MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II

Accesion For

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NOTE

This volume was vrittten and edited under the direction and supervision of Colonel John Boyd Coates, Jr., MC, USA, former Director and Editor in Chief, The Historical Unit, U.S. Army Medical Service.

ARNOLD LORENTZ AHNFELDT,

Colonel, Medical Corps,

Editor in Chief.
MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR II

THORACIC SURGERY

Volume II

Prepared and published under the direction of

Lieutenant General LEONARD D. HEATON

The Surgeon General, United Stales Army

Editor in Chief

Colonel ARNOLD LORENTZ AIINFELDT, MC, USA

Editorfor Thoracic Surgery

FRANK B. BERRY, M.D.

Associate Editor

ELIZABETH M. MCFETRIDGE, M.A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D.C., 1965

» "> diyj-fj.
SURGERY IN WORLD WAR II

Advisory Editorial Board

MICHAEL E. DEBAKEY, M.D., Chairman

FRANK B. BERRY, M.D. JOHN B. FLICK, M.D.

BRIAN B. BLADES, M.D. FBANK GLENN, M.D.

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

STERLING BUNNELL, M.D. (dec.) ISIDOB S. RAVDIN, M.D.

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

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

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

MATHER CLEVELAND, M.D. It. GLEN SPURLINC, M.D.

DANIEL C. ELKIN, M.D. (dec.) BARNES WOODHALL, M.D.

ROBERT M. ZOLLINGER, M.D.

Brigadier General DOUGLAS B. KENDEICK, Jr. (ex officio)

Brigadier General JAMES E. GRAHAM (ex officio)

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

The Historical Unit, United Slates Army Medical Service

Colonel ARNOLD LORENTZ AIINFELDT, MC, USA, Director

CHARLES J. SIMPSON, Executive Officer

Lieutenant. Colonel GILBERT A. BISHOP, MSC, USA, Chief, Special Projects Branch

CHAIU.ES M. WILTSE, Ph. D., Litt. D., Chief, Historians Branch

ERNEST ELLIOTT, Jr., Chief, Editorial Branch

Lieutenant Colonel JEROME RUDBERG, MSC, USA, Chief, Information Activities Branch.

RODERICK M. ENGERT, Chief, General Reference and Research Branch

HAZEL G. IIIXE, Chief, Administrative Branch

Library of Congress Catalog Card Number: 63-6000

For sale by the Superintendent of Documents. U.S. Government Printing Office

Washington, D.C.. 20402
THORACIC SURGERY

Volume II
MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department of

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

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

General, 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

Hospitalization and Evacuation^ Zone of Interior

Organization and Administration in World War II

Personnel in World War II

CLINICAL SERIES

Internal Medicine in World War II:

Vol. I. Activities of Medical Consultants

Vol. II. Infectious 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

Unknoiun Means

Vol. VI. Communicable Diseases: Malaria

Vol. VII. Communicable Diseases: Arthropodbome Diseases Other

Than Malaria
VIII

Surgery in World War II:

Activities of Surgical Consultants, vol. I

Activities of Surgical Consultants, vol. II

General Surgery, vol. II

Hand Surgery

Neurosurgery, vol. I

Neurosurgery, vol. II

Ophthalmology and Otolaryngology

Orthopedic Surgery in the Eim-opean Theater of Operations

Orthopedic Surgery in the Mediterranean Theoler of Operations

The Physiologic Effects of Wounds

Thoracic Surgery, vol. I

Vascular Surgery

Miscellaneous:

Blood, Program in World War II

Cold Injury, Ground Type

Dental Service in World War II

Veterinary Service in World War II

Wound Ballistics
Authors

BRIAN B. BLADES, M.D.

Lewis Saltz Professor of Surgery, George Washington University School of Medicine,

and Chief of Surgery, George Washington University Hospital, Washington, D.C.;

Consultant in Surgery, Walter Reed General Hospital; Consultant in Surgery, National Institutes of Health; Consultant in Surgery, U.S. Veterans' Administration.

Formerly Colonel, MC, AUS.

LYMAK" A. BREWER III, M.D.

Professor of Surgery, Loma Linda University School of Medicine, Los Angeles,

Calif.; Consultant in Surgery, U.S. Veterans' Administration, since 1946; Civilian

Consultant in Surgery to The Surgeon General, U.S. Army, since 1908; Consultant

in Surgery, U.S. Navy, since 19G4. Formerly Lieutenant Colonel, MC, AUS.

THOMAS II. BUKFORD, M.D.

Professor of Clinical Thoracic Surgery, Washington University School of Medicine,

St. Louis, Mo. Formerly Lieutenant Colonel, MC, AUS.

B. NOLAXD CARTER, M.D.

Professor of Surgery Emeritus, University of Cincinnati College of Medicine, Cincinnati, Ohio; Consultant to The Surgeon General, U.S. Army. Director, Surgical

Consultants Division, Office of The Surgeon General, 1942^15. Formerly Colonel,

MC, AUS.

MICHAEL E. DEBAKEY, M.D.

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

College of Medicine, Houston, Tex. Chief, General Surgery Branch, Surgical Consultants Division, Office of The Surgeon General, and Assistant Director, Acting

Director, and Director, Surgical Consultants Division, 1942^16. Formerly Colonel,

MC, AUS.

DwiGHT E. HAKKEX, M.D.

Clinical Professor of Surgery, Harvard Medical School, Boston, Mass.; Surgeon, Peter

Bent Brigiiam Hospital, Boston, Mass.; Chief of Thoracic Surgery, Mount Auburn

Hospital. Cambridge, Mass.; Chief of Thoracic Surgery, Maiden Hospital, Maiden,

Mass. Regional Consultant in Thoracic Surgery, European Theater of Operations,

U.S. Army, 1942-46. Formerly Lieutenant Colonel, MC, AUS.

740-941'-
Foreword

The first volume on thoracic surgery in the history of the U.S. Army

Medical Department in World War II was published in 1963. This is the

second and final volume of that special series.

In addition to administrative considerations, the first volume set forth

the routine of management of chest injuries from emergency care on the battle

field to final rehabilitation in a chest center. It dealt with special types of

wounds and with complications only incidentally. This second volume deals in

detail with both of those subjects, both of which deserve most careful attention,

for many of the concepts set forth were unknown in World War I and in civilian

thoracic surgery and were recognized for the first time in World War II.

The syndrome of the wet lung, for instance, undoubtedly existed in World

War I, but it went unrecognized and untreated, and its sequelae—often its

lethal sequelae—were massive atelectasis and pneumonitis. Yet, once the

existence of the syndrome was recognized and its pathophysiology elucidated,

its prevention, became a relatively simple matter and its management almost

equally simple.

Similarly, hemothorax undoubtedly existed in World War I, but again its

importance in military surgery was not realized, and such concepts as were

developed about it were later proved to be fallacious. Correct management—

that is, simple aspiration of the chest—did not always prevent organization of

the retained blood and did not always prevent infection of the organizing clot,

or even hemothoracic empyema, but it usually aborted most of these pathologic

processes. If organization of the clot did occur, decortication was the solution

of the problem of infection and hemothoracic empyema. The chest cripples

after World War I were happily absent after World War II.

The results achieved in these potentially dangerous complications of chest

trauma as well as in foreign bodies retained in the lung, the heart, and the great

vessels, constitute a record of real brilliance. Exactly how brilliant it was is

evident in. the final chapter of this volume, in which there appears the record

of a really unique endeavor, the follownp, in 1960-61, of a small group of

casualties who sustained their chest injuries in 1943-45. The series is small, it

is true, but there seems every reason to assume that the excellent status of this

small group, whose wounds were truly critical, is an index of the status of most

other casualties whose wounds were similarly critical.

Once again, as in the first volume of the series, I would express my thanks

to the authors and editors whose devoted work has made possible the production

of this and other volumes of the history of the U.S. Army Medical Department
XII FOREWORD

in World War II. And also, as in the first volume. I would pay particular

tribute to the hue work of Dr. Frank B. Berry, Editor for Thoracic Surgery,

whose enthusiasm, patience, and wise guidance carried this project past its

initial difficulties and discouragements to a highly successful conclusion.

LEONARD D. IIEATOX,

Lieutenant General,

The Surgeon General.
Preface

As was pointed out in the first of the two volumes which make up the

thoracic surgery series in the history of the U.S. Army Medical Department in

World War II, the fact that the story could not be told in one volume is a reflection of how this specialty came of age in the Second World War.

The first of the thoracic surgery volumes includes a historical note; the

general, including the statistical, background of thoracic injuries; administrative considerations in the Mediterranean and European theaters and in the Zone

of Interior; and the routine of management of war wounds of the chest from

emergency care on the battlefield to rehabilitation in a thoracic surgery center.

This second volume deals with the special types of thoracic wounds caused

by the missiles of modern warfare and with the management of their complications. As noted in volume I, the Pacific experience will be related in the

volume dealing with surgery in the Asiatic-Pacific theater.

