainage, 200

delayed primary wound closure, 300-301

forward thoracotomy, 200-201

morphine in World War 1,15

Pentothal sodium anesthesia, 149, 204

postoperative use of morphine, 293

transdiaphragmatic approach in thoracoabdominal wounds, 145

Control of auxiliary surgical group teams :

at theater level, 129

by Army surgeons, 129

Control of hemorrhage, in massive clotted

hemothorax, 139

Controlled respiration, 150, 204, 205

Contusion caused by bullets, 57

Contusion of—

lung, 201, 232, 23S, 270

myocardium, 23S

Convalescent hospitals, 172-173

in chain of evacuation, 7S

Convalescent patients, in Zone of Interior

chest centers, 171

COOK, T. Sgt. R., 317

Copper, sulfate hematocrit determination,

253

Coramine (Nikethamide), 30

Corps:

11—74, S4, 87, SS, 89, 91,104,105,194

auxiliary surgical group teams in, 109

XYI (Airborne), 129

Corpsmen, training of, in operating, 107

Corpus cavernosum, transfusion by, 250

Correction :

of cardiorespiratory disturbances, 243,

254-255

before evacuation, 1.92

Correction—Continued

of posture, 315

Costal cage, postoperative excursion of. 306

Costophrenic adhesions, 351

Cough:

after debridement, 280

after intercostal nerve block, 240

after operation, 293

clearance of tracheobronchial tree by, 192.

205

effect of pain on. 244

in bronchial obstruction, 142

in wet lung, 247, 254

mechanism of, 249

Cough reflex, abolition of, by morphine, 143,

192

Course of missile, as determinant of type of

wound, 59

Courses in—

British hospitals, 119-120

thoracic surgery, 165-160

CHILE, Col. G., 14,15

Crimean War, 4-5, 41

hernia of lung in, 0

CRISLER, Col. J. A., Jr., 119

Criteria of—

adequate resuscitation, 25S

admission to 1.60th General Hospital chest

center, 147

air evacuation, 206

return to duty, 306

safe surgery, 25S

shock, 239

surgery in field hospitals, 92

transportability, 187, 204-205

triage in clearing station, 216-21S

wound closure, 140

in World War 1,15

Cross-Rhine Operation, 129, 130

CKUCIIXA, T. Sgt. S. P., 174

Crushing injuries, 175, 191, 31S

in air-raid casualties, 32

in civilian practice, 28

management of, 142,145

See also Stove-inchest.

Crystalloid solutions, 250

CLLL.ERTSON, Capt. J. W., 61

Culture of wounds, 140

Curare, 205

CUTLER, Brig. Gen., E. C, 29, 44, 73, 114

114n. 115, 117, 118, 119, 120, 121, 123.

124, 125, 126, 127, 12S, 129, 131, 135,

136,145, 145n, 147
258 THORACIC SURGERY

Cyanosis, 219

absence of, in persistent dyspena, 317

as sign of anoxia, 233

in bronchial obstruction, 142

in exposure syndrome, 245

in massive clotted liemothorax, 138

in shock, 242

in tension pneumothorax, 250, 251

in wet lung, 293

oxygen therapy in, 243

Cyclopropane anesthesia, 84

in empyema, 150

D'AIIKEU, A. L., 33, 42, 43, 44, 45

Dakin's solution, for decortication, 26

DC-3 planes, 79

D-day:

ET-OUSA, 114, 110, 128, 130, 131, 141, 147

in Sicily, 91

Dead on arrival, 237

Deafened casualties, 170

Deaths before surgery, 131

from vagovagal reflex, 291

resulting from transportation, 78

See also Battlefield, deaths.

DEBAKEY, Col. M. E., 54, 59, 73, 74, 162

Debridement, 37,114, 193,195, 211, 302

historical note on, 3

in field hospitals, 196

in foreign bodies, 145

in open pneumothorax, 144

in organized liemothorax, in World War I,

23

in sucking wounds, 139

in World War I, 8, 9,11

inadequancy of, as cause of wound infection, 301, 302

inadequate, 139

on chest wall, 132

positioning at, 272-273

principles of, 3, 273-274

results of, 296

technique of, 190-191, 270-271, 272-2S1

See also Initial wound surgery.

DECKER, H. R,, 45

Decompensation, after excess of plasma

therapy, 255

Decompression, in—

acute gastric dilatation, 143

tension pneumothorax, 251-252

Decortication, 128, 154, 157, 175, 191, 192,

272, 300, 317, 33S

at thoracic surgery centers, 101

at 48th General Hospital chest center, 132

Decortication—Continued

at 160th General Hospital chest center,

151-152

British adoption of, 34-35

British use of, in World War I, 26

case fatality rates in, 148

first, 98

in World War II, 27-2S

use of, in postraumatic empyema, 25

for chronic empyema, 22-23

for clotted liemothorax, 15S

for empyema, 24-28

for liemothorax. 150

in evacuation hospitals, 96

in fixed hospitals, 97, 98

in German casualties. 37

in prevention of infection, 33

in thoracic surgery centers, 97,101

indications for, 151-152

risk of. 98

suggestion of. in World War I, 9

technique of, 26

through posterolateral incision, 282

timing of, 27, 28, 101, 151

Defects of chest wall. 175, 338

in bullet, wounds, 57

Delibrination in liemothorax, 24

Definitive mangement, 143-145,190-191

of thoraeoabdominal wounds, 20S

Deflection of missiles, by ribs, 230

Deformities of chest, 144, 310-311

after empyema, in World War I, 9,19

after liemothorax, 127

after surgery for chronic empyema, 23

dyspnea asociated with, 316

prevention of, 31, 33, 98, 187

special exercises for, 307

Dehydration, 241

crystalloid therapy in, 256

Delayed debridement, 272

Delayed mangement of associated w

Tounds,

140

Delayed primary wound closure, 140, 275,

27S, 300-302

in fixed hospitals, 97, 299, 300

in World War I, 15

infection as contraindication to, 124

results of. 301-302

DELOEME, B., 22. 24, 25, 2S, 45

Delta Base Section (SOLOC), 132

Deltoid tubercle, 230

Demonstration of special techniques, 74

Dental surgery teams, 104
INDEX 359

Density of tissues, relation of velocity of

wounding agent to, 56, 59

Denver, 106

Dependent drainage:

in empyema, 151

in open pneumothorax, 144

Deployment of surgical teams, 74

Depot technique of penicillin, 179

Depressant effects of morphine, 244-245

Determinants of types of wounds, 59

DE VIGO, John, 4

Diagnosis, 142,143, 219-236

errors in:

in battlefield deaths, 67

in Crimean War, 4

of hemothorax, 220

of pneumothorax, 220

of sucking wounds, 220, 232

of thoracoalxlominal wounds, 124, 20S

Diaphragm:

closure of, 145, 20S

immobilization of, 314, 316

after poorly treated hemothorax, 23

involvement of, in hemothorax, 9

marsupialization of, 15S

penetrating wounds of, 201

postoperative immobility of, 306

prevention of deformity of, 98

repair of, 209

rupture of, 191

use of, for wound closure, 144, 208, 278

voluntary control of excursions of, 315

wounds of, 4, 39-40, 175, 200, 234, 270

as indication for surgery, in World War

1,10

in World War I (British), 38

Diaphragmatic hernia, 152,153,175,191

Diathermy, 318

Dichloramine, in World War 1,15

Differential breathing, 314-316

Differential diagnosis of—

hemothorax, 191

thoracoabdominal wounds, 234

Differential pressure, in endotracheal anesthesia, 119,190,192, 208

Differentiation of—

beta hemolytic streptococcic and pneumococcic empyema, 19

traumatic and nontraumatic empyema, 17-

18

Digital control of hemorrhage, 143

Digital decortications, 26

Digitalis, in hemothorax, 6

Dijon, 97

Dilatation of esophagus, 172

Disability:

as result of delayed management of complications, 98

in chronic empyema, 35

separations, 179,181

Disadvantages of thoracotomy of necessity,

11

Diseases of chest, 171

Disposition, 121, 178,187

at thoracic surgery centers, 102

at Walter Reed General Hospital chest

center, 178-179

in forward installations, 216-218

in Mediterranean theater, 101,110

with retained foreign bodies in situ, 41-42

See also Return to duty.

Dissemination of information, 74,101

in ETOUSA, 122-125

inMTOUSA, S3

Distance from origin of missiles, as determinant of types of wounds, 59

Distribution of National Research Council

Manual, 190

Distribution of surgery in thoracic surgery

centers, 136

Division area:

medical care in, 187

urgent surgery in, 1SS

Division of Medical Sciences, National Research Council, 189, 20S

Divisions:

3d—82

4th Armored, 130

17th Airborne, 129,130

S9th—22n

Dizziness, after thoracotomy, 253

Dosage, of—

morphine, 143, 244

penicillin, 125

Down, C. N., 25

Drainage:

after initial wound surgery, 2SS-290

after limited thoracotomy, 27

in combined empyema-subphrenic abscess,

158

in empyema, 191, 174-175

in World War 1,12,19

with liver abscess, 153

in lacerations of liver, 12

in lung abscess, 175, 192
360 THORACIC SURGERY

Drainage—Continued Early ambulation, 14. 150, 100, 102. 300, 311,

ill pericarditis, 175, 210 338

in thoracoabdoininal wounds, 40 at 155th General Hospital chest center,

in wounds of liver, 145n 150

indications for, 288 at Walter Reed General Hospital chest

of subdiaphragmatic space, 200 center, 170

with associated wounds, 141 in empyenia, in World War I, 10

Drainage operations : Early experiences in Mediterranean theater,

at 48th General Hospital chest center, 132 103-107

poor timing of, in chronic empyenia, 22 Eastern Hase Section. ETOUSA, 117

Drainage tubes : Echelons of medical care, 73, 1SG-1S0, 107

fixation of, 144 EiiwAiais. A. TUDOR, 31, 34, 35, S2, 115, 110,

in etiology of chronic empyenia, 22 120,124-125, 140

postoperative management of, 107, 204 EFFI.KR. D. B., 177n, 180

DiiAi-KH. Maj. G., 22n EGGF.RS, G, 27

Dressings : Elective incision in thoracotomy, 10, 11

after debridenient, 277-280 Elective surgery at chest centers, 132, 155 inspections of, in forward installations,

210 Elective thoracotomy, 282-284

remedial breathing exercises after, 31S

Dry dressings, in World War I, 15 Electrolytes, limitation of. 128

Dryers, for X-ray films, 80 ; ELKIN, D. C, 41, 51

DtTiAX. 1). J.. 100 Ellesmere, Shropshire, 118

DrxiiAM. Maj. E. K., 18 EI.OESSER, L., 103,107

Dunkirk. 31, 32 Embolism, 205

Duration of— Emergency closure of sucking wounds, 120

hospitalizatkm, 305 Emergency management, 142, 143, ISO, 187,

operations in field hospitals, 131 180,100, 100, 213-21S

training in Zone of Interior, 105 of cardiac wounds, 210

Duties of anesthesiologists, 201, 265 of thoracoabdoininal wounds, 20S

DIJVAL, P., 0, 10, 20, 30, 43, 44 Emergency measures, in World War 1,10

Dyspnea, 210, 233 Emergency medical tag, 07, 231, 233

after poorly treated empyenia, 23 Emory University Hospital, 44, 51

after thoracentesis, 253 Empyenia, 124,148, 101

as contraindication to air evacuation, 200 after decortieation, 151-152,158

as indication— after forward thoracotomy, 211

for forward surgery, 105, 204 air evacuation in, 206

for remedial breathing exercises, 317 as basis for evacuation to Zone of Interior,

as persistent disability, 316-317, 33S 110

as result of exercise, 307 as cause of death, in World AVar I, 14

characteristics of, 232 as indication for surgery, in World War

emergency measures in, 214 1,16

in acute gastric dilatation, 143 associated with venesection, 4

in cardiac wounds, 6 hasilar, open drainage in, 151

in hemothorax, 0, 37 British experience with, in World War I,

in massive clotted hemothorax, 138 9,35

in retained foreign bodies, 42 case fatality rates in, 14S

in shock, 242 in World War I, 21-22

in tension pneumothorax, 250, 251 cavities, effect of early ambulation on, 311

in wet lung, 203 chronicity of, after World War I, 0

increase of, by gunfire, 220 Commission, 1S-22, 25-26, 2S

oxygen therapy in, 243 concept of, after World War I, 28

with anoxia, 242 decortieation in, 24-28
INDEX

Empyema—Continued

drainage of, 132, 101, 2S8-289

experimental studies on, in World War I,

20

German management of, 37

in civilian injuries. 51, 51

in lacerations of liver, 115

in retained foreign bodies, 12

incidence of, 29, 125, 206

in World War I, 12,17-24, 34,185, 305

literature on, after World War 1,17

management of, 174

at 100th General Hospital chest center,

151

before World War I, 1S-19

between World Wars, 2S-30

open drainage of, after decortication, 151-

152

prevention of, 114, 293

by decortication, 101

prevention of, by wound closure, 275

remedial breathing exercises after stabilization of, 317

rib-resection drainage in, 151, 191

Sec also Hemothoracic empyema; Chronic

empyema ; etc.

Emphysema, 191

Encysted hemathorax, after World War I, 9

Endoscopic equipment, S4

Endoscopy, 173,170

Endotracheal anesthesia, 107, 119, 144, 167,

172,190. 192,194, 261, 274

for intrafhoraeic exploration, 150

German use of, 37

in thoracoabdominal wounds, 20S

in wet lung, 248

introduction of, 13

training in, 103,122

Endotracheal eathetorization, before diagnostic routine, 219-220

Enemy wounded, care of, 137-13S, 202

Epidemics:

absence of, in World War II, 29

of empyema, in World War I, 21-22

Equipment:

at 155th General Hospital chest center,

157

British, 31

evaluation of, 73

for anesthesia, 262

in World War I, 13

in Zone of Interior, 167

for postoperative care in field hospitals, 95

for thoraeentesis, 252-253

Equipment—Continued

in European theater, 126-12S

in Mediterranean theater, 84—90

in Zone of Interior, 167

losses of, on Anzio beachhead, 45, 87

of field hospitals in Mediterranean theater,

92

of thoracic surgery teams in Mediterranean theater, 87-90

of thoracic surgery centers, 171-172

on Anzio beachhead, 87

shortages of, in Mediterranean theater,

87

Erector spinalis, use of, in wound closure,

270

Errors in—

drainage of empyema in World War 1,19

management of British combat casualties,

Esophageal fistula, 158

Esophagoscopy, 172

Esophagus:

contact of foreign bodies with, 175

dilatation of, 172

lacerations of, 258

mediastinal abscess after wound of, 158

surgery of, 174,170

wounds of, 0, 200, 270

ESTLANDER, J. A., 22

Estlander operation for chronic empyema,

22-23, 25

ESTRIK, Capt. J., 174

Ether anesthesia, 149, 204

in World War I, 10

induction of anesthesia with, 262, 263

Ether vaporizers, 262

Ethyl chloride, induction with. 262

Etiology of—

cardiac standstill, 292

chest pain, 244

chronic empyema, 22, 103

hemothoracic empyema, 23-24

hypopoxia, 254

mediastinal abscess, 158

persistent dyspnea, 316-317

shock, 232

tension pneumothorax, 139

wet lung, 247

European theater, 41, 113-100, 180, 257

administrative considerations in, 113-160

airlift of blood to, 128, 141, 257

attempted followup in, 159n

auxiliary surgical groups in, 128-131

blood bank in, 128

83?>CS1V—62-
362 THORACIC SURGERY

European theater—Continued Evacuation hospitals—Continued

consultant system in, 113-117 postoperative care in, 94. 95

control of Seventh U.S. Army by, 104. 130 removal of foreign bodies in, 00

differential breathing exercises in, 314- return to duty from, 90

31 (i segregation of casualties in. 90-07

dissemination of information in. 122-125 semielective surgery in, 00

equipment in. 120-12K staffing of, 00-07

evolution of clinical policies in. 138-141 thoracic surgery teams in. 95. 90-97, 105

shortages of X-ray lilms in. 120 training in, 79, 81

thoracic surgery centers in. 101. 131-137 Evaluation:

thoracic surgeons in, 117-118, 128-131 of anesthesia in European theater. 119

training in. 110-122 of casualties. 233. 237

Evacuability. Sec Transportability. before replacement therapy. 253-254

Evacuation. 73.100. 103. 1S7, 202-207 of early surgery in North Africa. 194-195

correction of cardiorespiratory dis urb- of equipment, 73,120

ances before, 102 of physical conditions of surgical care,

in Mediterranean theater, 75-70. 07, 102. 73-74

101 of potential for duty after thoracic surinfluence of. on care of casualties. 185 gery, 110

methods of. 73. 103 of qualifications of thoracic surgeons, 73

objectives of, 187 EVANS, Capt. M.. 140

of hemothorax. 13G Evolution of—

of stomach before operation, 257, 200 British policies in World War I, 8-9

of tracheobronchial tree. 280 clinical policies, 209-272

policies in European theater. 130-137 at 100th General Hospital chest center,

policies of chest center in Paris, 132 140

priority of, in open wounds, 141 in European theater, 123. 138-141

speed of, 271 in Mediterranean theater. 29. 75-70. 13S.