Special attention is devoted in volume II to certain complications of these

injuries whose significance was realized, or fully realized, for the first time in

World War II.

Ketained foreign bodies have always constituted a fascinating phase of

military chest surgery, though their management has not always been as discriminating, and therefore as successful, as it eventually became in this Avar.

The series of 134 operations performed by Lt. Col. Dwight E. Harken, MC,

in which foreign bodies were removed from the heart and great vessels, constitutes a remarkable achievement. There were no deaths in the series, and

all of the patients left the chest centers with normally functioning hearts. The

cardiac and cardiovascular operations performed at this and other chest centers

during the war helped to lay the foundations for the almost miraculous advances in this field since the war.

The concept of wet lung was developed in World War II by Maj. Thomas

PL Burford, MC. The methods devised to combat it prevented graver subsequent complications of chest wounds, As a result, the huge morbidity that

had attended these injuries in World War I was eliminated, and many lives

were undoubtedly saved.

Ilemothorax was recognized in World War II as one of the important

complications of chest wounds and as an antecedent of the more serious complications of organizing and infected hemothorax and hemothoracic empyema.

Prompt and adequate aspiration of the chest was a simple and uniformly

applicable measure of management that eventually came into general use.

Decortication proved the solution in patients with hemothorax which went

on to organization and infection because of bad management, or in spite of

sound management. The operation had been employed earlier for the type
XIV PREFACE

of empyema usual in civilian life, but not for complications of wounds of the

chest. Its bold, and imaginative application to organized hemothorax and

hemothoracic empyema by Major Burford was attended with such good results

that the operation promptly came into general use throughout the theater.

It is a tribute to the excellent quality of the chest surgery done overseas

that, after the first months of the war, relatively little active treatment was required by the thoracic casualties evacuated to Zone of Interior hospitals. The

thoracic cripples who thronged these hospitals after World War I were almost

never observed in World War II.

By tradition, a history of military medicine in any particular war has

ended with the end of the fighting. There have been almost no attempts to

determine the postwar results of special methods of treatment. Particular

attention is therefore directed to the final chapter in this volume, which deals

with the clinical and roentgenologic followup, in 1960 and 1961, of 167 casualties who sustained chest wounds in the 1943-45 period. The recorded data

represent an incredible amount of time and effort on the part of many persons

and agencies, but the followup was entirely the inspiration, and chiefly the

work, of Dr. Lyman A. Brewer III, formerly Map, MC. It was a practical

effort because the groundwork for it had been laid during the war: While Dr.

Brewer was serving as a thoracic surgeon with the 2d Auxiliary Surgical Group

in the Mediterranean theater, he kept an individual record for each casualty

he cared for personally. The selection of the patients whom it was considered

practical to followup in I960 and 1961 was made from this material.

This long-term followup study is a unique and praiseworthy endeavor.

It is unfortunate that more such attempts have not been made. The excellent

clinical and roentgenologic status of these casualties and their active engagement in the normal activities of civilian life give testimony, as Dr. Brewer

concludes, to the management of critical thoracic wounds during World War II

by (he policies and practices described in these two volumes.

As was pointed out in the preface to the first of these two volumes, it would

be impossible to produce books of the range of these volumes on thoracic surgery

without the 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 again to make acknowledgment to them :

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

The Surgeon General and Chief, Thoracic Surgery Section, Walter Beed General Hospital, Washington, D.C., during World War II.

Dr. Brewer, who served with Team No. 2, 2d Auxiliary Surgical Group, in

the Mediterranean theater and later in the European theater.

Dr. Burford, who served with Team No. 3, 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
PREFACE XV

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

and made many helpful suggestions.

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

Branch, Surgical Consultants Division, Office of The Surgeon General, and now

Chairman of the Advisory Editorial Board for Surgery.

Dr. Harken, Regional Consultant in Thoracic Surgery to the Senior Consultant in Surgery, European theater. Dr. Harken also directed the chest

center atthe 160th General Hospital, Stowell Park, Gloucestershire.

A large part of the artwork was Dr. Brewer's original conception, and he

directed the preparation of all of it from beginning to end.

Mr. Milton C. Bossoff, formerly Assistant Chief, Statistical Analysis

Branch, Medical Statistics Division, Office of The Surgeon General, collected

and tabulated the official statistics for the thoracic surgery volumes.

My grateful appreciation is clue to Mrs. Ethel Bauer Bamond, who served

as assistant to the Associate Editor and who typed the entire original manuscript with notable speed, accuracy, and real medical intelligence,

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

Historical Unit, U.S. Army Medical Service:

Maj. Albert C. Biggs, MSC, formerly Chief, General Reference and Besearch 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 clown numerous obscurities to their final solution.

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

volumes for publication and, with the assistance of Mrs. Martha R. Stephens,

Editor (Printed Media), prepared the artwork and its layouts in editorial style

for the printer.

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. McFetridge, 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, former 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. BEERY, M.D.
Contents

Page

FOREWORD XI

PREFACE.

Part I

SPECIAL TYPES OF WOUNDS OF THE CHEST

Chapter

I Special Types of Thoracic Wounds (Lyman A. Brewer 111, M.D., and

Thomas II. Burford, M.D.) 3

Wounds of the Chest Wall 3

Sucking Wounds °

Fractures of the Ribs and Adjacent Structures 11

Wounds of the Lungs 1

(

> Wounds of the Mediastinal Structures !•'

Wounds of the Trachea and Bronchi 21

Wounds of the Esophagus 24

Crushing Injuries 30

Blast Injuries 32

Associated Wounds 4o

II Wounds of the Heart (Including Retained Foreign Bodies), Mediterranean

(Formerly North African) Theater of Operations (Lyman A. Brewer III,

ALI)., and Thomas II. Burford, M.D.) 49

Incidence 49

Clinical Picture and Diagnosis 51

Cardiac Tamponade 08

Pathologic Process ('3

Pericardial Injuries 64

Contusions "ö

Lacerations 69

Penetrating and Perforating Wounds ^1

Migratory Foreign Bodies 78

Stab Wounds 84

Injuries of the Great Vessels So

Management of Cardiac Wounds 8;>

Technique of Cardiac Surgery 89

Analysis of Cases !'4

III Thoracoabdominal Wounds (Lyman A. Brewer III, M.D.) 101

General Considerations 101

Pathologic Process 102

Diagnosis 100

Exploration HO

Resuscitation and Prcoperative Preparation 111

XVII
XVIII CONTENTS

Chapter

III Thoracoabdomin.il Wounds—Continued *

aOe

Anesthesia 113

Surgical Approach 114

Incision 110

Technique 117

Special Surgical Considerations 121

Postoperative Care 125

Management in Base Hospitals 127

Case Histories 133

Experience of the 2d Auxiliary Surgical Group 130

Part II

COMPLICATIONS OF WOUNDS OF THE CHEST

IV Complications and Sequelae (Thomas H. Burford, M.D.) 145

Tension Pneumothorax 145

Hemorrhage 153

Acute Gastric Dilatation 157

Emphysema 157

Pulmonary Edema 101

Atelectasis 103

Hematoma of the Lung 105

Bronchopleural Fistula 109

Wound Disruption 173

Clostridial Myositis 175

Chylothorax 175

Lung Abscess 175

Mediastinal Abscess 178

Pneumonitis and Pneumonia 17S

Traumatic Osteomyelitis 17!)

Chronic Sinuses of the Chest Wall 180

Defects of the Chest Wall 181

Adhesive Pleuritis 183

Diaphragmatic Hernia ISO

Hernia of the Lung 197

Residual Symptoms 202

V Wet Lung (Thomas H. Burford, M.D.) 207

Concept and General Considerations 207

Pathogcncsis and Pathophysiology 208

Etiologic Factors 211

Clinical Picture 213

Diagnosis 215

Prophylaxis 210

Management 217

Results of Therapy 232

Case Histories 232

VI Hemothorax and Hemothoracic Empyema (Thomas H. Burford, M.D.) 237

General Considerations 237

Incidence of Hemothorax and Its Complications 238

Pathogenesis of Organizing Hemothorax 2-13
Contents

Page

FOEKWOED XI

PREFACE.

Part I

SPECIAL TYPES OF WOUNDS OF THE CHEST

Chapter

I Special Types of Thoracic Wounds (Lijman A. Brewer III, M.D., and

Thomas II. Burford, M.D.) 3

Wounds of the Chest Wall 3

Sucking Wounds °

Fractures of the Ribs and Adjacent Structures 11

Wounds of the Lungs R>

Wounds of the Mediastinal Structures 1-'

Wounds of the Trachea and Bronchi -1

Wounds of the Esophagus -4

Crushing Injuries 30

Blast Injuries 32

Associated Wounds 4.:)

II Wounds of the Heart (Including Retained Foreign Bodies), Mediterranean

(Formerly North African) Theater of Operations (Lyman A. Brewer III,

M.D., and Thomas II. Burford, M.D.) 49

Incidence 49

Clinical Picture and Diagnosis öl

Cardiac Tamponade öS

Pathologic Process ('3

Perieardial Injuries f>4

Contusions *>ö

Lacerations ''•'

Penetrating and Perforating Wounds "1

Migratory Foreign Bodies '8

Stab Wounds 84

Injuries of the Great Vessels 85

Management of Cardiac Wounds 85

Technique of Cardiac Surgery 89

Analysis of Cases ()4

III Thoracoabdominal Wounds (Lyman A. Brewer 111, M.D.) 101

General Considerations 101

Pathologic Process 1"2

Diagnosis 1"G

Exploration H"

Resuscitation and Preoperative Preparation 111

XVII
XVIII CONTENTS

Chapter

III Thoracoabclominal Wounds—Continued *

a

0

e

Anesthesia 113

Surgical Approach 114

Incision 116

Technique 117

Special Surgical Considerations 121

Postoperative Care 125

Management in Base Hospitals 127

Case Histories 133

Experience of the 2d Auxiliary Surgical Group 136

Part II

COMPLICATIONS OF WOUNDS OF THE CHEST

IV Complications and Sequelae (Thomas II. Burford, M.D.) 145

Tension Pneumothorax 145

Hemorrhage 153

Acute Gastric Dilatation 157

Empln'sema 157

Pulmonary Edema 161

Atelectasis 103

llematoma of the Lung 105

Bronchoplcural Fistula 169

Wound Disruption 173

Clostridial Myositis 175

Chylothorax 175

Lung Abscess 175

Mediastinal Abscess 178

Pncumonitis and Pneumonia 178

Traumatic Osteomyelitis 179

Chronic Sinuses of the Chest Wall 180

Defects of the Chest Wall 181

Adhesive Pleuritis 183

Diaphragmatic Hernia 186

Hernia of the Lung 197

Residual Symptoms 202

V Wet Lung (Thomas H. Burford, M.D.) 207

Concept and General Considerations 207

Pathogenesis and Pathophysiology 208

Etiologic Factors 211

Clinical Picture 213

Diagnosis 215

Prophylaxis 216

Management 217

Results of Therapy 232

Case Histories 232

VI Ilemothorax and Ilemothoracic Empyema (Thomas H. Burford, M.D.) 237

General Considerations 237

Incidence of Hemothorax and Its Complications 238

Pathogenesis of Organizing Hemothorax 243
CONTENTS XIX

Chapter

VI Hemothorax and Hemothoracic Empyema—Continued Pa9

e

Pathologic Changes in Chronic Traumatic Hemothorax 249

Bacteriology of Organizing Hemothorax 261

Physiopathology of Hemothorax 263

Clinical Picture and Diagnosis 263

Management of Simple Hemothorax 267

Clinical Picture and Diagnosis of Hemothoracic Empyema 272

Empyema in the World Wars 273

Management of Infected Hemothorax and Hemothoracic Empyema 275

Decortication of the Lung 278

Technique of Decortication 289

Postoperative Management After Decortication 29S

Decortication in Empyema of Nontraumatic Origin 300

Special Studies of Pulmonary Decortication 301

Case Histories 311

VII Management of Retained Intrathoraeic Foreign Bodies, Mediterranean (Formerly North African) Theater of Operations (Lyman A. Brewer III,

M.D., and Thomas H. Burford, M.D.). 325

Incidence °-°

Indications for Surgery °25

Surgical Timing 328

Techniques of Localization 332

Surgical Technique °46

Analysis of Cases 348

VIII Management of Retained Foreign Bodies in the Heart and Great Vessels,

European Theater of Operations {Dwight E. Harken, M.D.) 353

Anatomic Location of Missiles ü5o

Foreign Bodies In and About the Heart 3oo

Foreign Bodies In and About the Great Vessels 380

Migratory Intravascular Foreign Bodies 580

Experiences at the 155th General Hospital Thoracic Surgery Center 393

Part III

OBSERVATIONS ON WOUNDS AND DISEASES OF THE CHEST

IN THE ZONE OF INTERIOR

IX Management of the Sequelae of Combat-Incurred Wounds, Zone of Interior

{Brian B. Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBahey,

M.D.) 399

Status of Returning Casualties 399

Clinical Considerations 400

Organizing Hemothorax 401

Hemothoracic Empyema 404

Retained Foreign Bodies 407

Chest Wall Defects 412

Draining Sinuses of the Chest Wall 412

Associated Wounds 413
XX CONTENTS

Chapter Page

X Surgical Aspects of Diseases of the Chest (Brian B. Blades, M.D., B. Noland

Carter, M.D., and Michael E. DeBakey, M.D.) 415

Bronchieetasis 415

Pulmonary Tuberculosis 424

Lung Abscess 428

Empyema 429

Actinomycosis 431

Spontaneous Pneumothorax of Xontubcrculous Origin 432

Malignant Neoplasms 433

Lesions of the Esophagus 439

XI Long-Term (1943-61) Followup Studies in Combat-Incurred Thoracic Wounds

(Lytnan A. Brewer 111, Af.D.) 441

Background of Study 441

Materials and Methods 442

Basic Data 445

Therapeutic Classification 445

Initial Wound Surgery 445

Subsequent Surgery 449

Mortality and Disposition.. 450

Wounds of the Chest Wall 451

Lacerations of the Lung 4ß2

Mediastinal Injuries 46S

Blast Injuries 473

Thoracoabdominal Wounds 47(5

Ilematoma 49g

Wet Lung 501

Hemothorax 506

Retained Foreign Bodies 513

Postdischarge Followup 522

Summary and Conclusions 525

APPENDIX

Special Reports and Statistical Data (B. Noland Carter, M.D., and Michael K.

DeBakey, M.D.) 529

IXDEX 555

Illustrations

Figure

1 Superficial bullet wounds of chest wall not involving bony structures 3

2 Schematic showing of pathologic physiology of sucking chest wound 6

3 Schematic showing of pathologic physiology of flail chest 13

4 Management of flail chest 14

5 Schematic showing of results of laceration of main bronchus 21

6 Thoracic laceration of esophagus 24

7 Cervical laceration of esophagus 25

S Acute suppurative mediastinitis secondary to perforation of esophagus 26

9 Large esophagoplcural fistula with total right pyopneumothorax 29

10 Schematic showing of pathologic physiology of blast injury 40

11 Fatal cardiac contusion 50

12 Survivor of cardiac wound shortly after machinegun slug had been removed

from his heart 51
CONTENTS XXI

Figure rage

13 Foreign body in left ventricle of heart 54

14 Foreign body in wall of left ventricle near cardiac apex 56

15 Serial electrocardiograms taken after penetrating wound of heart 57

16 Machinegun bullet in right side of heart near junction of right auricle and right

ventricle °'

17 Shell fragment in anterior wall of heart in region of right ventricle 5S

IS Schematic showing of pathologic physiology of acute pericardial tamponade... 59

19 Pneumopericardium with retained foreign body just behind heart 60

20 Management of cardiac tamponade by aspiration 62

21 Scattered petechial and confluent hemorrhages of right ventricle caused by

penetrating bullet wound of sternum 6'

22 Electrocardiogram of patient with cardiac contusion 09

23 Technique of cardiac surgery ' 0

24 Technique of cardiac surgery ''

25 Repair of through-and-through wound of heart 73

26 Repair of through-and-through wound of heart "7

27 Migratory intravascular foreign body 8°

28 Migratory intravascular foreign body SI

29 Migratory intravascular foreign body 82

30 Retained shell fragment in close apposition to ascending aorta 86

31 Retained .38-caliber bullet lying directly against ascending aorta for 20 years.. 87

32 Technique of cardiac surgery 90

33 Technique of cardiac surgery 92

34 Suppurative pericarditis 96

35 Types of wounds of diaphragm possible from penetrating or perforating missiles. 104

36 Schematic showing of maximum expiratory excursion of diaphragm 107

37 Technique of transdiaphragmatic operation for left-sided thoracoabdominal

wound 1"