timing of. 107. 100 185-212

to base hospitals. 130 in World War I, 14

to Zone of Interior, 70-70. 07, 102. 137, 187 in Zone of Interior, 108-171

Evacuation hospitals : mission of field hospitals in Mediterabdominal (thoracoabdominal) wounds ranean theater, 00-91

in, 00 Exercise tolerance, 338

ambulance transportation to, 78 Exercises :

auxiliary surgical group teams in, 105- in empyema, in World War I, 19

100, 108, 129, 130 in World War I, 11, 14

care of multiple wounds in, 07 required after operation, 295, 300

care of transportable casualties in. 0 3-94. supervision of. 307

05 ,s'cc (ilxo Remedial breathing exercises.

case fatality rates in, 03 Exhaustion, influence of, in open Pneudecortication in. 00 mothorax, 14

diagnosis in, 210 Experimental studies on—

equipment in, 84 blast injuries, 40

evacuation from, on Anzio, 70 empyema in World War I, 20

in chain of evacuation, 77 Exploratory thoracotomy, 170

in Mediterranean theater, 05-97 Exposure syndrome, 245

in North Africa, 103-194 Exsanguination. as cause of death, 140

in Sicily, 90 Exteriorization of—

initial wound surgery in, 19S colon, 200

mission of, 95-97,187 lung, 102

on Anzio, 70 External jugular vein, transfusion by, 250

patient staff ratio in, 03 Extrapleural rib resection, 139

penicillin therapy in, 290 Extrapleural thoracoplasty, 22-23
INDEX o r- o

obi)

Extrapleural thoracotomy, 2S4

Extremities:

examination (if, 230

exercise of. 311

incidence of wounds of, 00

wounds of, in battlefield deaths, (i(i

Face, wounds of, in World War I, 60

Facilities—

for training in thoracic surgery, 105

of thoracic surgery centers in European

theater, 1:«. 150,171-172

of Walter Reed General Hospital chest

courier, 177

Facilities Utilization Branch, Office of

The Surgeon General, 109, 170

Failure of—

catheter suction, 201

delayed primary wound closure, 301-302

resuscitation, 237, 258, 203

False dyspnea, 317

Fascial grafts, wound closure by, 277

Fever, in hemothorax. 33. 34

Fibrinolysin, effect of absence of, in heniothorax, 33

Fibrosis of lung, in chronic empyeina, 20

Fibrous adhesions, 310

Fibrothorax,33

in civilian injuries, 51

Field ambulance, 14

Field Hospitals:

anesthesia in, 110

auxiliary surgical group teams in, 74-75,

02-94. 105-100.108, 131

bed capacity of, 203

case fatality rates in, 03, 131

concept of, 01-92

development of, in Mediterranean theater,

75-70. 00-95

diagnosis in, 219

equipment of. 84-80. 02

evacuation from. 95

on Anzio, 79

first use of, 203

in chain of evacuation, 70-77

in Sicily. 190

indications for surgery in. 204-205

influence of, on case fatality rates, 01

initial wound surgery in, 100

mission of, 91-02, 123-124,187,100

on Anzio, 70

morphine administration in, 244, 245

penicillin therapy in, 290

physical facilities of, 02

Held Hospitals—Continued

postoperative care in, 94-05

resuscitation in, 238

roentgenologic examinations in. 234

staffing of. 92-94

thoracotomy in, 271-272

training in, 70, 93

transfusion in, 255

triage at, after resuscitation, 202

X-ray equipment of, 85-80. 234

>SVe (ilno Hospitals, field.

Financial savings by elimination of thoracic

cripples. 103

Ei.xnr.Ay, llaj. F. 31., 255

FI.NNEY, Brig. Gen. .T. 31. T., 14

Fistula. Sec specific types.

Fixation of wounds. 307

Fixed hospitals:

initial wound surgery in. 98

mission of, 97-98, 299-300

Sec nlno Base hospitals; General hospitals; Hospitals: Station hospitals.

Frrzi'ATRicK, llaj. L. .1., 102

Flail chest, 240, 248-249

Flak suits, 3

Flap technique of wound closure, 270

Flavine dressings, in World War I, 15

Flexibility of evacuation system, 102-103

Florence, 79, S7

Fluid balance, 241. 294-295

during sulfonamide therapy, 295

Fluid levels, on roentgenograms, 234

Fluid loss, in anoxia, 242

Fluoroscopic determination of postoperative

respiratory function, 300

Fluoroscopic examination, in clotted heniothorax, 151

Fluoroseopy, 172

before initial wound surgery, 235

during remedial breathing exercises. 315

in persistent dyspnea, 310

Flutter valve, 144, 190. 200, 251

Followup in—

European theater, 159

thoracic surgery centers, 109

World War I. 13

Foreign bodies, 130, 191, 200-201, 2S4

as cause of hemorrhage, 25S

as indication for—

forward thoracotomy, 200

surgery in World War I, 10, 10

at 155th General Hospital chest center,

157

British experience with, 42
364 THORACIC SURGERY

Foreign bodies—Continued

case fatality rates in surgery for, 14S

disability separations for, 170, 181

drainage in. 12

free in pleural cavity, 230-231

French management of, in World War I,

10

historical note on, 40, 41-42

in chest wall, 132

in Crimean War, 4

in heart (pericardium), 44-45, 210

in hemofhorax. 24

in lung, 132, 270

in pleural cavity, 130, 270

in pulmonary parenchyma, 130

in World War I, 0, 41-42

incidence of retention of, 58

indications for removal of, in World

War I, 4, 11, 41-42

infection with, 51. 105

late results of, 31

localization of. 130, 231

management of, 145,175, 107, 300

at 160th General Hospital chest center,

150

in U.S. Civil War, 5-G

registry of, 181

removal of, 100-191,10G. 303, 338

at decortication, 25,151

at initial wound surgery. 271-272, 273

at traumatic thoracotomy, 270

in evacuation hospitals, 06

in organized hemotliorax, 23

in World War 1,19-20

roentgenologic diagnosis of, 235-230

timing of, 98

without symptoms, 41

Forest Glen, 177

FORLAXIXI, C, 12

Formal thoracotomy, 10,11-12, 94

in World War 1,16

in wounds of diaphragm (British), 38

incision in, 281

FOIISE, Capt. M. A., 174

FOESEE. Col. J. H, 102,106, 109, 103

Fort George Wright. 336

Fort Riley, 21

Fort Riley Hospital, 22n

Forward areas:

function of consultants in, 113

indications for thoracotomy in, 303

provision of surgery in, 102-103

triage in. 203-204

Forward hospitals:

equipment in, 80-87

indications for surgery in, S3

in World War 1,10

management of hemotliorax in, 7S

thoracotomy in, 103,198-201

treatment of German casualties in, 35-36

FOWLER, G. R., 22. 24, 25

Fowler decortication, 22

Fowler's position, 295

Foxholes, effect of, on vulnerability to

wounding, 00

Fractures:

in Spanish Civil War, 40

of clavicle, 274

of ribs, 101, 232. 245-240, 31S

management of at debridemont, 273

of scapula, 274

of sternum, 5

France, Rattle of, 32

service of auxiliary surgical groups in, 130

Franco-Prussian War, 7

Frankfurt, 117

FKASEK. IAX, 4-5. 43

French Army, 105n

chest wounds in, in—

World War 1, 7, 0-10

Crimean War, 5

surgeons, 123

Frencbay Park, 82

Friedländer's bacillus, 157

Frozen shoulder girdle, 314

Function, preservation of, OS

Functional studies after operation, 306

Functions of—

consultants, 73-74, 113, 115-117

Subcommittee on Thoracic Surgery, National Research Council, 163

thoracic surgeons in field hospitals, 93

Fused chest, 306

prevention of, in hemotliorax, 144

GALE, T.. 3

CASK, G. E., S, 28

Gas-oxygen anesthesia, in World War I, 16

Gastric dilatation, 205

Gastropleural fistula, 153

Gastroscopy, 172

General hospitals :

anesthesia in, 119

auxiliary surgical group teams in, 105,

108, 100

in chain of evacuation, 77-78

in North Africa, 100
IXDEX 365

General hospitals—Continued

initial wound surgery in, 100

medical thoracic sections in, 305-300

mission of, 1ST

supporting Fifth U.S. Army, S3, 299

transfer of casualties from, to chest confers, 100

8'ee also Hospitals, .general.

General measures, 143-144

General surgeons, training of, 103

General surgery:

base section consultants in, ETOUSA, 113

regional consultants in, ETOUSA, 113-114

teams in field hospitals, 93, 104

training in, as background for thoracic

surgery, 106-107

Geneva Convention, 137,13S, 202

German Armies, incidence of wounds in, in

World War I. 7

German casualties, forward treatment of,

35-30

German prisoners of war, in North Africa,

98

German thoracic surgery, 35-37

quality of, 138

Germany, auxiliary surgical groups in, 130

Gigl i 's saw, 284

GINN, Col. L. II., 82

GLASS. Capt. W. I., 173

Glottis, hyperactivity of, 150

GORDON-TAYLOR, Sir GORDON, 9, 30, 3S

Grady Hospital, 51

GRAHAM, E. A.. 15-18, 20, 25, 44, 103. 105, 190

Granuloma, after local suit'onamide therapy,

281

Great vessels at hilus, hemorrhage from, 144

Great vessels, foreign bodies in, 150

Ground troops, body armor for, in Korea, 3

Grosvenor Square, 140

Gunfire, psychologic effect of, 220

Gunpowder, invention of, 3

GURD, FRäSER, 26

Guy's Hospital, 4

Gwathmey anesthetic machine, 14

IIAICJHT, C, 248

HAMMOND, Brig. Gen. W. A., 5

Hand-driven portable suction machines,

85-86

Hanging cast, 141

HARKEN. Lt. Col. D. E„ 113n, 115, 117. US,

120, 124, 127, 131, 138, 146, 146n, 147, 314

HARTMAN, Capt. C. C, 18

Hauptverbandplatz, 35, 36

IIAWLKY, Jlaj. Gen. P. K., 114, 115, 118. 119,

12S, 131,135, 146

HAYS, J\I. R., IS

Head :

examination of, 230

wounds of, 140

as contraindication to Trendelenburg

position, 272

in battlefield deaths, 67

in World War I, 00

Headquarters, auxiliary surgical groups,

105

Heart:

acute dilatation of, in air-raid casualties,

32

foreign bodies in, 150, 210

in World War 1,10

hemorrhage from, 13S, 196

historical note on, 42-45

prevention of dysfunction in, 98

wounds of, 136,191, 210, 2S2. 284

as indication for forward surgery, 204

dyspnea in, 6

in etiology of shock, 253

restriction of exorcise after, 311

survival after, in U.S. Civil War, 0

Sec also Cardiac; Pericardial; special

regions.

Heat loss in shock, 15

HEDBI.OOM, C. A., 27

Heidbrink anesthetic machine, 172

Homatocrit determination—

after operation, 294

by falling-drop technique, 253

Hematocrit levels, as indication for transfusion, 302

Hematoma:

infection of, 6

of lung, 11

Hematoma formation in hemothorax, 33

Hcmaturia, during sulfonamidc therapy, 295

Hemoconcentration, in shock, 192

Hemodilution, 240

Hemolytic streptococcus, in dairy products,

22

Hemopneumothorax, 6, 37, 195-196, 230, 243

control of hemorrhage in, 12

management of, in resuscitation, 252-253

signs of, 233

treatment of, at chest centers, 102

Hemoptysis, 191, 232

as indication for removal of foreign bodies,

41

in lung abscess, 157
366 THORACIC SURGERY

Hemorrhage, 88, 114, 191 Hemothorax—Continued

as cause of— aspiration of, 190, 193,195, 200, 201

death in "World "War I, 9 in civilian injuries, 2S

shock,241 in "World War I, 23

as criterion of nontransportability, 124 associated with cardiac wounds, 210

as indication for— British experience with, 33-35

forward surgery, 190, 204, 237 British management of, in World War I.

forward thoracotomy, 190, 200, 258, 270 9

thoracotomy in "World "War I, 9-10,16 diagnosis of. 220

at decortication, 25, 20 dyspnea in, 232

control of, 190, 258 effect of, in shock. 241-242

by air replacement, 12 evacuation for, 180

in U.S. Civil War, 5, 0 German management of, 37

in "World "War I, 10 historical note on, 3. 4. 0

diagnosis of, 142, 219 in air-raid casualties, 32

effect of. in shock, 241 in bullet wounds, 50

from chest wall, 195, 190 in civilian injuries, 51, 54

from intercostal artery. 191, 25S in etiology of hypoxia, 254

from mammary vessels, 258 in thoracic surgery centers. 130

in bullet wounds. 50 incidence of, 23. 54

in cardiac wounds. 210 incomplete evacuation of, OS

in German casualties, .'10-37 late results of inadequate treatment of.

in hemothorax, 13S 31

in high explosive wounds, 58 management of, 136,144,191

in liver abscess, 153-154 at 100th General Hospital chest center.

in wet lung, 24S 150

in wounds of lung. 201 at thoracic surgery centers, 102

influence of. in open Pneumothorax, 14 in Crimean War, 4

into subfascial spaces. 191 in fixed hospitals, 300 < management of. 143,144,191 in resuscitation. 252-258

transfusion in. 143. 192, 254 in U.S. Civil War, (i

Hemorrhagic infiltration of lung. 232 In World War I, 11, 10

Hemostasis. 114 pathologic process in, 9. 83-84

in hemothorax, 191 postoperative aspiration of, 197

Hemoslatic suture, 191, 190 postural evacuation of, 3, 4

Hemothoracic empyema, 145, 193-194,190 rigidity of chest wall in. 233

British experience with, 33-35 stages of clotting process in. 88-84

decortication for, 98 thoraeentesis in. 120-127

etiology of. 23-24 »S'cr also Clotted hemothorax: infected

in base hospitals. 98 hemothorax ; Organizing hemothorax:

in thoracoabdominal wounds. 38 etc.

in "World "War I, 17-18, 23-24 Hepatic abscess. in thoracoabdominal

management of, 130, 300 wounds. 153

reactivation of, in reconditioning pro- Hernia of lung—•

gram, 338 during reconditioning, 33S

Hemothorax. 124.180. 143, 243. 258, 270 in U.S. Civil War, 0

active bleeding in, 138 Herniation—

air evacuation in, 200 in wounds of diaphragm. 4

air replacement in. in "World "War I. 12 of abdominal viscera. 191

anaerobic infection in, in "World "War I. of viscera in thoracoabdominal wounds.

10 40

as indication for surgery, in "World War I, Hernioplasty, pulmonary, 0

10 HEYI), C. G.. 89, 40
INDEX 367

High explosive missiles, 54

infection after, 10

High frequency current, 84

High velocity missile wounds of heart, 43

High-velocity missiles, 272, 301

Hilnr dissection, in thoraeotomy, 282

Hii.i.MAN. Brig. Gen. C. C, 1G3, 165, 167, 168

I-Iilus, hemorrhage from great vessels at,

144

Hirtz compass. 42

Historical note:

air replacement, 12

anesthesia in World War I, 33

blast injuries, 45-40

British experience in. 30-35

British management, of hemothorax in

World War I, 9

chest wounds, 3-49

Crimean War, 4-5

debridement, 3

decortication. 24-2S

empyema in World War I, 17-24

foreign bodies, 5. 40

French experience in World War I, 9-10

German thoracic surgery, 35-37

heniothoracic empyema in World AVar I,

23-24

hemothorax. 3, 4

in U.S. Civil War, 6

in World War I, 11

hernia of lung, 6

incidence of chest, wounds, 60-61

management of open pneumothorax, in

World War 1,0

pneumothorax, 0, 9-10

tension pneumothorax, G, 11

thoracoabdominal wounds, 38-40

U.S. Civil War, 5-6

U.S. experience in World War I, 10-24

World War I. 7-24

wounding agents, 54

wounds of heart and pericardium, 42-45

History of U.S. Army Medical Department

in World War II, 16, 186

History taking. 220

HOOIIE, O., 7, 60

Holding hospitals, clearing platoons as, 96

Holding period, after surgery, 194

Holding policy, in European theater, 136-137

Hollow viscera, wounds of, 38, 258

HOLST, Col. J. C. 128

Homans' sign. 295

HOMER. 3

HOOK. Bear Acini. F. B.. USN (MC), 103

Hospital centers, 133

for U.S. Army of Occupation, 117

Hospital centers:

12th—131,155

15th—115,140

S04th—131

814th—131

81St.li—132

819th—132

820th—132

(1810th (Provisional)—131

Hospital Planning Division, Office of The

Surgeon General, 171

Hospital-stay days, reduction of, 103

Hospital trains, 78

Hospitalization, policies of. 90, 305-300

Hospifailization and Evacuation Division.

Office of The Surgeon General, 109

Hospitals:

effect of location of, on surgical timing.

1SS

in Mediterranean Theater of Operations,

90-102

inspection of, 74

location of, 109

mission of, 189

Hospitals, evacuation:

Sth—82

9th—105n, 108, 197

11th—197

3Sfh—82, 197

77th—81, 84, 193,197

94th—200, 207

122d—122

123.(1—122

124th—122

134th—122

401st (French)—S3

Sec also Evacuation hospitals.

Hospitals, field:

10th—91

Uth—75, 91

12th—122

Sec alxo Field hospitals.

Hospitals, general:

named:

Baxter, 171, 311, 310-339, 310n, 338

Brooke, 171

Brims, 171

Fitzsimons, 102, 160.171, 172, 177

Halloran, 171

Hammond, 1.71

Percv .Tones. 173
308

Hospitals, general—Continued

named—Continued

Kennedy, 171,173-177, 20.8

Lawson, 102.174

Massachusetts, 214n

Walter Reed, 101-102. 100, 107, 171, 173,

177-1S0

numbered:

5th—132

loth—122, 131, 132

17th—100

21st—07. OS, 302

23d—132

24th—70. 100, 102, 100

30th—117

30th—110,190

43d—132

48th—131. 137

50th—132

70111—70,100

00th (Hospital Plant Xo. 4173), 131. 155

137th—118, 131

140th—US

141st—174

155th—US. 140, 151, 155-100

160th—115, 118, 122, 125-120, 131, 130,

140-155, 14(iii, 314-316, 316n

300th—100

Sec ahio General hospitals.

Hospitals, station :

10th—122

52(1—83

53(1—100.102. 100, 207, 301

Sec also Station hospitals.

Hospitals, various:

Army Air Forces Reconditioning and Convalescent Regional Hospital, 330

Mt. Alto Veterans Hospital, ISO

IStli Surgical Hospital, 104

IIOWAKI). Assistant Surgeon B., 5

Hunsox, Maj. T. R., 174

HUGHES. Lt. Col. F. A., 173

Huinerus. fractures of, 140, 141

HUI-TEE, .1., 3

Hunteria n Lecture, 1010-38

Hyperresonance, in tension pneumothorax,

250

Hypotension, 245

Hypoventilation, as cause of cardiac standstill, 292

Hypoxia, 242, 240

as cause of cardiac standstill, 202

association of vagovagal reflex with, 201

etiology of. 254

THORACIC SURGERY

Immobility of diaphragm, after operation,

67

Immobilization, of—

diaphragm, 314, 310

fractured ribs, 245-246

Improvised anesthetic apparatus, 202

equipment, ,87, 120. 157

transfusion equipment, SS

Inadequate debridement, 130

Incidence, of—

blast injuries in World War I, 45-46

cardiac arrest. 242

cardiac wounds, 210

chest wounds, 00-04

in British Army, 31

in U.S. Civil War, 5-0

in Crimean War, 4, 5

in Mediterranean theater, 73

in World War I, 7, 60-01

clotting in hemothorax, 33

complications, 20, 51, 303

in shell-fragment wounds, 5S

empyema, 20, 200

in World War 1.12. 35

hemothorax, 23, 54

in civilian injuries, 51, 54

hernia of lung, 0

infection, 54

in civilian wounds, 51, 54

in foreign bodies, 145

in German casualties, 30

in Mediterranean theater, 101

in U.S. Civil War. 0

multiple wounds. 250

penetrating wounds, 51

perforating wounds, 51

retained foreign bodies, 58

respiratory infections. 20

tension pneumothorax, 250

thoracoabdominal wounds, 61, 73

in field hospitals, 04

wounding agents. 54

wounds of lung in Crimean War, 4

tS'ee uJfiO Statistics.

Incision in—

formal tltoracotomy. 281

thoracotomy, 200, 270, 271

thoracoabdominal wounds, 30—10, 200

wounds of liver, 200

Sec also special types.

India, 32

Indications for—

conservatism in World War I, 8-0
INDEX 369

Indications for—Continued

decortieation, 151-152

in chronic empyema, 25-27

in evacuation hospitals, 90

delayed primary wound closure, 300-301

drainage, 288

evacuation to fixed hospitals, 97

forward surgery in World War I, 16

forward thoracotomy, 199-201, 270-271,

303

intravenous crystalloid therapy, 25G

limited thoracotomy in World War I, 11

lobeetomy, 153

plasma transfusion, 255

postoperative bronchoscopy, 265-266, 290

postoperative replacement therapy, 294-

295

postoperative thoracentesis, 291

remedial breathing exercises, 317-318

removal of foreign bodies, 12, 136, 145, 1S1

in Crimean War, 4

in evacuation hospitals, 96

in World War 1,10, 11

replacement therapy, 253-254

semielective surgery, in evacuation hospitals, 96

surgery in field hospitals, 196, 204-205

surgery in forward hospitals, 9-10, S3

surgery in World War I, 16

thoracentesis, 252

thoracotomy, 10-12, 138-139

at initial wound surgery, 196

in World War I, 10-12

of necessity in World War I, 11

transdiaphragmatic approach in thoracoabdominal wounds, 145

British use of, 39

traumatic thoracotomy, 201, 281

Trendelenburg position, 272

Individual supervision of exercises, 307

Indoctrination:

by auxiliary surgical group teams, 129

in clearing stations, 203

of civilian surgeons, 71

Sec also Training.

Induction of anesthesia, agents for, 263

Infected clotted hemothorax, 130

Infected hemothorax, 34, 144-145, 150, 157,

191, 272

as indication for radical thoracotomy, in

World War 1,16

associated with foreign bodies. 139

decortieation for, 9S

in thoracoabdominal wounds, 153

053081—02 20

Infected hemothorax—Continued

in World War I, 9

management of, 300

with detached rib fragments, 139

Infected unclotted hemothorax, 136

Infection:

absence of, in base hospitals in Mediterranean theater, 98

after inadequate debridement, 272

after primary wound closure, 32, 278

after wounding by high-velocity missiles,

272

as cause of death in cardiac wounds, 44

as contraindication to delayed primary

wound closure, 301

as delayed complication, 198, 200

as indication for removal of retained foreign bodies, 41

as indication for surgery, in World War I,

10, 16

as result of early evacuation, 192

as result of wound closure under tension,

275

associated with foreign bodies, 51, 145,

195, 199

caused by multiple wound inspections, 230

chronieity of, in World War I casualties,

161-162

control of, 191

in abdominal wounds, 237

in associated wounds, 140

in pneumothorax, in World War I, 9-10

in retained foreign bodies, in World War

1,9

in shell-fragment wounds, 58

in U.S. Civil War, 6

in World War I, 193

incidence of, 36, 54,101

influence of, in open pneumothorax, 14

of chest wall, 191

prevention of, 33, 19S, 241, 269, 272, 299

in blast injuries, 145

in World War 1,10

Infiltration anesthesia, 192, 203

Inflammatory hydrothorax, 18

Influenza epidemics, in World War I, 17, 29

Information, dissemination of, 33, 101, 122-

125

Inhalation anesthesia, 119

contraindicated in blast injuries, 145

training in, 122

Initial wound surgery, 187, 195, 197, 21S, 269,

300

components of, 271
370 T1-I01UCIÜ SUKGERY

Initial wound surgery—Continued

drainage after, 288-290

in evacuation hospitals, !)(">

in «eld hospitals, 100

in fixed hospitals, 08, 101)

in North Africa, 104

in prevention of infection. 20

in thoracic surgery centers, 100

in thoracoalMlominal wounds, 200

indications for thoracotomy at, 10(5

on Anzio beachhead, 70, 70

timing of. 200. 237-238

Sec aluo Debridement.

Inspections of hospitals. 74, 102

Inspections of wounds, avoidance of, 124

Instrument kits, 120

Instruments, shortages of. 104

Inter-Allied Conference on War Medicine,

35.124-125

Inter-Allied Consultant Conference. 125

Intercostal artery, hemorrhage from, 138.

101

Intercostal drainage, 101. 288. 204

after decortication. .''5

in open pneuinothorax, 144

Intercostal incision. 282

for removal of clot. 144

Intercostal nerve block. 124. 200, 203. 287,

::il

at operation. 20.'!

at thoracotomy, lot)

before intercostal incision. 282

control of pain by, 143

in bronchial obstruction, 142

in crushing injuries, 142

in diagnosis of thoracic-abdominal

wounds. 220, 234

in resuscitation, 240

in wet lung. 205. 247

instruction in use of, 82

Intercostal nerves :

protection of. at debridement. 274

wounds of. 234

Intercostal spaces, postoperative narrowing

of. 300

Intercostal vessels, hemorrhage from, 143,

144.258

Intermittent positive pressure anesthesia,

2(50

Internal mammary vessels, hemorrhage

from, 138. 143, 144, 101. 258

Infernal transfers to convalescent hospitals,

173

Internist, as shock officer, 230

Interstitial bronchopneumonia, 18

Interstitial fluid, in wet lung, 247

Intra-abdoniinal complications, in wounds

of liver. 145

Infra-alveolar fluid, in wot lung. 247

Intrabronehial hemorrhage, in wet lung. 247

Inlracranial injuries. 104

Infraperifoneal hemorrhage. 258. 250

Infrapleural instillation of penicillin. 125,

271.281. 200. 200

after deeortieafion. 35

Intrapuimonary hemorrhage, in wet lung,

247

Infrafhoracie pressure during anesthesia. 14

Intravenous administration of morphine,

210, 245, 247

Intravenous anesthesia. 110, 120

training in. 122

Intravenous preoperafive medication. 203

Intravenous therapy, in chest centers. 174

Invasion, of—

Continent, 123. 12(5. 128

thoracic surgery after, 115

North Africa. 121. 128

Sicily. 00. 01

southern France. 00. 211. 257

IOVIXE. Maj. V. II.. 180

Irreversible shock, in wet lung. 248

Irrigation of ploural cavity :

at debridement. 271. 275. 28(5-287. 200

in empyenia. 28

Irritating packs, in empyenia. 151

Irritation :

of diaphragm. 234

of intercostal nerves. 234

Isohemie pain. 240

Italian campaigns. 00, 303

transportation in. 78

use of curare during. 205

Italian experience witli air replacement, in

World War 1.12

Italy. 32. 05. 05. 130, 204. 211. 230. 234. 255,

257. 200

auxiliary surgical group teams in, 104,

100. 130

equipment in. 80-87

evacuation of casualties from, to North

Africa. 07

German surrender in. 35

transportataion of auxiliary surgical

group teams in. 80

.TACKSOX. L„ l(i(!

•IACOISS, E. 1'., 18
INDEX 371

Jeeps, 1)0, 21S

JERGEKEX. Maj. P., 82

JOIIXSOX. Maj. J.. 174

JOLLY. 1). AY.. 40. 44

KAY. Pf. Col. E. P... 173.174

KKI.I.KK. Col. AA*. L.. 22. 23, 24. 25. 101,103

Kewstoke EMS Hospital. S2

KJMHROUGII. Col. .1. c, nn, IIS

KIXSELI.A. Maj. K. A., IS

KIRK, Maj. Gen. N. T.. 301, 102. 103. 107

Korean War, 185

plastic body armor in. 3

KKEISELMAX. .1.. 107

Kriegslazaretten, 30

L-5 planes. 7!)

Laeeralion( s ). of—

blood vessels by foreign bodies, 139

bronchus(i), 251

esophagus, 25S

liver. 45, 200

drainage in. 12

lung. 100. 101. 193, 201. 270. 288

Irachea. 251.258

LAEXXEC. R. T. II.

Lanibotte forceps, 270

Landing Craft. Tank. 70

LAXG. Maj. .1. T.. 317

pAKISEY. P>AKOX 1).. 3

Laryngoscopy. 172

Laryngospasm. 204

Larynx, cocainization of, 150

Lafissimus dorsi. use of. in wound closure,

144

Lavage of pleural cavity, at operation. 275,

280-287, 20(i

Learning curve. 03. 303

LEE. Lt. Col.]!. J..39

Left main bronchus, postoperative evacuation of. 200.290.201

Leghorn. 79

Lend-Lease, 133

Lethality of—

acute gastric dilatation. 143

cardiorespiratory disturbances, 209

chest wounds, 113, 190

in battlefield deaths, 00-07

forward thoracotomy, 270

high-velocity missiles. 50

intraploural hemorrhage, 144

modern wounding agents, 00

open pneumothorax, 10-20

Levin tube, 143. 257, 290

Liege, 132

Ligation of—

axillary artery, 132

internal mammary artery, 101

thoracic duct, 152

Ligature control of hemorrhage, 190

PILIEXTIIAL, IP, 25, 27

Limitation, on replacement therapy, 00,12S

Limitations of plasma, 255

Limited exfrapleural thoracoplasty, 22-23

Limited thoracotomy:

in empyema, 27

iSVe (//-so Traumatic thoracotomy.