38 Thoracoabdominal wound requiring later drainage of anterior subphrenic abscess following laceration of liver 1°"

39 Thoracoabdominal wound requiring later drainage of large intrahepatic abscess. 131

40 Management of subphrenic abscess secondary to laceration of liver 132

41 Coexistent bile empyema and subphrenic abscess 134

42 Pathologic physiology of tension pneumothorax 146

43 Tension pneumothorax of various origins W"

44 Pressure (tension) pneumothorax 150

45 Lateral roentgenogram showing extreme degree of pressure pneumothorax with

mediastinal shift 1°1

46 Management of tension pneumothorax 152

47 Schematic showing of pathologic physiology of mediastinal emphysema 158

48 Managern ent of mediastinal emphysema 160

49 Management of mediastinal emphysema 161

50 Technique of intermittent positive pressure oxygen administration in field and

evacuation hospitals 16^

51 Postoperative atelectasis with complete collapse of lung 163

52 Posteroanterior roentgenogram showing hematoma and clearly defined missile

track in left lung 166

53 Posteroanterior roentgenogram showing typical intrapulmonary hematoma 167

54 Posteroanterior roentgenogram showing sharply defined intrapleural hematoma. 167

55 Hematoma of lung 16^

56 Bronchopleural fistula 1'^

57 Sinus of chest wall resulting from traumatic osteomyelitis of clavicle 181
XXn CONTENTS

Figure Page

5S Defect of anterior chest wall 182

59 Diagrammatic representation of infolded lung (adhesive pleuritis) 184

60 Traumatic diaphragmatic hernia 188

61 Diaphragmatic hernia 190

62 Diaphragmatic hernia 192

63 Anatomic distribution of 28 diaphragmatic hernias 194

64 Diaphragmatic hernia 195

65 True hernia of lung 198

66 Technique of repair of pulmonary hernia 200

67 Management of patient with wet lung 218

68 Intercostal nerve block in management of painful wounds of chest wall 220

69 Technique of tracheobronchial catheter aspiration 224

70 Administration of oxygen under intermittent positive pressure in management

of wet lung 230

71 Hemothorax with recurrent pulmonary hemorrhage 244

72 Posteroanterior roentgenogram showing clotted right hemothorax 246

73 Massive liquid hemothorax without infection 247

74 Photomicrograph showing organizing hemothorax with replacement of acute

fibrinopurulent deposit 250

75 Photomicrograph showing fibroblastic membrane from clotted hemothorax 11

days after wounding 251

76 Photomicrograph showing section of peel of clotted hemothorax 4 weeks after

wounding 252

77 Photomicrograph showing section from clotting hemothorax 253

78 Photomicrograph of section through membrane, pleura, and lung in posttraumatic empyema 12 weeks after wounding 254

79 Cross-sectional diagram showing pathologic process in clotting, organizing

hemothorax 255

80 Photomicrograph showing layer of fibrin 3 mm. thick, removed from visceral

pleura in uninfectcd clotted hemothorax 11 days after wounding 256

81 Fibrotic process in organizing hemothorax 257

82 Photomicrograph showing calcium deposition in collagenous tissue layer of exudate on visceral pleura in organizing hemothorax 258

83 Photomicrograph showing biopsied section of lung and pleura after removal of

overlying exudatc 259

84 Photomicrograph showing replacement of fibrinous exudate, pleura, and adjacent

lung 260

85 Photomicrograph showing infected organizing hemothorax 261

86 Spontaneous resolution of clotted hemothorax 264

87 Posteroanterior roentgenogram showing right clotted hemothorax 264

88 Lateral roentgenogram showing clotted hemothorax over right lower and middle

lobes 265

89 Clotted hemothorax with spontaneous clearing 266

90 Clotted hemothorax with spontaneous clearing 267

91 Management of hemothorax by thoraccntesis 26S

92 Schematic showing of recurrent hemothorax after thoraccntesis 270

93 Schematic showing of massive clotted hemothorax 271

94 Decortication in hemothoracic empyema 277

95 Management of hemothoracic empyema by rib-resection drainage 278

96 Posteroanterior roentgenogram showing massive liquid empyema on right side

4 weeks after rib-resection drainage 279

97 Management of clotted hemothorax with retained foreign body 282
CONTENTS XXIII

Figure Pa0

e

98 Management of clotted hemothorax with retained foreign body 2S4

99 Technique of decortication 290

100 Techniques of decortication showing alternate methods of entering pleural

cavity 291

101 Technique of decortication 292

102 Technique of decortication 292

103 Technique of decortication 293

104 Technique of decortication 294

105 Management of clotted hemothorax by decortication 295

10G Management of massive liquid hemothoracic empyema 296

107 Technique of decortication 290

108 Typical temperature charts of patients with hemothoracic empyema treated

by primary decortication with penicillin coverage 299

109 Comparative results of management of empyema in World Wars I and II 302

110 Management of hemothorax by secondary decortication 304

111 Management of hemothoracic empyema by primary decortication 304

112 Management of hemothoracic empyema by decortication 305

113 Management of clotted hemothorax by primary decortication 305

114 Spontaneous clearing of clotted hemothorax 311

115 Management of clotted hemothorax by decortication 312

116 Management of hemothoracic empyema by primary decortication 313

117 Management of clotted hemothorax by primary decortication 314

118 Posteroanterior roentgenogram showing organizing clotted hemothorax on left

side 316

119 Management of organizing clotted hemotliorax by decortication 317

120 Management of clotted hemothorax with retained foreign body and bronchoplcural fistula by primary decortication 318

121 Management of tension hemopneumothorax and total hemothoracic empyema

by secondary decortication 319

122 Management of infected clotted hemothorax by early primary decortication-- 322

123 Management of infected clotted hemothorax with complications by early

primary decortication- - °-°

124 Retained foreign body in lung 330

125 Retained foreign body in lung 331

126 Retained foreign body in posterior chest wall 333

127 Localization of intrathoracic foreign bodies by division of chest into arbitrary

sectors °°1

128 Localization of intrathoracic foreign body ^35

129 Localization of foreign body in chest wall 00°

130 Localization of intrapulmonary foreign body 3o0

131 Localization of foreign body in lung °°'

132 Localization of foreign body in chest wall 338

133 Localization of foreign body in chest wall 339

134 Localization of foreign bodies in chest wall 339

135 Localization of foreign body in lung 340

136 Localization of foreign body in diaphragm 341

137 Localization of foreign body in diaphragm 342

138 Localization of foreign bodies in right chest °4o

139 Localization of foreign body in mediastinum 344

140 Localization of foreign bodies in lung and mediastinum 345

141 Localization of foreign body in intrapleural space 346

142 Intrapleural foreign body associated with massive empyema 347
XXIV CONTENTS

Figure Page

143 Specimens of metallic foreign bodies removed from lungs and pleural cavity 350

144 Gross location of foreign bodies removed from cardiac and vascular structures

at 160th General Hospital 354

145 Missiles removed from chambers of heart, with their location 355

146 Roentgenograms showing original position of fragment in right ventricle 35S

147 Electrocardiograms taken before first cardiotomy 358

148 Positioning of patient at successive cardiotomies 35!)

149 Roentgenograms showing position of fragment in right auricle after first

operation 359

150 Electrocardiograms taken after first cardiotomy 360

151 Roentgenograms showing fragment again in right ventricle after second cardiotomy 361

152 Electrocardiogram taken after second cardiotomy 361

153 Electrocardiograms taken during third and successful cardiotomy 363

154 Migration of foreign body at successive cardiotomies 363

155 Electrocardiograms taken after third and successful cardiotomy with removal

of fragment from right ventricle 364

156 Patient just before evacuation to Zone of Interior, after three cardiotomies 364

157 Electrocardiograms taken before cardiotomy showing left ventricular damage__ 365

158 Preoperative roentgenograms showing retained missile in left ventricle 366

159 Preoperative roentgenograms showing retained fragment in left auricle 367

160 Electrocardiogram taken before operation showing possible damage to anterior

myocardial wall 368

161 Technique of removal of retained shell fragment from left auricle 368

162 Electrocardiogram after left auricular cardiotomy and removal of intra-auricular

shell fragment 369

163 Incisions used to obtain exposure of foreign bodies in heart 370

164 Roentgenograms showing foreign body in chamber of right ventricle 371

165 Technique of removal of foreign body 371

166 Technique of combined intercostal-transsternal approach to right aspect of

right ventricle 372

167 Roentgenograms showing missile in right auricle 373

16S Technique of removal of foreign body 374

169 Technique of posterior approach to pericardium and heart on right 375

170 Roentgenograms showing foreign body in interaurieular septum and right

auricle 37(>

171 Technique of removal of foreign body in right auricle by incision in superior

vena cava 377

172 Roentgenograms showing foreign body in pericardial abscess well back on

diaphragmatic surface of heart 378

173 Electrocardiograms taken during operation for removal of pericardial foreign

body 379

174 Roentgenograms showing .30-caliber bullet in hilar region of left lung 381

175 Roentgenograms taken immediately after left thoracotomy 382

176 Technique of removal from right pulmonary artery of foreign body 383

177 Roentgenograms showing retained shell fragment posterior to right sternoclavicular joint in region of innominate artery 384