LIXTOX, AY., 314

Lipiodol localization of empyema, 151

LISTEH, J., 7

Literature, of—

blast injuries, 45—40

empyema, after AA'orld AATar 1,17-1S

Litter carries, in Mediterranean theater,

78

Litter carry :

from battalion aid station, 21S

from battlefield, 2PS

from clearing station, 21,8

to field hospitals, 92

Liver:

bile leakage in wounds of, 39

drainage in lacerations of, 12

lacerations of. 200, 145

management of wounds of, 145,145n.

transdiaphragmatie approach in wounds

of, 39, 40

wounds of, 38, 40, 234

in World War L 3S

Liver abscess, 153-155

subdiaphragmatic drainage of. 154

Lobectomy, 31, 33. 175.170

at 100th General Hospital chest center,

153

disability separalion for, 170

for bronchiectasis. 175

for pulmonary cysts, 175. 170

Local anesthesia. 120. 102. 195. 203

in chest wall injuries. 144

Local chemotherapy, 120

Local fluid losses, 241

Local infiltration anesthesia in World AArar

I. 10

Local infiltration anesthesia for relief of

pain.240
373 THORACIC SURGERY

Local penicillin therapy, 141 Lung—Continued

Local sulfonamide therapy, 139,141, 192,196, status of, 20

215-216, 250, 281, 295, 301 in chronic empyema, 24

in battalion aid station, 216 in organizing hemothorax, 27

Localization : suture of, into parietal pleural defect, 11

in acute pneumonic empyema, 21, 22 wounds of, 272, 284

of foreign bodies, 130, 145, 231, 235-236, in Crimean War, 5

300 »See also Pulmonary.

Location, of— Lung abscess. 6,19, 148.175

evacuation hospitals in Mediterranean as indication for surgery in World War I,

theater, 95 16

thoracic surgery centers, 170-171 associated with foreign bodies, 139

thoracoabdominal wounds, 3S at 155th General Hospital chest center.

wounds of heart, 44 157

Loculation, in clotted hemopneumothorax, drainage of, 132, 157, 192

151 remedial breathing exercises after stabiliLOCKWOOD, A. L., 38 zation of, 317

London. S2,120 LY.VCII, Capt. .T. P., 146, 314

Loss of drainage tubes in pleural cavity, 144

Low-tension current, 84 MCCLOSKY. Capt. D. P.., 317

Low-velocity missiles, 54 Magill endofracheal tube, 149, 248, 290

Lower nephron nephrosis, 295 Maintenance of patent airway, 214, 293-294

in sulfonamide therapy, 281 MAKINS, G. H., 43. 44

Lumbar area, examination of, 230 Malignant lymphoma, 176

Lung: Malignant teratoma of mediastinum, 176

collapse of, as indication for surgery in Malvern Wells, Worcester, 331

World War 1,10 Mammary vessels, hemorrhage from, 138,

during intrathoracic surgery, 13 143, 144, 191, 258

contusion of, 201, 232. 23S, 270 Management of—

damage to, in— acute gastric dilatation, 143

bullet wounds, 50 blast injuries, 143, 145

relation to velocity of missile, 56, 59 bronchial obstruction, 142

thoracoabdominal wounds, 145 bronchiectasis. 175

exteriorization of, 192 brouchopleural fistula, 152

flbrosis of. in chronic empyema, 25-26 cardiac tamponade, 191

foreign bodies in, 132,150, 270 chest wounds, in North Africa, 193-194

hematoma of, 11 chronic empyema, in World War I, 22-23,

hemorrhage from, 138, 196 31

hemorrhagie infiltration of, 232 chylothorax, 152

hernia of, 6. 338 civilian trauma, 187-188

laceration of, 190, 391,193, 201, 270, 288 clotted hemothorax (British). 34-35

penetrating wounds of, 141 combat casualties at Kennedy General

perforating wounds of, 141 Hospital chest center, 174-175

postoperative reexpansion of, 293

prevention of dysfunction of, 98

reexpansion of, 191

removal of foreign bodies from, 190-191

resection of, 33,141,191

in air-raid casualties, 32

in organized hemothorax, in World War

complications in base hospitals, 98

complications of thoracoabdominal

wounds. 130

crushing injuries, 142.145

diaphragmatic hernia. 152-153

empyema. ]57-158, 174

before World War I, L8-19

between World Wars, 28-30

1,23 by British, in World War I, 9

rib fragments in. ]?,9 changes in. after World War I, 21-22

specimens of wounds of, in museums, 4 in German casualties, 37
INDEX 373

Management of—Continued

flail chest, 248-249

foreign botlies, 145,157,175, 197, 300

at ICOtli General Hospital cliest center,

150

in Crimean War, 4

in heart (pericardium), 210

hemorrhage, 143, 144, 191

hemopneumothorax, in resuscitation, 252-

253

hemothoraeic empyema, 136

hemothorax, 13G, 144, 191

in Crimean War, 4

in fixed hospitals, 300

in U.S. Civil War, 6

in World War 1,11, 16, 23

lacerations of liver, 145, 207

lung abscess, 157

mediastinal abscess, 158

open pneumothorax, 142,144,191

postdecortieation empyema, 158

pulmonary cysts, 175

shock, 196, 219, 237

in German casualties, 36-37

stove-in chest, 32,191, 214

sucking wounds, 139, 189, 190, 195, 19G,

200, 205, 20S, 243, 249-250

thoracic casualties with multiple wounds,

102

thoracoabdominal wounds, 145, 153-155,

196

in World War I (British), 38

tension pneumothorax, 142, 144, 191, 195,

196, 200, 243, 250-252

wet lung, 243, 247-24S

in air-raid casualties, 32

wounds of diaphragm, 39

wounds of liver, 145,145n

»S'ee also Teehnique(s).

Manchester, 122

Maniacal manifestations, in cerebral anoxia,

232, 243, 245

Manpower losses, reduction of, 137

Manual compression of breathing bag. 205

'•Manual of Therapy, KTO," 116, 122-123,

124.137, 139. 141-142

Manual on thoracic surgery, NRC, 163, 107-

16S

Manual reexpansion of lung, 2S7

Manual support of chest, during coughing,

214

Manuals on medical care, 189-193

Marcianise, 83, 199, 201, 204, 207, 211, 269,

270

Margin of safety, in Pentothal sodium

anesthesia, 264

Marseilles, 97

Marsupialization of diaphragm, 158

MARTIN, Maj. Gen. J. I., 35, 66, 204

Massive atelectasis, 191

MATAS, R., 13n

Maxillofacial teams, 104,105

Maxillofacial wounds, 83

MAYO, C. H., 25

MEADE, Lt. Col. R. H., 173, 173n

Measles, epidemics of, in World War I, 17

Mechanism of coughing, 249

Median incision, in thoracoabdominal

wounds, 209

Mediastinal—

abscess, 158

decortication, 26

displacement, 33, 232, 265

emphysema, 191

flutter, 249

hemorrhage, 195

pleura, stabilization of, in empyema, 21

pressure, in tension pneumothorax, 11

shift, 27, 33, 232, 265

in massive clotted hemothorax, 138

in tension pneumothorax, 250

Mediastinitis, drainage in, 132

Mediastinotomy, 191

Mediastinum:

exposure of vessels in, 282-284

foreign bodies in, in World War I, 16

hemorrhage from, 138, 196

neoplasms of, 176

stabilization of, 206, 265

wounds of, 200, 270

Medical battalion, 261st Amphibious, 75

Medical Bulletin ETO, 122

Medical chests, 126

Medical consultant in diseases of chest, 172

Medical Department, mission of, 17

Medical education, after U.S. Civil War, 7

Medical Field Service School, 121

Medical laboratories :

2d—65

15th General Medical, S2

Medical personnel, losses of, on Anzio, 76

Medical thoracic sections, 205-30C

Medical consultants in base sections,

ETOUSA, 113

Mediterranean theater:

administrative considerations in, 73-111

atelectasis in, 247
0>7/l THORACIC SURGERY

Mediterranean theater—Continued Mignano, 200

auxiliary surgical groups in, 74, 102-109, Migration of foreign bodies to heart, 210

32!) Migratory foreign bodies, 45

blood bank in, 00 Military medical manuals, 110, 122-123, 124,

chain of evacuation in, 70-70 137, 130, 141-142. 103, 107-178, 180-103,

classification of surgery in, 300n 208

concept of pleural la vage in, 287 Mines, 107

conferences in. 74, .82-83 Mirecourt, 07

consultant system in, 73-74 Misassignment of thoracic surgeons, 104

development of decortication in, 27-28, MISCALL. Lt. Col. I,.. 118.131

1.11 Mission of—

development of field hospitals in, 75-70 clearing stations, 01

early experiences in, 122, 103-107 echelons of medical care, 180-180

equipment in. S4-00, 120 Empyema Commission, 18

evacuation hospitals in, 05-07 evacuation hospitals, 05-00

evacuation in. 75-7!) field hospitals, 01-02.100

evolution of clinical policies in, 20, 55, fixed hospitals, 07-08, 209-300

75-70. 138. 145n. 185-212 hospitals, 187,180

field hospitals in. 75-70. 00-05 Medical Department, 17

fixed hospitals in. 07-08. 108 research unit. AEF. in World War I, 13-14

German officers in, 138 thoracic surgery centers, 08-100,132

hospitals in, 00-102 Missile in chest, entrance of in buttocks, 124

management of— Missiles, course of, 220, 230-231, 232

bone fragments in. 130 MITCHELL, LI. Col. G. A. G., 125

sucking wounds in. 214 MITCHELL, Maj. J. F., 18

thoracoabdominal wounds in. 200 Mobile thoracic surgery teams. 84 morale in forward hospitals of, 250

nonstandard equipment in, 120 Mobility of evacuation system, 102-103

policies of drainage in. 288 Modesto, 171

professional meetings in. 74. 82-83 Montaltodi Castro, 200

rehabilitation in. 300, 311 Monte Lungo, 200

reparative surgery in, 200 Montepescali. 200

replacement therapy in, 141 MOOKK. E.. 41

shortages of thoracic surgeons in, 74--75,

81

shortages of X-ray films in. 120

Morale of casualties. 03,170

Morbidity:

in heniothorax. 127 studies on shock in. 200

reduction of. by early surgery, 103 thoracic surgery centers in. 75, 08-102. 137

training in, 70-82 MORELLI, E., 12

transportation in. 75-70 Morphine:

traumatic thoraeotomy in, 281-282 administration of, before operation, 203

Meetings of— contraindications to, in World War 1,15

consultants. 11!). 132. 135 depressant effects of, 192, 240

regional consultants, ETCH'SA, 123 diagnostic use of, 231

Third U.S. Army surgeons, 110 dosage of, 143, 244

emergency administration of, 215, 210

MELTZF.E, S. J., 13

in resuscitation, 244

Membrane, in chronic empyema, 25 in wet lung, 247

Memphis, 171 instruction in use of, 82

Memngococcic cerebrospinal meningitis, 22n overdose of, 194, 245

Metallic foreign bodies, 13!) clinical picture of, 245

Metapneumonic empyema, 17-18 in World War 1,15

differential diagnosis of, 34 poisoning, 245, 203

Middle East, 32,58 postoperative restriction of, 203
INDKX öii)

Morphine—Continued

respiratory depression after, 192, 241!

syrettes, 12(!

Morphine-atropine, as anethesia in World

War I, 10

Mortality :

in field hospitals, 02

in thoracic surgery centers in Mediterranean theater, 110

in traumatic thoracotomy, 20

in World War 1,129

of hemothorax, 127

of pneumonectomy, 175-170

of thoracoalxlominal wounds, 129

reduction of, by early surgery, 103, 104

relation of, to emergency care, 213

kS'ee nlxo Case fatality rates ; Statistics.

Mortars, 107

Mosciioownz, A. B., 18

Motor cortex control of respiration, 314, 315

Mountain fighting:

air evacuation in, 79

transportation in, 78

MOV-NIIIAX, H.,20, 25

MOZINGO. A. E.,19

Mucus component in wet lung, 247

Mule transport in Apennines, 78, 21S

Multiple damage from bullets, 57

Multiple transfusions, desirability of fresh

blood for, 12S

Multiple wounds, 100-107, 220-221

anesthesia in, 203

as basis for evacuation, 110

as cause of nontransportability, 205

as indication for surgery in World War I,

10

blood replacement in, 250

caused by high explosives, 57

in battlefield deaths, 60

in evacuation hospitals, 97

in field hospitals, 93

in thoracic surgery centers, 102

priority of surgery in, 259

»S'cr ulxu Associated wounds.

MUI.VIHII.L, Lt. Col. I)., 83

MUXDT. Capt. II. G., 174

MURPHY, .1. B., 12

Museums:

specimens of cardiac wounds in, 43-44

specimens of lung wounds in, 4

Mushroom pack, 190

Muzzle loader, 7

Myasthenia gravis, 170

Myocardium, contusion of, 238

Nancy, 132

Xaples, 105, 250, 257

air evacuation to, from Anzio, 79

evacuation from Anzio to, 70

Napoleonic Wars, 3, 6, 45

Narrowing of intercostal spaces after operation. 300

Nasogastric decompression, 290

in acute gastric dilatation, 233

Nasophrayngeal administration of oxygen,

202

National Research Council, 163, 105, 109n,

208, 210,189

National Research Council Manual, 190-193,

208-209, 210

Nausea and vomiting, 232

Navy, care of casualties by, in Sicily, 75

Neck:

examination of, 230

exposure of vessels at base of, 282-284

wounds of, 230

in World War I, 7, 00

Necrosis of detached rib fragments, 139

Needle aspiration of chest at operation, 275

Neoplasms, accidental finding of, 177

Neoplasms of mediastinum, 176

Neuropsychiatric states, 121

Neuropsychiatry, 16S

Neurosurgeons, 118,172

Neurosurgeons in tables of organization, 75

Xeurosurgery, performance of, by protected

prisoner personnel, 138

Neurosurgery, short courses in. 165. 160

Neurosurgical centers, 170,178

Neurosurgical service at Walter Reed General Hospital, 102

Neurosurgical teams, 104, 105

New York Police Department, 28

NICHOLSON, W. F., 42, 5S

Nissen huts, 133

Nitrogen level of tidal air, 317

Nitrous oxide:

anesthesia, 149,150, 202, 264

induction of anesthesia with, 263

NIXON. J. A., 38

Nomenclature of sucking wounds, 205n

Nomenclature of wound closure, 300n

Nonclosure of wounds, at initial operation,

195,300

Noneombat personnel as blood donors, 90

Nonpenetrating wounds, 51, 191

Nonstandard equipment, 87, 120-127,12S

Nontransportable casualties, 91, 123-124,

271
THORACIC SURGERY

Nontransportable casualties—Continued

care of, in field hospitals, 91-02. 19«, 2«1

in Mediterranean theater, 76

in Sicily, 196

Nontransportability due to associated

wounds, 205

Normandy, 32

Nonurgent phase of chest surgery, 197

North Africa, 96, 97, 211

air evacuation in, 299

air evacuation to, 78

anesthesia in, 262

blood supply in, 90

complications in, 303

deficiencies of equipment in, 120

equipment in, 84-92

evacuation hospitals in, 100

evacuation of casualties to, 97

first casualties from, 162

forward thoracotomy in, 269

general hospitals in, 100

invasion of, 84,121, 128, 107,109

operations of auxiliary surgical groups in,

104, 10S, 130

North African campaigns, 27. 94. 104. 105,

234. 250

North African campaigns, field hospitals

after, 92

North African experience, 121,193-190

North African theater, 27, 33, 97,170

Sec also Mediterranean theater.