178 Technique of removal of retained missile from innominate; artery 385

179 Roentgenograms 3 days after wounding showing clear lung fields 386

ISO Roentgenograms 1 month later, 2 days after sudden onset of pain in left lower

hemithorax 387
CONTEXTS XXV

Figure Page

181 Migration of bullet from left pulmonary artery into main pulmonary artcry

and into right pulmonary artery 388

182 Probable course of migratory missile from left auricle through left ventricle and

aorta into innominate artery 389

183 Course of migratory bullet from entry into inferior vena cava through right

auricle and ventricle 390

1S4 Encapsulated hemothorax managed by decortication 403

185 Traumatic hemothorax 404

186 Hemothoracic empyema managed by anterior drainage 406

187 Retained foreign body with delayed manifestations due to infection 409

188 Retained foreign body without symptoms 410

189 Retained foreign body without clinical manifestations 411

190 Bronchospirometric tracing 1 month after left lower lobe lobectomy for bronchiectasis 422

191 Bronchospirometric tracing 7 weeks after left lower lobe lobectomy for bronchicctasis 422

192 Bronchospirometric tracing 8 weeks after right middle and lower lobe lobectomy

for bronchiectasis 423

193 Bronchospirometric tracing 7 weeks after resection of left lower lobe and lingula

of the upper lobe for bronchiectasis 423

194 Patient after final closure of tuberculous sinus complicating thoracoabdominal

wound 16 months earlier 428

195 Punchcard designed to secure data in long-term followup of veterans witli combat-incurred wounds of chest 444

196 Schematic showing of large defects of chest wall 452

197 Serial roentgenograms in large defect of chest wall 454

198 Schematic showing of sucking wound with defect of chest wall 457

199 Serial roentgenograms in sucking wound with defect of chest wall complicated

by severe infection 461

200 Sucking wound of left posterior chest with early infection 464

201 Serial roentgenograms of sucking wound with early infection 467

202 Anterolateral sucking wound of left chest 469

203 Serial roentgenograms in mediastinal injury with intrapcricardial foreign bodies

and hematoma 472

204 Serial roentgenograms in blast injury 475

205 Schematic showing of thoracoabdominal wound 478

206 Serial roentgenograms in thoracoabdominal wound 480

207 Schematic showing of thoracoabdominal wound 482

208 Serial roentgenograms in thoracoabdominal wound 4S5

209 Schematic showing of thoracoabdominal wound 488

210 Serial roentgenograms in thoracoabdominal wound 490

211 Schematic showing of thoracoabdominal wound 492

212 Serial roentgenograms in thoracoabdominal wound 494

213 Schematic showing of thoracic wound with massive hematoma of the right lung- 497

214 Serial roentgenograms of hematoma of right lower lobe of lung 500

215 Schematic showing of large sucking wound of chest 503

216 Serial roentgenograms of sucking wound of chest with wet lung syndrome 505

217 Schematic showing of chest wound with massive chest wall and intrapleural

trauma 509

218 Serial roentgenograms in thoracic wound complicated by massive hemothorax„ 512

219 Schematic showing of chest wound with retained foreign body 514
XXVI CONTENTS

Figure Page

220 Serial roentgcnograms in wound with intrapulmonary foreign body 516

221 Schematic showing of ehest wound with retained foreign bodies in lung 518

222 Serial roentgenograms of thoracic wound with retained bodies in lung 521

Color Plates

Number

I Appearance of heart at instant of incision into right ventricle 362

II Technique of dislocation of heart from pericardial sac 362

III Marked ventricular dilatation following dislocation of heart 362

Tables

1 Blast injuries of nonbattle origin, by numbers of admissions and deaths, and b3'

area, 1942-45 33

2 Battle-incurred blast injuries, by numbers of admissions and deaths, and by

area, 1942-45 34

3 Battle-incurred blast injuries of thorax and thoracoabdominal region, by numbers

of admissions and deaths, and by area, 1944 35

4 Battle-incurred blast injuries of thorax and thoracoabdominal region, by numbers

of admissions and deaths, and by area, 1944 36

5 Distribution of injuries and anatomic involvements in 56 combat-incurred

cardiac injuries 49

6 Distribution of 27 deaths in 56 combat-incurred cardiac injuries 97

7 Frequency of wounds and case fatality rates in 903 thoracoabdominal wounds

according to combinations of viscera 105

S Case fatality rate according to tinielag in 854 thoracoabdominal injuries 137

9 Case fatality rate according to surgical procedure in 903 thoracoabdominal

wounds 138

10 Number of admissions and deaths for lung abscess, by area, 1942-45 176

11 Number of secondary cases of lung abscess, by area, 1944-45 177

12 Incidence, admissions, secondary diagnoses, and deaths from diaphragmatic

hernia, by area, 1944-45 1S7

13 Admissions for empycma of the chest, by area, 1942-45 241

14 Distribution of 20 percent sample of secondary cases of empycma of the chest,

by area and type of admission 242

15 Admissions for bronchiectasis, by area, 1942-45 415

16 Operations for pulmonary tuberculosis, Fitzsimons General Hospital, H)44-45_. 425

17 Incidence of malignant neoplasms of respiratory system and of esophagus, by

area, 1944-45 "- 434

18 Morbidity and mortality from malignant neoplasms of respiratory system and

of esophagus, 1944-45 435

19 Deaths due to malignant neoplasms of respiratory system and of esophagus, by

area, 1944-45 436

20 Thoracic damage in 167 followed-up thoracic casualties according to surgical

procedure in forward hospitals 447

21 Associated injuries in 167 followed-up thoracic casualties according to surgical

procedure 447
CONTENTS XXVII

Number rage

22 Intra-abdominal damage in 81 followed-up thoracic casualties according to

surgical procedure 448

23 Complications in forward and fixed hospitals in 167 followed-up thoracic casualties according to surgical procedure in forward hospitals 448

24 Surgery required in fixed hospitals according to surgery performed in forward

hospitals 449
Parti

SPECIAL TYPES OF WOUNDS

OF THE CHEST
CHAPTER I

Special Types of Thoracic Wounds

Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.

WOUNDS OF THE CHEST WALL

The simplest form of chest wound, the type which involved only the thoracic

wall and produced no bony or visceral injuries (fig. 1), always had one serious

possibility: The pain which followed might cause voluntary restriction of

respiration and of the cough reflex, which, in turn, could cause retention of

secretions and introduce the problems of wet lung. Injuries which involved

only the soft parts, such as abrasions and lacerations, were usually not serious.

Those associated with fractures of the ribs could be serious. Contusions of the

chest wall could also be serious.

An occasional patient who seemed to have only a simple contusion of the

chest wall developed pleural effusion, apparently because the pleura had shared

in the trauma. In these cases, which were usually diagnosed as traumatic

/*•

FIGURE 1.—Superficial bullet wounds of chest wall not involvingbony structures.
4 THORACIC SURGERY

pleuritis with effusion, the fluid was straw colored or amber and had the characteristics of a transudate. Eepeated aspiration was usually the only treatment

necessary, but in an occasional case, in which the pleural fluid had a high fibrin

content, clotting occurred, and the total picture was suggestive of clotted hemothorax. If the condition remained static, decortication might be necessary.

Contusions of the chest wall were also responsible for some intrathoracic

hematomas (p. 165).

Case History

The following case history illustrates the intrathoracic complications that

sometimes followed a wound of the chest wall not, in itself, of major importance:

Case 1.—This casualty was picked up by aidmen between 1 and 2 hours after he was

wounded by shell fragments in the right shoulder and left knee. When he was received in

an evacuation hospital 11 hours after wounding, he was found to have a perforating wound

of the right upper chest, associated with a moderate hemothorax. Wet lung was demonstrated clinically by many loud rales and rhonchi and was confirmed by roentgenograms.

Roentgenologic examination also showed comminuted fractures of the posterior portion

of the second and third ribs, and possibly of the fourth rib, on the right side. No foreign

bodies were visible on this roentgenogram nor on the roentgenogram of the left knee, which

showed an epiphyseal fracture of the tibial tubercle.

Fourteen hours after the patient's admission to the hospital the wound of entrance

just below the outer third of the right clavicle was widely debrided under local analgesia,

and a large amount of clotted and liquid blood was evacuated. A small fragment of the

fractured right clavicle was removed. The wound was sprinkled with powdered sulfanilamide, and a petrolatum-impregnated gauze dressing was applied. Paravertebral nerve

block wirh procaine hydrochloride was carried out at the level of the seventh cervical

vertebra and the first through the fourth thoracic vertebrae. The hemothorax was

aspirated through the seventh intercostal space in the posterior axillary line, and the

500 cc. of blood thus obtained was used as an autotransfusion, with 500 cc. of physiologicsalt solution. B-ronchoseopy was employed to clear profuse secretions from the tracheobronchial tree. The wound of the left knee was debrided.

The postoperative course was satisfactory for the first 4 days. Then paravertebral

block had to be repeated because of pain. No fluid was found in aspiration at this time.

On the eighth day, 1,350 cc. of bloody fluid was aspirated from the right chest. Repeated

aspiration on the 10th day produced 150 cc. of thick, pinkish fluid, and on the 12th day, 725

cc. of thin fluid of the same color was removed. Thereafter the chest was dry.

When the patient was evacuated on the 22d postoperative day, he had entirely recovered from his chest injury, but he still had some loss of function of the upper right arm.

Comment.—Contusion of the chest wall was present to some degree in all injuries of

the chest in which direct violence was a factor. It undoubtedly played a part in the casejust recorded, helping to produce both wet lung and hemothorax. There was no direct communication between the pleural cavity and the wound of the chest wall.

Although this patient had an extensive wound of the chest wall, with hemothorax and

wet lung, there was no indication for formal thoracotomy. The infection in the chest wall

was controlled by adequate debridement. The lung was expanded by needle aspiration of

the blood in the pleural cavity, thus increasing the vital capacity, and intercostal nerve

block allowed the patient to breathe deeply and cough effectively with relief of the wet

lung syndrome.
SPECIAL TYPES OF THORACIC WOUNDS 5

SUCKING WOUNDS

General Consideration

A sucking wound (fig. 2) is defined as a wound in which there is more or

less free interchange of air through the wound between the pleura! cavity and

the outside atmosphere. The term, as pointed out elsewhere (vol. I), is both

unsuitable and misleading, and blowing wound is preferable nomenclature.

Sucking wound, however, has the sanction of usage, and for that reason, its use

is continued in this volume.

Potentially, if not actually, all penetrating and perforating wounds of the

chest observed in World War II were sucking wounds. A sucking wound

sometimes sucked (blew) constantly and sometimes only when the skin and

muscle planes were in a certain alinement. The regional anatomy frequently

determined whether or not a wound sucked. Generally speaking, a large wound

was more likely to suck than a small wound, but size was not the most important

determining factor. A relatively small wound in the anterior chest wall, 2 cm.

or less in diameter, might suck constantly because in this area the muscles are

scanty and the interspaces wide. A larger wound located posteriorly, in the

heavy muscles of the back, might be less likely to suck.

Other considerations also determined whether or not a wound sucked. If

the missile traversed the chest at such an angle that the external wound of entiy

was at a considerable distance from the point of its entrance into the pleural

cavity, the movement of the intervening muscles of the chest wall might prevent

the wound from sucking at one moment and permit it to suck at another. If

the wound involved the muscles of the pectoral girdle, movement of the upper

extremity on the injured side might so realine the openings in the skin and

pleura that sucking occurred constantly.

Casualties with chest injuries were usually transported supine or in the

sitting or semisitting position, but not many were wounded in these positions.

Change of position after wounding therefore influenced the blowing characteristics of the wound.

Pathologic Physiology

Studies by Graham (1) (pp. 285-319 of reference cited) with Bell in

World War I showed that a wound that exposes the lung and pleural cavity

is not necessarily fatal. It can be tolerated if the amount of air entering the

wound from the exterior is not greater than the difference between the tidal

air and the original vital capacity. In the absence of treatment, the outcome

is determined by the size of the wound and the original vital capacity.

The lung on the injured side does not collapse to the point of nonfunction

when it is exposed to atmospheric pressure after wounding, even when the

pleural cavity is free of adhesions (2). Furthermore, the pressures exerted on

the exposed lung during the respiratory cycle are not always atmospheric.

74G-!H1V—Gi5 R
THORACIC SURGERY

A

FIGURE 2.—Schematic showing of pathologic physiology of sucking chest

wound. A. Entrance of air into chest on inspiration through wound in chest

wall (a), the amount of air being directly proportional to the size of the opening

as compared with the surface area of the open glottis. Collapse of lung on

affected side (b), with passage of air out of affected bronchus. Entrance into

bronchus of some air from collapsed lung (c), with passage to intact lung.

Shift of mediastinum toward nninvolved side (d), hemothorax (e). B. Escape

of air on expiration through sucking wound of chest wall (a). Expansion of

collapsed lung (b). Passage of air from uninvolvecl side to lung on involved

side, thence out trachea (c), producing the so-called pendular breathing. Shift

of mediastinum to involved side (d). Hemothorax (e).
SPECIAL TYTES OF THORACIC WOUNDS

c

D

FIGUKE 2.—Continued. C. Packing of sucking wound (a),

after which respiration becomes more normal. Hemothorax

(e). D. Development of tension pneumothorax because air

cannot escape from tear in lung (a), after wound is adequately

packed. If it develops, it must be treated by closed (catheter)

drainage of cavity. Hemothorax (e).
g THORACIC SURGERY

The thorax is a flexible container, which moves during the respiratory cycle,

and there may even be negative pressure in the exposed side during inspiration.

The response to negative intrapleural pressure occasioned by enlargement of

the chest on inspiration is a rush of air through the glottis. If the size of the

traumatic opening is less than the size of the glottis, a sufficient amount of air

enters through the glottis to answer the tidal air requirements and for functional necessities, and there is no danger of asphyxiation. When, however, the

size of the wound approaches or exceeds the size of the glottis, the amount of

air which enters the chest through the open wound during each inspiration

is large enough to interfere with the tidal air requirement intake, and asphyxiation is a real danger.

Another factor must also be taken into consideration in the pathologic

physiology of chest wounds, interference with the function of the contralateral

side. In the healthy person, the mediastinum is not held down by adhesions

or stiffened by previous inflammatory disease. It is therefore capable of transmitting pressure, and as a result, the intrathoracic pressure is likely to be

almost identical in both cavities. In other words, the decrease in vital capacity

caused by an open wound of the chest is bilateral in the normal person, whereas

a casualty with a stiffened mediastinum can sometimes tolerate even very large

wounds.

When the amount of air entering an open chest wound during each inspiration is large enough to interfere with the tidal air requirement intake, some

degree of asphyxia is inevitable. A vicious circle then ensues:

1. There is an initial and increasing reduction in the vital capacity.

2. The mediastinum shifts with each inspiration and expiration, since it

is no longer opposed by the lung on the injured side.

3. The mediastinal shift (flutter) increases in rapidity as the reduction

in vital capacity increases.

4. The mediastinal shift has a direct and deleterious effect on the right

heart, for anatomic reasons. The base of the heart is fixed, but the apex is

relatively free. The apex therefore is capable of movement and is relatively

unaffected by mediastinal flutter. The base is incapable of movement, and

kinking of the large vessels that enter the right side of the heart is the next

consequence of this phenomenon.

5. Pendulum respiration ensues and causes a further decrease in the vital

capacity. On each expiration, air from the contralateral lung, with its predominant carbon dioxide content, is only partly exhaled. The residual amount

enters the main and secondary bronchi on the injured side. On the next

inspiration, the air taken into the uninjured lung is thus composed of both

atmospheric air from the trachea and air from the injured lung, with a high

carbon dioxide content.
SPECIAL TYPES OF THORACIC WOUNDS 9

Immediate Management

Casualties with large sucking wounds were usually in shock and nontranspoitable. All casualties with actual or potential sucking wounds were

always in jeopardy, whether or not the wound was blowing at the particular

moment of examination.

Surgical closure was necessary to bring about permanent restoration of

normal cardiorespiratory physiology and to prevent intrapleural infection.

This did not mean, however, that immediate surgical closure was necessary.

Early in tire war, in obedience to the dictum that all sucking wounds

should be closed promptly, attempts were often made to close these wounds

hastily by suture as soon as the casualty reached the most forward medical

installation. U.S. Army medical officers promptly learned, just as British

medical officers had learned (vol. I), that this was a disastrous policy unless

ample facilities were at hand for debridement and careful surgical closure.

These facilities were not available ahead of a field hospital. When closure

was undertaken without careful preliminary debridement, one or all of several

complications might occur, including tension pneumothorax; extensive subcutaneous emphysema; or infection of the wound, with disruption, which

produced a recurrence of the original sucking wound, with the difference that

it was now surrounded by tissues that were infected and no longer suitable for

approximation. The incidence of empyema was high in wounds that broke

down after repair. It reached 50 percent in some series.

That treatment was a matter of extreme urgency was not open to debate.

It was also quite simple. As already described (vol. I), medical aidmen were

originally instructed to cover sucking wounds with an occlusive dressing

(fig. 2C). Later, all chest wounds were treated in this way, on the ground

that a wound that did not suck at one time or in one position might suck in

another. On the battlefield, any type of dressing that was available could be

used, even a piece of clothing. As soon as the casualty was brought to the

battalion aid station, the temporary dressing was replaced by a larger dressing,

preferably at least twice as large as the wound. It was thickly impregnated

with petrolatum and was covered with a still larger gauze dressing held firmly

in place with strips of adhesive. If the wound was very large, coarse sutures

were placed through the skin and tied over the dressings.

This sort of dressing closed the chest efficiently for 5 or 6 hours, or longer.

During this period, the patient was transported to a clearing station in which

it was determined, by triage, whether he should be transferred to the adjacent

field hospital for emergency surgery or could safely be transported to an evacuation hospital farther to the rear, though it was frequently necessary first to

change the dressing. When a petrolatum-impregnated gauze dressing had

become caked with blood, it had stiffened and was no longer pliable enough to

act as a one-way valve. A needle with a flutter valve attachment was usually

placed in the second interspace parasternally to provide for the escape of air

and prevent tension pneumothorax (fig. 2D).
10 THORACIC SURGERY

As the war progressed, emergency management of sucking wounds became

so satisfactory that their potential seriousness was considerably minimized.

Surgical Closure

Small wounds.—Small sucking wounds, 2 cm. or less in diameter, although

they were likely to blow continuously if they were located in portions of the

thoracic cage where muscle was scanty, could usually be closed without difficulty.