North Atlantic Patrol, 164

Nurses :

courses for:

in anesthesia, in European theater, 122

in field hospitals, 93

in thoracic surgery sections, 118

in thoracic surgery teams, 100, 107

training of, in European theater, 121, 129

Nursing care—

at 100th General Hospital chest center,

140

at Kennedy General Hospital chest center.

174

in field hospitals. 92

Nutrition, effect of early ambulation on, 311

Nutritional deficiencies, after operation, 306

Oakland. 166

Obliterative pleurltis, in empyema, 151

Obstruction of airway—

as cause of cardiac standstill, 292

from aspiration of vomitus. 292

in etiology of shock, 243-254

Office of Chief Surgeon, ETOUSA. 114, 117,

122

Professional Services Division of, 121

Supply Division of, 127

Office of Surgeon, Communications Zone,

U.S. Army of Occupation, 117

Office of The Surgeon General, 69, 102, 103,

104. 165, 167, 169. 170, 172, 202, 210

Consultant in Thoracic Surgery in, 161

Professional Services Division of, 119

Omaha Beach, 130

One-stage lobeetomy, 31

Open drainage:

after acute pneumonic stage of empyema,

21

air evacuation in, 200

in basilar empyema, 151

in empyema, 157, 158

after decortieation, 151-152

in World War I, 12, 21

See also Rib-resection drainage.

Open pneumothorax, 143, 205

anesthesia during, 205

as cause of death, in open drainage of

empyema. 21

as cause of postoperative complications,

14

British management of, in World War I, 9

diagnosis of. 142

drainage in, in World War I, 12

influence of vital capacity on, 14

management of. 142, 144, 191

produced by debridement, 274

thoracotomy in, in World War I, 13

Operating-room lighting, 8S

Operation MARKET, 129

Operation SHINGLE, 76

Opium, in hemothorax, 6

Oran, 193

Organization, of—

auxiliary surgical group teams. 104-108

convalescent hospitals, 172-173

thoracic surgery sections, 11S-119

Kennedy General Hospital chest center,

174

Walter Reed General Hospital chest center, 178

155th General Hospital chest center, 156

Organizing hemothorax:

decortieation for, 96,101

in World War 1.17-18, 23

management of, 300

Sec also Clotted hemothorax: Infected

hemothorax; etc.
INDEX dt i

Orthopedic surgery centers, 170, 178

Orthopedic surgeons, consultation with. 172

Orthopedic surgery teams, 101, 105

OSLEK, W.. 7

Osteomyelitis, of ribs, 22

OUGUTEKSOX. Col. A. W., 00

Overdosage of morphine. 19-1, 215, 2(13

in World War I. 15

Overhydration, 11)2

Overlooked sources of hemorrhage. 230

Overlooked wounds of entrance, 230

Oxygen administration—

after initial wound surgery, 202-203

at operation. 205

during anesthesia. 119. 150, 192, 202. 261

Oxygen deficiency. 232. 233, 212, 213

cerebral damage in, 238

in etiology of shock, 253-251

Oxygen:

in air evacuation, 191

in blast injuries, 113,115

in exposure syndrome, 215

in resuscitation, 33, 213-211

in tension pneumothorax, 251

in wet lung. 2-17. 218

level of blood, 317

level of tidal air. 317

therapy. 192.195. 200. 238

in German casualties, 37

in North Africa, 101

Paeiiie Ocean areas, 57,170, ISO

Packing:

control of hemorrhage by, 113

in wounds of liver, ]15u

TAGET, S., 13

Pain :

characteristics of, 231-232

control of, by intercoastal nerve block,

132,200

in abdomen, 232, 233-231

persistence of, 338

postoperative relief of, 31, 293, 311

relief of, 205, 211, 213, 211-210, 259

in forward hospitals, 219

in resuscitation, 210

in wet lung, 255

Paracentesis—

in cardiac wounds, 0

in World War 1,10

thoraeis, 1, 1S-19

Paradoxical respiration, 112, 211, 216, 218-

219, 273, 2S0

effect of, in shock, 212

Paradoxical respiration—Continued

in flail chest, 219

in stove-in chest, 32

Paramedian incision, in thoracoabdominal

wounds, 209

Paravortebral nerve block. 82. 203. 287

PAKE, A., 3.1

Paresthesia, after phrenic crushing, 2s7

Parietal pleura, closure of, 11

Parietal wounds :

in etiology of wet lung, 217

management of, in World War I, 11

Parietophrenic adhesions, 315

Paris, 117, 125,1.31. 132.135, 137

PARKER, Alaj.E. F., 110

Partial lobectomy, for lung abscess. 157

Partial wound excision, in World War I,

10

PASTEUR. P., 7

Pathogenesis of tension pneumothorax, 210

Pathologic process in—

beta hemolytic streptococci empyema, 19

blast injuries, 15

bullet wounds, 51. 55-58

chronic empyema. 22. 21, 25-20

clotted hemothorax. 33-31

hemothorax, 9

high explosive wounds, 57-58

penetrating wounds, 51

perforating wounds. 51

pneumococcic empyema, 19

postpneumoirie empyema, 19

pulmonary hematoma, 11

relation to velocity of wounding agent, 59

retained foreign bodies, 1

retained rib fragments, 139

shell-fragment wounds, 55-58

wet lung, 217

Pathophysiology, 51,197-198, 209

corerction of, 29

before surgery, 33

in World War I, 11

of bulelt wounds, 50

studies in, 13

Pathophysiology of—

cardiorespiratory mechanism. 190

chest deformities, 310, 310-317

chronic empyema, 23

fused chest, 311

hemothorax, 191

high explosive wounds, 57-58

open pneumothorax, 13

organizing hemothorax, 27, 2S

perforating wounds, 51

053081—62 27
<t~C 0 1 ö THORACIC SURGERY

l'.u-i.. Lt. Col. J., 180

Pearl Hurbor, 163

Pectoral muscles, use of, in wound closure,

270

Peetoralis major, use of. in wound closure,

144

Pelvis, case fatality rates in wounds of, 00

Pendulum respiration, in sucking wounds.

219

Penetrating wounds, 51, 141, 101

closure of, 4

hemoptysis in, 232

in Crimean "War, 4-5

in U.S. Civil War, 5-0

results in, 8

velocity of causative missiles in, 55-50

Penicillin :

administration in battalion aid station,

210

bacteriostatic dosage of, 125

depot technique of. 179

effect of, in liemotlioraeic empyema. 35

in cardiac surgery, 44

in suppurative pericarditis, 175

intrapleural instillation of. 125. 141, 271,

2S1, 290, 290

after decortication, 35

introduction of. 29

supplies of, in European theater, 128

therapy, 192, 303

after operation, 290-297

in delayed primary wound closure. 302

training in, 121

Pentathal sodium (Thiopental sodium)

anethesia, 84, 144, 149-150, 202, 205

in German casualties. 37

induction with, 203

Percussion, 230

Perforating wounds, 51. 142. 191

German management of, 37

Perforation of pleural cavity, by rib fragments, 139

Pericardial decortication, 20

Pericardicentesis, 191

Pericardiostomy, 191

in German casualties, 30

Pericarditis. 210

Pericardium :

foreign bodies in, 150. 210

in World War 1,16

historical note on wounds of, 43

involvement of, in chest wall defects, 175

wounds of, 6. 130

Perichondral sutures, in crushing injuries,

145

Periosteum, regeneration of bone from. 273

Peripheral circulation, reduction of. 245

Peripheral circulatory depression, during

anesthesia, 149

Periston (PVP),36

Peritoneal contamination. 242. 257. 258

Permissive transfers to chest centers, 132-

134

Personnel Division, Office of The Surgeon

General. 164. 172

Personnel:

of reconditioning program, 307

of research unit, AEF, in World War I. 13

Petit de la Villeon, blind fluoroscopictriangulation technique, 42

Petrolatum-impregnated gauze, in World

War I, 15

Phases of wound management, 197-198

Philadelphia. 106

Phrenic crushing, 176. 20S. 278

at thoracotomy, 287

in tboracoabdominal wounds. 145. 209

Phrenic nerve block :

after thoracotomy in World War I. 11

at operation, 14

Phrenodiaphragmatic rigidity. 23:',-234

Physical examination, 220-23,0

Physical facilities, of field hospitals, 92

Physical status, influence of. in open

Pneumothorax, 14

Physician-patient relation. 23.",

Physiologic basis of surgery. 29

Physiologic concepts. 185-180

Physiologic considerations during surgery,

14

Physiologic disturbances, 8, 10. 197-198. 213

correction of, 190, 200. 219-220

before evacuation, 204

hemothorax in, 191

Physiologic effects, in sucking wounds. 249

Physiologic effects of wounds, 187,189

Physiologic function, under anesthesia, 149

Physiologic management of chest wounds.

198

Physiology:

differences in concepts of, in World Wars,

20

of cardiorespiratory system, 0, 8. 239

of respiration, 314

Physiotherapists, 307. 318
INDEX ;79

Physiotherapy:

after operation, oil

between World Wars, 47

for frozen shoulder girdle, 314

in empyema, in World War 1,10

Pinpoint pupils, 245

PISANJ, Lt. Col. P.. X, 121

Pistoia, 70, 100

Planning', for U.S. Army of Occupation, 117

Plasma :

excessive administration of, 255

experimental pleural instillation of, 2S7

in shock,102

infusion after operation. 204

limitations of, 2S, 20,141. 255

protein levels after operation, 28Sn, 204

protein levels, determination of, 253

replacement, in—

cardiac wounds. 210

thoracoabdominal wounds. 208

sets improved from salvaged equipment,

88

supplies in Xorth Africa, 00

transfusion, 255

in battalion aid station, 21G

Plastic body armor, 3

Plastic reconstruction of chest wall. 175

Plastic secondary wound closure, 277

Plastic surgeons, IIS

Plastic surgery, 113

performance of, by protected prisoner

personnel, 13S

Plating of chest wall defects, 175

Pleura:

abrasions of, 2SS

spinal iluid fistula into, 140

wounds of, in Crimean War, 4

Pleural adhesions:

after operation. 306

as cause of thoracic immobilization, 310

caused by trauma of gauze, 2S0-2S7

incidence of, 205

Pleural cavity:

drainage of. in World War I, 12

emphasis on. in World War I. 20

foreign bodies in, 130, 270

lavage of. before wound closure, 206

penetrating wounds of, 141

perforating wounds of, 141

rib fragments in, 139

toilet of, in World War 1,11

Pleural closure at debridement, 271, 275

Pleural contamination. 257, 25S

in thoracoabdominal wounds, 242

Pleural effusions, 6, 16, 191

Pleural hematoma, 33

Pleural infection, after inadequate debridement, 301

Pleural membrane, in chronic empyema, 24

Pleural pain.231-232

Pleural thickening after poorly treated

hemothorax, 23

Pleural transudates in hemothorax, 256

Pleurectomy, 25

Pleurisy, in U.S. Civil War. 6

Pneumococcic empyema, 10

Pneumonectomy, 162

disability separation for, 170

for bronchiectasis. 175

for civilian-type lesions. 175-170

Pneumonia :

as cause of death, in World War I. IS

as complication of wet lung. 32

confusion of hemothorax with, 34

in World War I, 10. 17

incidence of, at onset of World War II. 20

Pneumonitis, from aspiration of vomit us,

202

Pneumothorax, 191, 243, 258

air evacuation in, 206

as contraindication to air evacuation, 147

at operation, in World War 1,10-20

changing concepts of, 20

diagnosis of, 220

dyspnea in, 232

effect of, in shock, 242

French management of, in World War I.

9-10

in etiology of hypoxia, 254

in management of empyema, 18-10

in U.S. Civil War, 6

management of, at thoracic surgery centers, 102

with hemothorax, 101

See also special types.

Po Valley, 70, 87

Policies:

evolution of, 269-272

in European theater, 123

in Mediterranean theater, 75-76, 185-

212

in thoracic surgery centers, 172

in World War 1,14

in Zone of Interior, 1CS-171

of hospitalization, 305-306

of management, effect of standardization

of on mortality, 64

of reconditioning program, 307-311
380 THORACIC SURGERY

Population of thoracic surgery centers. 100, Postoperative mission of—

132.. 130, 147-148, 103-13(5, 170, 173 177- evacuation hospitals, 90

17S field hospitals, 91. 92. 94-93

Portable anesthetic machines, 87, 89 Postoperative penicillin therapy, 290-297

Portable oxygen apparatus, 88 Postoperative pleural adhesions. 300

Portable suction machines. SO Postoperative pleural effusions, in "World

Portable X-ray machines, SI "War I. 12

Position: Postoperative recreations, 30(5

as determinant of type of wound, 30 Postoperative respiratory depression, 204

at wounding. GO. 220, 230-231, 232 Postoperative respiratory function, fluorochanges of, after operation, 293 scopic determination of, 300

creation of sucking wound by change of. Postoperative roontgenologio examination,

214, 230 293

effect of, on vulnerability to wounding. GO Postoperative transfusion, 292

Positioning: l'ost pneumonic empyema. 183, 317

at debridement, 272-273 in World War I, IS

at thoracentesis. 233 reactivation of, in reconditioning program,

during anesthesia, 2(54 338

during evacuation, 21.4 Postpneumonio infection, 98

for transfusion, 233-23G Posttraumatie empyema :

fur X-ray examination, 234-233 decortication for, 23-27

in open pneumothorax, 142, 214 differential diagnosis of. 34

in shock routine, 242-243 rib-resection drainage in. 33

Positive pressure anesthesia. 107, 121 , 1-iri, rostural drainage in sucking wounds. 249-

201. 202, 204. 274, 287, 293 230

for decortication. 0 Postural evacuation of hemothorax, 3, 4

for wound closure, 288, 293 Postural management of flail chest, 249

in German casualties, 37

training in. 103

Postural method in cardiac foreign bodies,

210

Positive pressure apparatus, 89

Posit ive pressure oxygen—

at operation, 2(50

in wet lung, 248

Posterolateral thoracotomy, 272. 284

Postgraduate training, 103-104

Posture:

correction of, 313

in classical chest deformity, 310

Potential for military duty, after thoracic

surgery, 110

Postinfluenzal empyema, in "World W'ill' I, Pol t er-Bucky grid, 233

183 Precautions in blood replacement, 90,128

Postmeasles pneumonia, in "World "War I. 18 rreinvasion briefing, European theater, 110,

Postoperative antibiotic therapy, 293-2" 17 121

Postoperative aspiration of— Preoperative bronchitis, 293

chest. 140. 144. 273 Prooperative bronchoscopy, 200

heniothorax. 197 Prooperative evacuation of stomach, 237, '

Postoperative bronchoscopy, 290-291, 293- 292

294 Preoperative management, 97, 102, 107,109

Postoperative complications. 292 Preoperative medication, 2(53

Postoperative development of wet lung. 247 Preoperative preparation, 237-239, 202-203,

Post operative effusions, 280 297

Postoperative exercises, 300 in cardiac wounds, 44

Postoperative management, 107, 109, 144, in field hospitals, 93

140,197. 294. 297 inadequacy of, in "World War 1,16

after initial wound surgery, 292-293 Preoperative training in breathing exercises,

of closed drainage. 200 310

of drainage tubes, 294 Pressure dressing after debridement, 277
INDEX 381

Pressure pneumothorax. Sec Tension Pneumothorax.