Lacerated skin and muscle were trimmed away, and accessible rib fragments

were removed. Blood and clots were aspirated from the pleural cavity whenever they were present. In the absence of other indications, however, the

wound was not enlarged into a formal thoracotomy for exploration or for

removal of small metallic foreign bodies.

The pleural defect was usually closed by a few sutures in the intercostal

muscle or, occasionally, by a small muscle plug in lieu of a pedicled graft.

The more superficial muscles and the subcutaneous tissues were closed in layers,

with sutures of line interrupted silk. The skin was left open, to be closed at

the base.

Intercostal water-seal drainage of the pleural cavity was frequently instituted, even in small wounds, both because the lung had often been injured and

because air leakage was a possibility.

Large wounds.—Sucking wounds associated with large defects in the thoracic wall and with multiple rib fractures were usually grossly contaminated.

Thorough excision of devitalized tissue was therefore necessary, together with

excision of all loose rib fragments and of 3 to 6 cm. of the damaged costal ends.

Excision was thorough, but as much periosteum and intercostal muscle and

fascia was preserved as seemed safe. When a debridement had been carried out

according to these principles, a traumatic thoracotomy had often been accomplished, through which intrapleural exploration could be conducted. Foreign

bodies were removed if they were readily accessible. The lung was sutured if

there was leakage of air or oozing of any consequence from the parenchyma.

Otherwise, no lung surgery was done (p. IT). The pleural cavity was thoroughly cleansed.

The adequate exposure necessary for the debridement of large sucking

wounds often made for difficulties in closure, particularly if the wound was in

the anterior chest, where the muscle layer was scanty and the interspaces wider.

Suture under tension had to be avoided. It was always undesirable, and it was

particularly undesirable in contaminated areas. Even when the wound was

located basally, the diaphragm was never used to close the pleural defect if

other tissues could be utilized.

Closure of the deepest layer of the wound could often be effected by using

the intercostal structures, periosteum, and deep fascia. If large segments of

ribs had been removed, these tissues were relaxed and could be manipulated more

readily. Eelaxing incisions in the long axis of the intercostal bundles were

helpful.
SPECIAL TYPES OF THORACIC WOUNDS 11

When necessary, the first muscle layer could be reinforced with pedicle

flaps or muscles (vol. I), or the inferior surfaces of the deep muscles could be

approximated to the first layer of the closure by interrupted sutures. When

muscle tissue had been lost, subcutaneous dissection of the muscle sometimes

simplified closure, or relaxing incisions might be employed at some distance

from the defect. The subcutaneous tissues were usually closed, but skin closure

was deferred. The dressings were applied with a moderate amount of pressure.

Tension pneumothorax was always a risk after a sucking wound had been

closed. Some surgeons considered careful postoperative observation the only

precaution necessary. Others preferred to use a safety valve in the form of a

catheter with a flutter valve or a large-bore needle in the second anterior

interspace.

Since the empyema rate was greater in sucking wounds associated with

large defects of the thoracic wall, posterolateral closed intercostal drainage was

sometimes employed. A second intercostal tube in one of the upper anterior

intercostal spaces was useful in encouraging prompt reexpansion of the upper

lobe. If empyema occurred, it was then limited to the base of the lung. If

penicillin or a sulfonamide had been instilled into the chest and the posterior

tube had been temporarily clamped off, the anterior tube could be relied upon

to facilitate prompt expansion of the lung.

FRACTURES OF THE RIBS AND ADJACENT STRUCTURES

Simple Fractures

Simple fractures of the ribs were not common in combat-incurred injuries.

When they were encountered in combat zones, they were usually the result of

traffic or other civilian-type accidents. Relief of pain was secured by intercostal nerve block. Strapping was not practiced.

Solid, painless healing of simple rib fractures required about 6 weeks.

If several ribs were fractured, another 2 or 3 weeks had to elapse before the

patient could resume his full activities.

Simple fractures represented no threat to life, but they accounted for a considerable loss of manpower because of the time required for total convalescence.

Costochonclral separations were remarkably infrequent. They were managed, like simple fractures, by intercostal nerve block. Recovery was usually

prompt, but even if pain at the costochonclral joint was persistent, joint

resection was never practiced.

Simple fractures of the clavicle were managed by standard measures.

Wiring was unnecessarily radical; it enhanced the chances of infection and could

give rise to suppuration, which often was prolonged. Such heroic surgery was

occasionally encountered early in the war, but it was never performed by physicians aware of the essential function of the clavicle and of its excellent natural

capacity for recovery from trauma.
12 THORACIC SURGERY

Simple fractures of tlie scapula were also infrequent in war wounds. They

required only immobilization of the shoulder by a sling.

Acromioclavicular and sternoelavicular injuries as well as fractures of the

glenoid fossa required special orthopedic care. Since they were not managed

primarily by thoracic surgeons, they are discussed in the volumes on orthopedic

surgery in this series.

Compound Fractures of the Ribs

About 75 percent of all combat-incurred penetrating and perforating

wounds of the chest were associated with compound fractures of one or, more

often, of several ribs. The scapula and clavicle were often similarly injured,

and comminution of the bony structures might be extreme.

Pathologic process.—Occasionally, a tangential injury to the chest resulted in the fracture of one or more ribs in such a manner that the sharp edges

of the fractured ribs penetrated the pleura even though the missile itself did

not. Bone fragments from fractured ribs, because of their irregular, jagged

edges and the respiratory movements of the chest, sometimes caused long,

ragged pulmonary lacerations and other damage more serious than that caused

by the original missiles. Even if this did not happen, penetration of the intact

pleura by bone fragments could cause a pneumothorax, and continued trauma

to the lungs by embedded bone fragments resulted, in a, few cases, in both

empyema and lung abscess. Both infection and sequestration were, however,

remarkably infrequent, because of the almost universal practice of adequate

debridement in forward hospitals.

Flail chest.—Flail chest, with paradoxical respiration, resulted from

multiple fractures of several ribs. It was not often seen, but it was extremely

serious because of the consequent reduction in vital capacity (fig. ?>). The more

the chest wall was sucked in toward the contralateral side during inspiration

and the less it returned to the normal position on expiration, the greater was

the decrease in vital capacity and the more the patient compensated by

breathing faster.

Immediate management.—The immediate treatment of fractured ribs

(fig. 4) was the relief of pain by intercostal nerve block, which usually lasted

for 24 hours or more. When the casualty was able to breathe deeply, cough,

and raise sputum, he became transportable, if associated wounds did not require

forward surgery, and definitive treatment could be deferred until he reached an

evacuation hospital.

Adhesive strapping was practically never used. It was often unsuccessful

in accomplishing immobilization and relieving pain, and the adhesive often

caused additional discomfort. Strapping was also unphysiologic. Many patients with fractures of the ribs showed varying degrees of wet lung with increased bronchial secretions and intrapuhnonary bleeding. Raising the fluid

would have been difficult or impossible because of pulmonary compression and

the restriction of expansion of the chest caused by strapping.
SPECIAL TYPES OP THORACIC WOUNDS 1 °

B

PICUKK 3.—Schematic showing of pathologic physiology of flail

chest. A. Inspiratory phase. Chest wall collapses inward (a),

forcing air out of bronchus of involved lung into trachea and bronchus to uninvolved lung and causing shift of mediastinum to miinvolved side (b). B. Expiratory phase. Chest wall balloons outward (a) so that air expelled from lung on uninvolved side (b) enters

lung on involved side and mediastinum shifts toward involved side

(a). This is a very inefficient form of respiration, and the patient will

die of hypoxia and exhaustion if it occurs in an extreme phase and

is not relieved.

740-04 l

v—05 4
14 THORACIC SURGERY

B

FIGUHE 4.—Management of flail chest. A. Intercostal nerve

block, to block painful impulses on affected side and thus cut down

paradoxical respirations and allow for deeper breathing and more

effective cough. (For further details of technique, see fig. 68,

p. 220.) B. Application of circumferential elastic binder, to prevent chest wall from ballooning out on inspiration and to allow

diaphragm to function more effectively.
SPECIAL TYPES OF THORACIC WOUNDS 15

D

t^fStV-. y-,^

FiouiiK 4.—Continued. C. Overhead traction. Whether the injury is a fracture of the sternum, the cartilages, or the ribs, the

paradoxically moving portion of the chest may be stabilized by the

use of large towel clips fixed into the ribs or other damaged structures

or by wire passed underneath them. Stabilization could usually be

accomplished successfully by the use of two pulleys and weights, of not

more than 5 pounds. D. Wire splint, fixed on cither side of flail

portion of chest, supports towel clips or wires attached to the fractured

ribs by means of rubberbands.
16 THORACIC SURGERY

In civilian practice, a patient with flail chest would be ideally treated in a

respirator. This was, of course, completely impractical in military surgery.

Xerve block often resulted in a considerable improvement in symptoms and a

considerable reduction in the paradoxical movement of the chest wall. If it

was not successful, adhesive strapping, undesirable as it was, sometimes had

to be employed, or an elastic binder was used. Positioning with sandbags was

occasionally useful, but traction was seldom employed. If simpler measures

were not succeessful, operation had to be resorted to. Costal fixation was

secured by placing stainless steel wire or heavy silk through the ends of the

shattered ribs. Tracheotomy was sometimes necessary also.