Prevention of—

cardiac standstill, 202

deformity, 31

empyema, 114

infection, 33, 241, 269, 299

thrombosis and embolism, 295

Preventive medicine, at onset of World War

II, 29

Primary thoracotomy, in air-raid casualties,

32

Primary wound closure, 140, 278, 300

Principles of—

debridement, 273-274

forward thoracotomy, 269

reparative surgery, 299

Prioritiesfor surgery, 13S

Priorities of—

associated wounds, 140-141

evacuation in open wounds, 141

multiple wounds, 205

sucking wounds, 209

thoracoabdominal wounds, 39,140, 209

in Spanish Civil War, 40

thoracic surgery, 259

Prisoners of war, 137-138, 202

Proeaine hydrochloride block of phrenic

nerve, 14

Proeaine hydrochloride injection at

thoracotomy, 150

Processing at Walter Reed General Hospital chest center, 178-179

Professional meeting (s) —

at Caserta, 19S

at JIarcianise, 199

in European theater, 124-125

Professional personnel:

assignment of, 73, .164-165, 188

at chest centers, 140,155. 173-174

for postoperative care in field hospitals,

94-95

for thoracic surgery sections, 118-119

in convalescent hospitals, 173

in field hospitals, 92-94

in hospital centers, 133

in shock wards, 238-239

in thoracic surgery centers, 75, 146, 155,

172. 173-174

Professional Services Division, Office of

Chief Surgeon, ETOPSA, 113, 115,121

Professional Services Division, Office of The

Surgeon General, 119, 167

Prognosis, 128

in Crimean War, 4

of thoracoabdominal injuries, in World

War I, 38

Projection of course of missile, 230-231

Prostheses in wound closure, 277

Protected prisoner personnel, 137-13S

Protein content of pleural serous effusion,

256

Psychiatric care after operation, 306

Psychologic basis of disposition, 110

Psychologic considerations, 259

Psychologic effects, of—

early ambulation, 311

prolonged physiotherapy, 311

wounding, 305

Psychosomatic aspects of retained foreign

bodies, 42

Pulmonary collapse, in—

hemorrhage, 232

hemothorax, 33

Pulmonary compression, after badly treated

hemothorax, 23

Pulmonary contusion, in etiology of shock,

253

Pulmonary cysts, 175,176

Pulmonary damage, in comminuted rib fractures, 145

Pulmonary dysfunction, after hemothorax,

127

Pulmonary edema, 200

from excessive replacement therapy, 12S,

254

in blast injuries, 254, 294

in hypoxia, 254

in wet lung, 248

Pulmonary embolism, 311

Pulmonary function:

loss of, in hemothorax, 144

reduction of, 242

restoration of, 198

Pulmonary hematoma, 254

Pulmonary lacerations, in sucking wounds,

250

Pulmonary parenchyma, foreign bodies in,

139

Pulmonary resection, 42, 144

.See also Lobectomy; Pneumoneetomy.

Pulmonary tissue, reaction of, to trauma,

247

Pulmonary tuberculosis, surgery for, 28

Pulmonary vein, septic thrombophlebitis of.

159
382 THORACIC SURGERY

Pulmonary ventilation, control of, during

anesthesia. 150

See aluo Lung.

Pulse:

in shock, 242

initial determination of, 219

Purulent exudate. in wet lung, 217

Pylorospasm. 257

Pyogenic empyema. 157

Pyothorax. »s'rr Empyema; Ilemothoracic

empyema: etc.

Qualifications, of—

anesthesiologists on thoracic surgery

teams. 107

nurses on thoracic surgery teams, 107

surgical technicians, 107

thoracic surgeons, 73, ] 17-118, 12!)

in field hospitals. 93-04

in forward hospitals. 103-104

on thoracic surgery teams, 100-107

Quality of German surgery, 13.N

Quantitative blood replacement, 255

Quantitative fluid replacement. 254-255

Quantitative replacement therapy in resuscitation. 253-254

Quantitative thoraeentesis, 253

QVIST. <;.. 41

Rabat. 105

Radiology departments, 108, 172

Radiology teams. 104

RAMSDELL. E. G. 42. 43

Rank, of thoracic surgeons, 114

RAXKIX, Prig. (Jen. F. W.. 172

Rate of transfusion. 255

Rationale of—

aspiration during acute stage of pneumonic empyema. 21

remedial breathing exercises. 314

thoraeentesis in hemothorax, 34

Rationing of blood, in European theater, 128

Reaction of pulmonary tissue to trauma, 247

Reactions to autotransfusion. 250

Reconditioning. 187. 305-339

Reconditioning centers, 150

Reconditioning program, personnel of, 307,

33S

Reconstructive surgery, 187, 197, 300

Records :

at chest centers. 147. 178-179

importance of. 124

in reconditioning program. 314-315. 330

Records—Continued

of auxiliary surgical group teams, 105n,

108-109

Recovery room. 179

Recreation after operation, 306

Recreational phase of remedial exercises,

318.330

Recurrent chronic spontaneous pneuniothorax, 17(1

Recurrent empyema during reconditioning,

338

Recurrent, hemorrhage after thoraeentesis,

252

Recurrent tension Pneumothorax, 142

Redebridement—

after inadequate dehridenient, 301

before delayed primary wound closure,

140

Reduction of mortality by early surgery. 104

Reduction of timelag. 103

RKKII. J. M. W., 314

Reeducation in voluntary breathing, 315

Reexpansion of lung—

after operation, 293

after wound closure, 288

in open pneumothorax, 144

Reflex changes under anesthesia, 149

Reflex dysfunction of hemithorax, in bullet

wounds, 57

Regimentation, 188

Regional Adviser in Thoracic Surgery,

British Emergency Medical Service, 125

Regional block anesthesia, 119,122. 203

Regional consultants, 113-114. 124

for Army of Occupation, 117

meetings of, in European theater. 123

Regional nerve block, in flail chest, 249

Regional organization of chest centers (British ), 31

Registry of retained foreign bodies, 181

Rehabilitation, 29. 78.187. 305-339

at 155th General Hospital chest center,

150-157. 159-100

at 100th General Hospital chest center,

140. 149. 314-310

at Walter Reed General Hospital chest

center, 179

in fixed hospitals, 97

in Mediterranean theater, 311

in World War I. 13

Relaxing incisions, for wound closure, 227

Relief of pain. 241, 243. 244-240

after operation, 293. 311

in wet lung. 255
INDKX 383

Remedial breathing exercises, 149, 179, 307,

310-311

in clotted heniothorax, 151

in einpyema, 151

in European theater, 140, 149, 314-310

in Zone of Interior, 314, 310-339

indications for. 317-318

rationale of. 314

routine of—

at Baxter General Hospital chest center. 318-330

at 1011th General Hospital chest center,

314-310

Removal of drainage tubes, 294

Removal of foreign bodies, 195, 199, 300, 33S

from heart, 210

in evacuation hospitals, 90

Renal failure. iS'ee Lower ncphron uephrosis.

Repair of diaphragm, 209

Reparative surgery. 79, 187, 197, 299-303

in lixed hospitals, 97

in thoracic surgery centers, 101

replacement therapy in, 302-303

timing of. 101

Replacement of blood loss at, operation, 205

Replacement therapy, 141. 238, 241, 243, 203

after operation, 294-295

before diagnostic routine, 220

in blast injuries. 143

in cardiac wounds. 44

in empyenia. 151

in German casualties, 30

in reparative surgery, 302-303

in resuscitation, 253-257

in shock. 190

in thoracoabdoniimil wounds, 257

in wounds of lung, 200

indications for, 253, 254

restriction of, 90,128

See aluo special agents.

Research unit in AEF, in World War I, 13-

14,18. 20

Resection of lung. 23,191

Resection of pulmonary hematoma, in World

War I. 11

Reserve medical officers, training of, 105

Residual axillary empyema, 1.5S

Residual chest pain, 33S

Residual empyema, open drainage of, 151

Residual hemothorax, 317

Respiration :

effect of—

morphine on. 244

Respiration—Continued

effect of—Continued

pain on, 231, 244

evaluation of, 233

in morphine poisoning, 245

in shock, 242

in wet lung, 247, 293

initial determination of, 219

maintenance of, at operation, 205

Respiratory depression, after morphine, 192

Respiratory embarrassment:

as contraindication to Pentothal sodium,

144

enhancement of, by acute gastric dilatation, 233, 257

Respiratory infections:

in World War 1,10

incidence of, 45

Respiratory stimulants, 192

Response to resuscitation, 25S-259

Restlessness—

in cerebral anoxia, 243, 244, 245

in tension pneumothorax, 251

Restrictions on use of—

penicillin, 128

X-ray films, 120

Resultsiii penetrating wounds, 3

of decortication, 151-152,157

of delayed primary wound closure, 301-

302

of empyema in World War I, 19

of rapid training, 105-100

of reconditioning program, 33S

of standardization of therapy in Mediterranean theater, 207-208

Resuscitation, 28, 124, 197-19S, 211, 213, 237-

259, 203, 209

before history-taking, 220

before initial wound surgery, 33

components of, 33

effect of—

on forward disposition, 219-220

on mortality rates, 237

failure of. 237, 203

in clearing stations, 210-218

in field hospitals, 92. 93

in forward hospitals, 29

in hemothorax. 138

in multiple wounds, 140

in thoraeoabdominal wounds, 257

objectives of, 207, 238

response to,258-259

responsibility of anesthesiologist for. 203
384 THORACIC SURGERY

Resuscitation—Continued

routine of, 241-259

thoraeentesis in, 252-25.'!

transportability after, 203

triage after, 202

Retained foreign bodies. »See Foreign

bodies; Migratory foreign bodies.

Return to duty, 91,10,137

after surgery, 305-306

from evacuation hospitals, 96

from fixed hospitals, 97

from thoracic surgery centers, 101,102

with foreign bodies in situ, 41

Rhine River, 148

Rbonchi, in wet lung, 247, 254

Riardo, 82, 206

Rib fractures, 102,191, 230, 245-246

in crushing injuries, 318

in etiology of wet lung, 247

in flail chest, 248-249

management of, at debridement, 273

Rib-resection drainage:

case fatality rates in, 148

in clotted hemopneumothorax, 151

in empyema, 150, 151, 191

in empyema in World War I, 21

in German casualties, 37

in liver abscess, 153-155

in wounds of liver, 209

Ribs, osteomyelitis of, 22

Rigidity of abdominal wall, 233-234

Rigidity of chest wall, in hemothorax, 233

Risks of—

decortication, 98

traumatic thoracotomy, 201

RoiiEiiTsox, O. H.. 28

Rockefeller Institute, 13

ROE, H., 18

Roentgenologic consultations, 172

Roentgcnologie diagnosis, 142, 234-236

in acute gastric dilatation, 143

Roentgenologic examination, 114, 121. 143,

196, 221

after operation, 295

before definitive surgery, 195

before evacuation, 139

before induction, 177

in empyema, 151

in forward hospitals, 231

in hemothorax, 33, 34,145

projection of course of missile by, 230

Roentgenologic localization—

in clotted hemothorax, 151

of foreign bodies, 145

Romansky penicillin technique, 179

Rome, 79, 83, 96, 206, 240

ROSEA'OW, K. C, 22n

Routine of—

penicillin therapy, 296

remedial breathing exercises, 314-316, 318-

336

resuscitation, 241-259

sulfoiiamide therapy, 295-296

Royal Air Corps, 119

Royal College of Surgeons, 4, 43,125

Royal Society of Medicine, 124, 125

Rupture of—

abdominal viscera, 20S

diaphragm, 191

St. George's Hospital, 4

St. Pons, 132

St. Thomas' Hospital, 4

SAINT, Maj. C, 38

Salerno landings, 100

SAMSON, Lt. Col. P. C, 27-28, 9S, 100, 108,

lOSn, 199

San Antonio, 171

SAXGEH, Lt. Col. P. W., 83

Santa Fe, 171

SAUEKBRUCII, F., 64

SCADDING, .1. G., 58

Scapula:

fractures of, 274

movement of, in remedial breathing exercises, 318

Scar tissue formation:

after wounding, 301, 302

in chronic empyema, 25

SCHEDE, M., 22

Schede operation, 22-23, 25, 26, 37

Scoliosis, after poorly treated hemothorax.

23

Secondary hemorrhage as indication for

surgery, in World War I, 16

Secondary infection of hemothorax. 23-24

Secondary resuscitation, 238-239

Secondary wound closure, 155, 300

after inadequate debridement, 272

Sedative cough mixtures, 247

Segmental control of respiration, 315

Segregation of casualties:

by types of wounds, 124,129

in evacuation hospitals, 96-97

in field hospitals. 93

with infections, 168

in World War I, 8

Seine Base Section. 132
INDEX 385

Selection of casualties for chest centers, 136 Shock—Conti nued

Selection of trainees, 105-160 management of—Continued

SELLOJRS, T. EL, 125 in field hospitals, 91, 216-218

Semielective surgery, in evacuation hos- in German hospitals, 36-37

pitals, 96 Pentothal sodium contraindicated in, 83

Semimobile evacuation hospitals, 06 studies on, in Mediterranean theater, 296

Senior Consultant in Surgery, ETOUSA, teams, 104,105

122-123 in field hospitals, 93

Septic surgery sections, in World War I, S in North Africa, 194

Septic thrombophlebitis of pulmonary vein, of auxiliary surgery groups, 239

150 Trendelenburg position in, 264, 272

Sequelae, 137,101 unconciousness in, 232

of inadequately treated hemothorax, 23 wards:

of retained foreign bodies, 41 in field hospitals, 95

Serofibrinous serositis, in hemothorax, 24 oxygen therapy in, 243

Serous effusions, 143 personnel of, 23S-239

in hemothorax, 256 Shore-to-ship evacuation in Sicily, 75, 70

Serratus anterior, 282 Short courses in thoracic surgery, 118

Shell-fragment wounds: Shortages of—

incidence of, 54 anesthetic machines, 86

pathologic process in, 55-58 blood, 141

SITEFTS. Et, Col. E. M., S3, 84, 102, 100, 206 equipment, 87,126, 194

Shock. 15. 101 thoracic surgeons, 101, 163,164,185

as cause of cardiac standstill, 202 in European theater, 117-11S

as contraindication to— in Mediterranean theater, 74-75, 81, 93

preoperative medication, 263 X-ray films, 86,126

surgery, 0 Shoulder drop, after badly treated hemoas criterion of nontransportability, 124 thorax, 23

as indication for forward surgery, 204 Shoulder:

associated with hemorrhage, 143, 204 entrance wounds in, 324

caused by severities of transportation, 78 wounds of, 220-221, 296-207

clinical picture of, 242, 253-254 Shoulder girdle:

concept of, 241-242 fractures of, 140

criteria of, 230 prevention of deformity of, OS

during operation, 25 remobilization of. 318, 311

effect of morphine in, 244-245 Shoulder girdle exercises. 310, 311

etiology of, 232, 253-254 Shrivenham Barracks, 121 from peritoneal contamination, 258

heat loss in.15 Sicilian campaign, 256

anesthetic equipment in, 204 hemoconeentration in, 192

complications in. 303 imminence of, as indication for forward field hospitals in. 263

surgery, 106 Sicily, 96,196-197. 255

in German casualties, 36 air evacuation from. 70

in hemothorax, ]38 anesthesia in. 262

in high explosive wounds, 58 auxiliary surgical group teams in 104. 105,

in thoracoabdominal wounds, 208, 242

in World War 1,10

100,130

care of casualties in, 75

instruction in, 82 equipment in, 84-S6

lower nephron nephrosis after, 281 evacuation hospitals in, 06

management of. 106, 210, 237, 241-244, 258, evacuation of casualties from, 76, 07

201 invasion of, 01,100

at battalion aid station, 210 results in, 207

in clearing station. 216-21S thoracoabdominal wounds in, 200
380 THORACIC SURG FRY

Sicily—Continued Spinal fluid fistula into pleura, 149

transportation in, 78, 80 Spirometry, 110, 317

X-ray equipment in, 85—80 Spleen :

Signs. 23.V2.S4 transdiaphragmatie approach to wounds

in shock, 242 of, 39, 40. 145

of cerebral anoxia, 243 wounds of. 200, 234. 258

>S'ce also Clinical ])icture. Splenization, 11

Silent abdomen, 234 Split-lhickness skin grafts, 139. 140, 302

Sinuses— Spokane, 171, :!11

after decortieafion, 27 Spontaneous idiopathic pneumothorax 102

as indication for surgery, in World "War I, Stabilization of chest wall. 243, 258

10 in crushing injuries. 142, 145

Site of election for— in flail chest, 240. 248-240

thoracentesis, 253 Stabilization of mediastinum at oper; lion,

thoraeotomy, 10, 11.270, 271 205

Size: Staffing of—

as indication for removal of foreign bodies. evneuntion hospitals. 90-97

41 held hospitals. 92-94

influence of. in penetrating' wounds, 3-4 thoracic surgery centers. 100-101. 10:!

of missile, as determinant of type of Staged remedial exercises, 318-330

wound. 5!) Staged surgery in combined empyema and

Skin temperature», in shock. 242 liver abscess. 154

Skin, use of. in wound closure, 277 Staging of surgical care, 73. LS0-1N9

Smoking, 102 Standardization of surgical policies. 139,

S.wiJEii, Col. II. E.. 3.1, 30, til. 73, 81. 82, 140, 185-212

84. 87. 90. 91. 92. 105. 194. 199, 203 Stalihi/locoeciix iniroix. effect of. on hemoSoft-tissue lesions. 4!). 232 fhorax. 33

SOLOC. 132, 130 Station hospitals :

Sor.TAL-, A.B., 23 in chain of evacuation, 77-78 , Somme. Battle of. if. 38 mission of, 187

SOMMKISS. Lt. Col. C. US supporting Fifth C.S. Army, 83

Sources of blood, in Mediterranean theater, thoracic casualties in. 102

250-257 thoracic surgeons in. 118

South African War, 8 thoracic surgery centers in. 100

South Pacific Area. 174 ,s'cc also Hospitals, station.

Southern France, 90,130, 211, 257 Statistics:

auxiliary surgical group teams in. 104 abdominal injuries. 108-109

Southern Line of Communications (SO- auxiliary surgical group teams. 03. 105.

LOC). 132,130 120-131

Southwest Pacific Aren. 00 battlefield deaths. 00-07, 221

Spacing of initial wound surgery, 200 British chest centers. 125

Spanish Civil War:

blast injuries in. 45-40

thoraeoabdominal wounds in, 40

wounds of heart in. 44

Spasm of abdominal wall, 234

Special treatment centers in chain of evacuation. 77-78

British incidence of empyema. 35

cardiac surgery, between World Wars

cardiac wounds. 4.3

case fatality rates, (iO-04

civilian injuries, 51, 54

clotted hemothorax, 158

Specialist ratings of enlisted men, 108 collection of. 74

Specialization : conservative management of penetr; t ing

development of, 10N-109 wounds, 198-199

in Army hospitals between wars, 10,8 deeortication, 20-27

SPEXCKI:, W. O., 25 delayed primary wound closure, 301-:! 12

Spinal cord, wounds of. 149, 220 died of wounds, 07
INDEX 38

Statistics—Continued

disposition in Mediterranean theater, 110

empyema. 175

after World War I, 22-2:$

errors in diagnosis in World War I, 10

evacuabilify, 206-207

foreign bodies in heart, 45

forward thoraeotomy, 109

improper triage, 203

incidence, 00-04

killed in action, 07

lobecf oiny, 158

penetrating wounds, 51

penicillin therapy, 207

perforating wounds, 51

postoperative bronchoscopy, 291

retained foreign bodies, 58

British experience, 42

thoracic surgery centers, 102, 110, 132, 147,

155-150, 170.17."., 174-170

thoracoabdominal wounds, 105, 207

in Spanish Civil War, 40

in World War I, 38

transfusion, 803

wounding agents. 54

»SYc (ilxo Case fatality rates; Incidence;

Mortality; etc.

Status of cardiac surgery, in 1041—210

Status of casualties :

appraisal of, 219

as indication for replacement therapy,

253

effect of, on surgical timing, 1S8, ISO

from Mediterranean then tor, 208

in Zone of Interior. 178, ISO

relation of. to evacuahility, 200

Status of thoracic surgery, in 1941—113, 161,

1S5

STAYER. Maj. (Jen. M. C. 105n

STEFIIEXS. Maj.II. B.,115

Sternal puncture, transfusion by, 250

Sternum :

fractures of. 5, 274

surgical access to, 284

STEVEXS. I,t. F. A., 18

STEWART. Lt. Col. .1.1)., 200

STOCKIXO. 1-5. C 18

Stomach :

evacuation of. before operation, 257, 290

herniation of. 153

transdiapbragmatic approach in injuries

of, 40, 145

wounds of. 209

STOXE, Maj. W. .T., 21,22n.

Stove-in chest, 190, 214, 232

in British air-raid casualties, 32

management of, 191

&Ve <ilxo Crushing injuries.

Stoves for sterilizing, 89

Stowed Park, 311

Strapping—

in flail chest. 249

in stove-in chest, 32

of fractured ribs, 245-240

Strasbourg. 3

Streptococcic infection, in hemothorax, 23-

24

Structural deformities after crushing injuries, 818

Subclavian artery, wounds of. 0

Subclavian vein, foreign body in. 45

Subcommitte on Anesthesia, National Research Council. 108

Subcommittee on Thoracic Surgery, National Research Council, 103, 104, 105, 167,

108, Kit), 109n, 189. 190

Subcutaneous emphysema, 191, 205

after closure of sucking wound, 143

after omission of drainage, 144

after wound closure, 10

diagnosis of, 142

Subdiaphragmatic drainage—

in lacerations of liver, 145

of liveiabscess, 154

Subdiaphragmatic space, drainage of, 200

Subfascial drainage, 101

Subphrenic abscess :

drainage of, 158

in lacerations of liver. 145

Subphrenic drainage, 153

Subphrenic hepatic abscess, 153

Subphrenic infection, in thoracoabdominal

wounds, 158

Sucking wounds. 121. 124. 108. 210. 280. 270

after debridement, 275

as contraindication to air evacuation, 200

as criterion of nontransportability. 124

as indication for—

forward surgery. 100. 204

surgery in World War I, 10

closure of,:88, 126.208

diagnosis of. 220, 282

effect of, in shock. 242

emergency measures in. 213-214

management, of. 82, 130. 189. 190, 195. 196,

200. 205. 243, 249-250

nomenclature of, 205n

occlusion of, 36
388 THORACIC SURGERY

Sucking wounds—Continued

priority of, 39, 209

signs of, 233

Suction drainage, in bronchopleural fistula,

152

Suction machines, 84, 89

Sulfadiazine blood level, 196

Sulfadiazine therapy, lower nephron

nephrosis after, 295

Sulfonamide powder, 120

Sulfonamide therapy:

after operation, 295-296

in cardiac surgery, 44

in chest surgery, 28

in delayed primary wound closure, 302

introduction of, 29

Supply Division, Office of Chief Surgeon,

ETOUSA, 127

Supply, influence of, on care of casualties,

185

>SVv also Equipment.

Suppuration as indication for surgery, in

World War I, 16

Suppurative complications in thoracoabdominal wounds, 153

Suppurative pericarditis, 175

Suppurative pleuritis, 108

in World War I, 8

Supracondylar fractures of humerus, 141

Suprasternal notch, wound of, 55

Surgeon:

II Corps, SS, 91, 92

Fifth U.S. Army, 87, 198

Seventh U.S. Army, 199

Surgeon General. Army, 13, 102,164, 165, 167,

109, 330

World War I, 18

Surgeons of Armies. ETOUSA, 113

Surgery:

as phase of resuscitation, 219, 238, 257

for pulmonary tuberculosis, 28

in clearing stations in North Africa, 87, 91,

106

physiologic considerations of, 13,14

priority of, in multiple injuries, 259

timing of, 191,263

Surgical Consultants Division, Office of The

Surgeon General, 102,104

Surgical coordinators, 117

Surgical emphysema, 195

Surgical risk, 148-149

classification by, 200-207

evacuation on basis of, 207

in empyema. 151

Surgical risk—Continued

in secondary resuscitation, 238-239

in wet lung, 247

Surgical teams, 74,105

in World War 1,104

Surgical technicians, 107, 119

Suture control of hemorrhage, 143, 208

Suture material, supply of, S7

Sweating, in shock, 242

Swindon, 121

Sympathetic nerve block, 240

Symptoms, 231-233

Sec also Clinical picture.

Synpneumonic empyema, 17-18

Systemic antibiotic therapy, 215, 290

Tables of equipment. 120,127

Tables of organization, 108

for field hospitals, 10S

provision for thoracic surgeons in, 75, 118

Tachycardia after exercise, 307

Tactical situation :

effect of, on—

evacuation, 202

hospital missions, 98

medical care, 185, 1SS

timing, 218

on Anzio, 76

Tamponarte of—

heart. 36, 190, 191, 210, 258, 242

liver, 40

Tangential wounds, 191

"Tarzan" exercises, 318

Teaching rounds, 121

Technicians:

courses in anesthesia for, in European

theater, 122

in reconditioning program. 307

training of, 129

Technique(s), 191-192

demonstration of, 74

development of, in chest centers, 101. 137

for removal of foreign bodies, 157

Technique (s) of—

air replacement in World War I, 12

anesthesia, 149-150,167. 263-205

anterior thoraeotomy, 282

aspiration of chest at debridement. 275

autotransfusion. 250

bronchoscopy, 294

cardiac surgery between World Wars, 44

cardiorrhaphy, 210

debridement, 270, 271, 272-281

decortication, 20,151,15S
INDEX 389

Technique (s) of—Continued Tension pneumothorax—Continued

drainage, 2SS-290 pathogenesis of, 250

of subphrenie abscess, 158 signs of, 233

emergency closure of sucking wo unds, thoracotomy for, 139

213-214 Tents:

inspection before delayed primary wound for auxiliary surgical group teams, 89, 127

closure, 301 for field hospitals, 92

muscle-flap wound closure, 276 thoracic surgery centers in, 133

occlusion of sucking wounds, 249-250 Terrain, influence of, on—

open drainage for empyema, 157-158 care of casualties, 185

oxygen administration, 244 evacuation, 202, 271

physical examination, 230 timelag, 21S

pleural drainage in World War I, 12 vulnerability to wounding. GO

pleural lavage, 2S6-2S7 Theater Chief Surgeon, ETOUSA, 122. 123,

posterolateral thoracotomy, 22S 128,131,135

postoperative bronchoscopy, 291 Sec also HAWI.KY, llaj. Gen. P. R.

pulmonary hernioplasty, 0 Theodorie, 3

reexpansion of lung, 288 Therapeutic pneumothorax, 17G

remedial breathing exercises, 31S-33G Therapy, evaluation of, in thoracic surgery

removal of retained foreign bodies, 42 centers, 101

stabilization of chest walls, 145 Thiopental sodium. Sec Pentothal sodium.

surgery in subphrenic-pleural infection, THOMSON, P. G., 45.

153-155

Thoracentesis, 191, 243, 270, 271, 272 thoraeeutesis, 253-254

(British), 34 after decortication, 35

in World War 1,10 after operation, 294

traumatic thoracotomy in World War I, at operation, 275

11 before diagnosis, 220

trachea! intubation, 2G4-2G5 effect of timing of, on British incidence

transfusion, 255-25G of empyema, 35

vascular ligation in U.S. Civil War, G

in Crimean War, 4

wound closure, 139,140 in fixed hospitals, 97

at debridement, 275-2S0 in hemothorax, in World War 1,16

in open Pneumothorax, 142,144 in management of hemothorax, 126-127

wound dressing, 278-280 in prevention of—

in World War 1,15 empyema, 114

Sec also Management. infection, 33

Tenderness in abdomen, 232 in resuscitation, 243, 252-253

Tension, wound closure under, 139,140, 302 in sucking wounds. 249

Tension pneumothorax, 143, 205, 250-251 in U.S. Civil War, 6

after closure of sucking wound, 142, 143, in World War 1,16

214, 250 indications for, 252

after debridement, 275 rationale of, in hemothorax, 34

after omission of drainage, 144 recurrent hemorrhage after, 252

as indication for surgery in World Wir I, See also Aspiration.

16 Thoracic diseases, 102,107

diagnosis of, 142 Thoracic duct, ligation of, 152

effect of, in shock, 242 Thoracic surgeons:

etiology of, 139 assignment of, 101, 104

in bullet wounds, 56 availability of, 163. 164

in U.S. Civil War, G classification of, 164

in World War 1,11 in tables of organization, 75, US

management of, 142, 144, 191, 195, 19G, 200, on thoracic surgery teams, 106-107

243,250-252 paucity of, in World War I, 8
390 THORACIC SURGERY

Thoracic surgeons—Continued Thoracoahdominal wounds, 67, 114, 124, 12S,

qualifications of. 320 136, 143, 101, 20S-200, 233-234, 252, 269,

in forward hospitals, 103-104 297

rank of. Ill air replacement contraindicated in, 12

shortages of. 10,103. 103, 1G1. 185 as contraindication to autotransfusion.

in European theater, 117-118 256

in Mediterranean theater, 74-7.1, SI, 03 as indication for forward surgery, 196, 204

Thoracic surgery : at 160th General Hospital chest center,

concept of. in World War I, 8. 17-18 153-155

courses in, at British hospitals, 115 British experience with, in World War I,

development of, between World Wars. 38-40

28-20 case fatality rates in, 61

performance of, by protected prisoner per- complications of, 136. 300

sonnel. 138 experience of 2d Auxiliary Surgical Group

postgraduate training in, 103-104 with. 63,105. 120-130

stains of— in German casualties. 37

at outbreak of World War II, 161,1S5 in World War 1,8.30.208

between World Wars. 31 incidence of, 61, 73, 74

teams. 06-97.102. 104. 105-106,128-131 indications for transdiaphragmatic techcomponents of. 100-107 nique in, 30

equipment of. 87-90 management of. 81, 91, 03, 00. 145. 196. 204

in field hospitals. 03-04 nontransportability in, 15

use of. in Sicily, 263 priority of, 140

Thoracic surgery centers. 20, 101-102, 108. replacement therapy in, 254

137 resuscitation in, 238, 257

auxiliary surgical group teams in, 105. 100 roentgenologie diagnosis in. 235

British. 31 shock in. 242

case fatality rates in. 102 Spanish Civil War experience with, 40

criteria of location of, 100 statistics of. 207

disposition at. 102 Sec ulxn under special organs.

distribution of pathologic entities in. 136 Thoracobrachial cast. 141

distribution of surgery in. 136 Thoracoplasty, 37, 175

equipment for, 127-128 after pneumonectomy. 176

establishment of, in— combined with decortication. 26

European theater. 131-132 in chronic empyema. 35

Mediterranean theater. 74-75 in tuberculosis. 176

Zone of Interior. 168-173 Thoracofomy. 124

facilities for. 133 as basis for evacuation to Zone of Inin European theater. ]01. 118. 124. 131- ferior, no

137. 146-100 contraindications to, in forward hospitals.

in Mediterranean theater. 75. 08-102. 137. 270-271

207 for organized hemothorax. in World War

in World War I. 8

I, 17-18. 23

in field hospitals. 271-272 in Zone of Interior. 168-173. 186 in forward hospitals. 103. 207. 211

inspections of, 162 in massive clotted hemothorax. 138-139

reports from, 173-181 in North Africa. 197

medical sections in, 305-306 in prevention of infection, 33

mission of. 98-100, 187, 290-300 in sucking wounds. 130

mortality in, 110 in tension pneumothorax. 250. 251

return to duty from. 102 in thoracoahdominal wounds. 200

training at. 70. 81. 101-102. 174, 177n in World War I. .8

Thoracic wounds, priority of, for surgery. indications for. 10-12. 138-130. 105. 260

205 of election, in World War I. 11. 16
INDEX 391

Thoracotomy—Continued

of necessity, 11, l(i

qualification for performance of, 191

requirements for blood in, 308

timing of, 107

Sec aIxo Formal thoracotomy; Traumatic

thoraeotomy; etc.

TjroKXTOx. T. F., 287n

Thrombophlebitis, 148, 311

Thromboplastic substances, 88

Tbrombosis, 205

Tliymus, tumor of. ITC

Tidal air. 317

Tidwortli Barracks, 121

Time factor, influence of, 185

Timelag. 103, 124, 18.S, 218, 244, 271

before surgery in field hospitals, 01

between wounding and wound closure, 301

in North Africa, 104

influence of, in shock, 241

prolongation of. 237-238

relation of, to evacuability, 200

Timing of—

closure of penetrating wounds, 4

deliridement, 272

decortication, 27, 28, 151

delayed primary wound closure, 301

in World War I, 15

drainage in empyema, 37

evacuation, 107. 100, 192-103

initial wound surgery, 107, 100, 200, 237-

28 S

open drainage in empyema, 21

removal of drainage tubes, 294

removal of foreign bodies, 42, OS, 100-191

reparative surgery. 101. 200

surgery. 1SS, 101, 108, 254, 2G3

French concept of. in World War I, 9

in tlioracoabdominal wounds, 20S, 257

in World War J, 10, 12

thoracentesis, 34, 35

thoracotomy, 107. 200-201

transfusion, in World War I. 10

Tissue damage from high-velocity missiles,

272

Tissue trauma, effect of in shock, 242

Toilet of pleural cavity, in World War I, 11

Tolandus of Parma, G

Total empyema. 275

in World War I. 22

Toul. 182

TOT;UOFF. Col. A. S. W., 118, 131, 155, 155n

TOVKI.I,, Col. K.M.. 110

TOWFKS, Capt. W. L.. 18

Trachea:

aspiration of, 85

intubation of, 203, 200

during anesthesia, 204-205

during anesthesia with curare, 205

lacerations of, 251, 25S

in sucking wounds, 250

obstruction of, 143

position of, after wounding, 230

shift of, in tension pneumothorax, 251

wounds of, 101, 200, 250, 270

as indication for forward surgery, 204

Traebeobroncbial tree:

aspiration of, 85, 200, 205

evacuation of. 102, 2S0

after intercostal nerve block, 240

obstruction of, 220

as indication for forward surgery, 205

Sec also Wet lung,

postoperative evacuation of, 293-294

selective spiromefry of, 317

Sec alxo Airway.

Tracheotomy, 101

in German casualties, 30

in wet lung. 248

in flail chest, 240

Traffic injuries, in Great Britain, 32

Training. 180, 180

before North African invasion, 121

by auxiliary surgical group teams, 129

evaluation of, 73

in anesthesia. 103.121-122, 107

in British hospitals, 115, 119-120

in bronchoscopy, 103

in European theater, 115, 118, 110-120.

140-147

in Mediterranean theater, 79-82

in field hospitals, 93

in operating-room techniques, 107

in positive pressure anesthesia, 103

in thoracic surgery centers. 101-102, 137,

174, 177n

in Zone of Interior, 105-100

of protected prisoner personnel, 137-1S3

of technicians, 129

Training Memorandum No. 3. Headquarters,

Western Base Section, ETO, 15 Feb.

1044—121

Training programs, development of, between

World Wars, 29

Transdiaphragmatic approach in thoracoabdominal wounds, 37. 89-40. 145. 145n. 190,

209
392 THORACIC SURGERY

Transdiaphragmatic approach in Triage. 189, 202-207, 203

thoracoabdominal wounds—Continued efficiency of, 00

British use of, 30 in clearing stations, 70, 01, 02. 210-218

in Spanish Civil War, 40 in North Africa. 194

Transdiaphragma tie-transpleural drainage, in relation to other casualties, 203

15S on battlefield, 3

Transfusion, 120,170-177, 203 TKIBRY, Capt. W. C, 05, 221

after operation, 292, 204 Trojan War, 3

at operation, 205 Trucks for auxiliary surgical group teams,

development of, between World Wars, 28 127

equipment. 87-80, 00 TIIVETA, J., 40. 44

German use of, 30 Truppenverbandplatz, 35

in deeortication. 20 Tuberculosis:

in field hospitals, 255 artificial pneumothorax in, 12

in reparative surgery, 302-303 lobectomy for, 175

in World War I. S, 10, 28 surgery of, 102.171, 170, 181

,8ee ttlxo Blood replacement. Tuberculous abscess of chest wall, 24

Transfusion reactions, death from, 140 Tuberculous pleurisy, 24

Transfusion techniques, 255-250 TuFFiEi:, Til., 22, 44

Tumor Board, Walter Reed General HosTransit hospitals, 135 pital chest center, 178

Transportability, SI, 05, 123-124, 187, 192- Tunisia :

103. 105, 202. 219-220 air evacuation in, 79

after blood replacement, 218 ambulance hauls in, 255

after intercostal nerve block, 240 evacuation hospitals in, 05

after surgery, 303 transportation in, 78

criteria of, 204-205 Tunisian campaign. 01, 95, 195, 240

German criteria of, 30 auxiliary surgical group teams in, 87, SO

in World War I, 14-15 equipment in, 02

Transportable casualties, care of, in evacua- thoracotomy in, 270

tion hospitals, SI, 93-94, 05 TL-RXEU. G.G., 0,25, 42

Transportation : TlJTTLE, Col. W. M„ 110, 100

administration of plasma during, 255 Type-specific blood, 90

after initial wound surgery, 290

casts in fractures of humerus. 141 Unclotted liemothorax, 130

difficulties, shortages of supplies from, 120 Unconsciousness, 232, 243

facilities, influence of. on surgical policies, Undermining incisions, 139

90 techniques of wound closure in, 140, 270,

for auxiliary surgical group teams, 87, 88. 302

80, 127 United Kingdom Base. 118. 131, 132, 133. 140

in Mediterranean theater, 75-79 air evacuation to, 135

in tension pneumothorax. 251-252 evacuation to, 132, 135-137

modes of, 21S prisoners of war in, 138

in Mediterranean theater, 78-79 thoracic surgery centers in, 31, 101, 131,

Traumatic amputation, 237 132, 133.140-100

Traumatic asphyxia, 191 United States. Sec Zone of Interior.

Traumatic pneumonia, 0 U.S. Army, incidence of chest wounds in, in

Traumatic thoracotomy, 201, 238, 270, 271, World War I, 7-8

274. 281-282 U.S. Army Air Forces, flak suits for, 3

in World War I, 11, 10

Trench Foot Conference, 125.135 U.S. Army Medical Department:

Trendelenburg position. 190. 242. 204, 205, after the Civil War, 7

272 in the World War, 15, 28. 30, 43. 45. 103

in bronchial obstruction, 142 U.S. Army of Occupation, 117
INDEX 393

U.S. Civil War, 5-0

status of surgery after, 7

wounding agents in, 54

University College, 4

University of Chicago, 287n

University of Michigan, 165

University of Pennsylvania, 160

Upper lob bronchus, obstruction of, 2S7

Urgent phase of chest wounds, 107

Urinary output:

after operation, 294

during sulfonamide therapy, 205

Utah Beach, 130

Yagal reflexes, 102

Vagovagal reflex, 26G-2G7, 201, 202

Vagus, stimulation of branches of, during

anesthesia, 150

Yal-de-Grace Hospital, 22, 38

Yalsalva maneuver, 31S

Valvular sucking wounds, 240

Vascular bed, in pulmonary collapse, 254-

255

Vascular parenchymal markings, 300

V-E Day, 137

Velocity of wounding agents :

as determinant of types of wounds, 59

effect of, 5, 50

relation of pathologic process to, 55-50

Velpeau dressing, 140-141

Venesection in—

Crimean War, 4

U.S. Civil War, 0

Ventricle(s) :

foreign bodies in, 210

wounds of, 43, 44

Veterans' Administration, 1S1

Violet de Lyon, 26

Visceropariefal decortication, 20

Viscosity of bronchial secretions, 120

Vital capacity:

in hemothorax, 252

in sucking wounds, 240

influence of, in open pneumothorax, 14, 20

reduction of, 242

Vitamin therapy, in empyema, 151

Vittel. 132

Vocal cords, hyperactivity of, 150

Vomiting, during operation, 200, 202

See also Nausea and vomiting.

Vomitus, aspiration of, 257, 202

Von Biilow drainage, in empyema, 37

Vulnerability of chest, to wounding, 50-00

Vulnerable areas of heart, 44

War Department. 160,170

War Department Circular No. 347, 25 Aug.

1044—170

War Department Field Manual 21-11—189

War Department Technical Bulletin 147,

March 1045—201, 210

War Department Technical Manual 8-210—

180, 100, 208, 210

Ward officers, 118

Washington, 171,180

Washington University, 160

Waterloo, 6

Waterseal drainage, 290

in empyema, 37

in tension pneumothorax, 251

See also Closed drainage.

WEEKS, C, 2S

WELCH, Lt. Col. C. S., 125

Wedge resection of retained foreign bodies,

42

Wet lung, 243, 240-24S

after excessive plasma administration, 255

bronchoscopy in,200

case fatality rates, in 247

catheter aspiration in, 266

chronology of, 247

clinical picture of, 247, 203

concept of, 246-24S

during anesthesia, 201

effect of, in shock, 242

in British air-raid casualties, 32

management of, 200, 205, 243, 247-248

by intercostal nerve block, 246

pain as cause of, 244

postponement of replacement therapy in,

254-155

role of morphine in, 244

role of strapping in, 245-246

signs of, 233

with flail chest, 240

See also Tracheobronehial tree.

Wheezing, in wet lung, 247

WHITAKER, Capt. L. S., 174

Whitchurch, Shropshire, 131

WHITTEMOKE, W., 6

WILLIAMS, Capt. A. C, 146

Winterized tents, 133

WIPE?,, Maj.T. B.,317

Women's Army Corps, 178

Woon, Capt. L. T., 317

World War I, 7-24, 162,103, 1S1,185,193

blast injuries in, 45

chest cripples after, 98, 101, 103, 161, 305,

307

653CS1—62-
394 THORACIC STRG10RY

World War I—Continued

concept—

of blood in ploural cavity in, 2ST

of chest wounds in. 108

of thoracic physiology in, 10-20

of thoracic surgery in, 17-18

delayed primary wound closure in, 300

equipment in, 1(57

incidence of chest wounds in, 7, 00-01

lack of resuscitation in. 237

mortality in, 120

results in. 141

surgical teams in. 104

thoracic surgery centers in, 10S

thoracoabdominal wounds in, 30, 20S

wounding agents in. 10, 54

Wound admissions, definition of, 54

Wound closure, 20. 140-141

at dehridement, 275-280

evolution of policies of. 300

in German casualties, 3G

in open pneumothorax, 144

in U.S. Civil War, 5-0

in World War I, 11

under tension. 130-140, 302

without wound excision. 32

AYound infection, after inadequate dehridement. 301

Wound management, phases of. 107

Wounding agents. 54-50. 205. 232. 271. 272

as determinants of types of wounds. 50. 00

as indications for removal of foreign bodies. 41, 5S

development of, 7

effect of velocity of, 5. 50

in battlefield deaths. (50

in British air-raid casualties. 32

in cardiac wounds, 43, 210

in civilian injuries, 28, 51

in Trojan War, 3

Wounding agents—Continued

in World War I, 7, 10

influence of,

on septic sequelae, 10

on transportability in World War I, 15

multiple wounds from, 107

X-ray equipment, in—

held hospitals. 05

Italy, 8(5

Sicily, 85-8(5

X-ray films, shortages of. 80, 120

YATKS. Lt. Col. JOHN L.. 8, 10, 11. 12, 15, 1(5,

17, 23. 25, 287

ZKMAX, Lt. F. D, 18

Zinc peroxide packing, in liver abscess, 153

ZOLLIXGER. Col. R. M., 125

Zone of Interior:

administrative considerations in. 101-181

airlift of blood from. 128, 141, 257

censorship of medical journals in, 121

consultant in thoracic surgery in. 101-1(52

evacuation to,

from European theater, 137. 150

from Mediterranean theater. 78, 07. 102,

302

plastic wound closure in, 277

reconditioning in, 307

reconstructive surgery in, 187

rehabilitation in. 310. 310-330

status of arriving casualties in. ISO. 208

surgery before evacuation to. 101

thoracic surgery centers in, 41. 108-173.

180

teams from. 118-110

thoraeotomy as indication for evacuation

to. 110

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HISTORY OF THE MEDICAL DEPARTMENT, U.S. ARMY, IN

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THORACIC SURGERY, VOLUME I

ACTIVE ARMY:

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USAR: Log Comd

OS Maj Comd (2) except

USAREUR (4)

SHAPE (2)

OS Base Comd (1)

Log Comd (1)

MDW (1)

Armies (1)

Corps(1)

Div (2)

Regt/Gp/Bg (1)

Med Bn (1)

MedCo (1)

MedDet (1)

TC (1)

USMA (5)

Svc Colleges (2)

Br Svc Seh (1) except

MFSS (5)

Med Specialist Sch (2)

Med Sec, GENDEP (1)

MedDep (1)

GenHosp (5)

Named AH (4)

USA Hosp (25-100 Beds)

(1)

USA Hosp (100-500 Beds)

(2)

USA Hosp (500-750 Beds)

(4)

USA Hosp (750-Over

Beds) (5)

(1); USA Hosp (1)

(1) ; Div (1) ; Bde (1) ; USA Hosp (1) ;

except

Med Cen (1) except

WRAMC (5)

BAMC (5)

WRAIR (5)

AFIP (5)

Def LogSptCen (1)

Def Med Spt Cen (1)

USAPERSCEN (1)

USA TRANS Tml Cmd (1)

Army Terminal (1)

PG(1)

Med Lab (1)

AFES (1)

Arsenals (1)

Med Fid Maint Shops (1)

DB(1)

Disp (1)

USA Corps (1)

MAAG (1)

Mil Msn (1)

JBUSMC (1)

9th Hosp Cen (1)

819th Hosp Cen (1)

Units organized under following TOE's:

8-510 (1)

8-551 (5)

8-590 (1)

Historical Unit,

USAMEDS (1,500)

TOE's 8-510, 8-551, 8-590 (1).

Request copies remaining on hand after initial distribution be returned to The Historical Unit, Forest Glen Section, Walter Reed Army Medical Center, Washington 12, D.C.