Surgical management.—The surgical management, of fractures of the ribs

required careful hidividualization of patients. In most instances, debridement

could be limited to the soft tissues. If the wound was tangential, there might

be extensive comminution of from three to five ribs without penetration of the

pleura. Often the greater portion of the damage was subscapular. In a few

cases, roentgenograms showed what looked like a picket fence of bony spicules

along the parietal pleura.

Whenever debridement included the removal of irregular, subpleural rib

fragments, the pleural cavity was necessarily entered, and the surgeon had, in

effect, performed a thoracotomy. He had to have sound reasons for extending

the wound and increasing the magnitude of the operation. The mere presence

of bone fragments within the pulmonary parenchyma was not an indication

unless they seemed responsible for continued bleeding or for an air leak.

One exception to this generalization was the presence of fragments partly

within the pulmonary parenchyma and partly within the pleural space. Fragments in this location could produce a good deal of trauma when the lung reexpanded and they came into contact with the chest wall. Both air leaks and

infections were possible sequelae. A number of cases were observed in which

the lung, the pleural cavity, and the chest wall were all involved in the infection

that followed debridement carried down only to the muscles, the bone fragments beino- left in situ.

WOUNDS OF THE LUNGS

General Considerations

Lacerations of the pulmonary parenchyma were encountered in practically

all perforating chest wounds. They varied from small puncture wounds to

very extensive lacerations.

When surgeons, early in the war, first encountered badly contused,

lacerated, boggy, hemorrhagic lungs, they found it hard to refrain from

immediate lobectomy. In fact, this operation would probably have been done

rather often if the casualties had not been in such poor general condition or

had not had associated major wounds. For these reasons, pulmonary surgery
SPECIAL TYPES OF THORACIC WOUNDS 17

was, of necessity, limited to simple suture. The sutures, also of necessity, were

superficial, since the friable, hemorrhagic tissues were incapable of holding

deep sutures. The practice was to perform one-layer closure, with interrupted

sutures of fine, nonabsorbable material on an atraumatic needle. It proved

surprisingly easy to secure an airtight closure in this manner, one reason being

that the tendency to leakage was diminished by the fact that the damaged

lung was somewhat slow to aerate completely. Roentgenograms examined

2 or 3 weeks after surgery showed remarkable clearing of the lung fields, and

clearing was usually complete in 6 to 8 weeks.

One reason for these good results can be explained in the form of an

analogy: Engineers found that the best protection for wiring in airplanes was

simply to fasten the wires loosely along the side of the plane. Missiles that

passed through wires thus placed seldom damaged all of them, whereas if the

wiring had been placed in a conduit, a single bullet that struck the container

could divide all of the wires in it, The same phenomenon was observed in the

lung. The blood vessels are surrounded by an elastic medium that permits them

to be easily displaced in any direction when a foreign body strikes them. As a

result of this physiologic capability, damage to the lungs was frequently more

limited than it might otherwise have been.

The real explanation of the tremendous recuperative power of the lungis its dual blood supply, through the pulmonary and bronchial arterial systems.

The blood supply, being in the form of a tree, was irreparably damaged only

when the trunk was severed. Since all the major blood vessels branch out

radially from the liilus, they had to be damaged near the point of origin to

cause lethal damage to the pulmonary parenchyma.1 Undoubtedly there were

many such injuries in World War II, but the casualties who sustained them

did not live long enough to reach field hospitals.

Management in Forward Hospitals

As the war progressed, the policy of leaving small lacerations of the lung

unsutured became general. No untoward effects were noted. Untreated lungs

were found to expand as well, and about as rapidly, as lungs which had been

sutured. These observations bore out the theory that the surrounding airless

lung, when it was infiltrated by blood, prevented postoperative parenchymal

pleura! fistulas.

Eventually it became the custom to suture lacerations of lung tissue only

on the following indications :

1. Obvious parenchymal pleura! fistulas.

2. Large lacerations, chiefly to reduce the amount of postoperative

drainage.

1 Wartime observations are borne out by a series of experiments on the pathologic effects of

foreign bodies in the pulmonary artery reported in 1959 (3). These studies showed that the lung can

recuperate when a branch of the artery or the lobar pulmonary artery is completely blocked. Only

when the main artery is blocked will the pathologic changes be irreversible. Severe pathologic changes

result, however, when the bronchial artery and the pulmonary artery to the involved lobe are blocked.
18 THORACIC SURGERY

3. Lacerations bleeding into the pleura! cavity.

4. Lacerations bleeding into the tracheobronchial tree.

It was logical to repair pulmonary lacerations that were oozing actively or

that presented serious air leaks. It was particularly important to suture lacerations that were bleeding into the tracheobronchial tree. In these circumstances,

even with repeated endotracheal suction, it would have been difficult to keep

the airway free of blood.

If the chest was to be drained, closure of a small air leak was not considered

important. Air leaks were identified by filling the hemithorax with physiologic

salt solution under pressure of 10 to 15 mm. ELO; it was necessary that the

lung be completely covered with the solution.

There was no indication for pulmonary repair in the contusion type of

injury, since it caused either scattered areas of hemorrhage in both lungs, as in

blast injuries, or massive bleeding that involved all the lobes. This therapeutic

point of view is in interesting contrast to the World War I concept that all

hemorrhagic infiltrations ('\splenizations'*) had to be resected if a fatal issue

were to be prevented (4)

Occasional small peripheral wedge resections were performed for localized

areas of necrosis around foreign bodies. Otherwise, there were few valid indications for resection in forward hospitals. They were limited to:

1. Irreparable damage to a major bronchus.

2. Partial traumatic amputation of a portion of a lobe in which the bronchi

had been transected and little or no blood supply remained.

3. Damage to major pulmonary vessels of such a character as to require

complete ligation. Very few patients in this category lived long enough to

reach a forward hospital.

The records of the 2d Auxiliary Surgical Group, covering 2,267 thoracic

and thoracoabdominal wounds, show only a single lobectomy in a forward hospital, on a patient who died in the course of the operation. Pneumonectomy

was not attempted in any instance.

Management in Base Hospitals

Even in base hospitals, indications for pulmonary resection seldom arose.

An occasional peripheral wedge resection was performed, as in forward hospitals, to remove a localized area of necrosis around a foreign body or on the

indication of a small peripheral posttraumatic abscess or multiple bronchopleural fistulas. The tissue to be excised was held between clamps. After

hemostasis had been secured, the raw edges of the lung were sutured together,

and the edges of the pleura were inverted with two rows of interrupted sutures

of fine silk. Air leakage did not occur with this type of suture.

The experience of the 2d Auxiliary Surgical Group shows how infrequent

was the need in "World War II for the radical excision of lung tissue. Maj.

Thomas II. Burford, MC, and Maj. (later Lt. Col.) Paul C. Samson, MC, found

it necessary to perform only one lobectomy and only two total pneumonectomies
SPECIAL TYPES OF THORACIC WOUNDS 19

in the base hospitals in which they worked. In retrospect, they questioned the

wisdom of allthree operations:

The lobectomy was performed for a massive liquefied hematoma of the

upper lobe, which had shown no evidence of regression over a 4-week period.

The patient died on the operating table. In this case, simple external drainage

would probably have been wiser.

The first pneumonectomy was performed on the indication of a chronic

fistulous tract resulting from a penetrating shell-fragment wound. The tract

was more than 1 cm. in diameter and extended through both upper and lower

lobes at the hilus. Surgical obliteration was impractical. The patient survived the pneumonectomy but eventually died from empyema and purulent

pericarditis.

The second pneumonectomy, in which death occurred from the same causes,

was performed on the indication of multiple recurrent fistulas, a collapsed lung,

and an infected hemothorax. The original injury was a perforating wound

from a rifle bullet. Pathologic examination of the excised specimen showed

multiple areas in which alveoli were ruptured, and widespread vascular damage

was indicated by thrombosis of numerous small vessels. In this case, it would

probably have been wiser merely to drain the empyema and accept the collapse

of the injured lung as permanent.

The results in these cases show that the mortality for pulmonary resection

performed for thoracic injuries or their sequelae is so high that operations of

this sort are seldom if ever indicated. They should be undertaken only on

clear-cut indications and only after the most careful consideration.

In the Mediterranean theater, an increasingly conservative attitude toward

lobectomy and pneumonectomy was gradually crystallized as experience in the

management of combat-incurred casualties increased. In the last year of the

war. in treating a series of 338 chest injuries at the 21st General Hospital, Maj.

Lyman A. Brewer III, MC, found no indication for lobectomy in any of the

patients. In one case, it was thought that lobectomy might be necessary later,

but the decision was deferred until the lung had had a chance for maximum

recovery and the patient could be studied more deliberately in the Zone of

Interior.

WOUNDS OF THE MEDIASTINAL STRUCTURES

General Considerations

Wounds of the mediastinal structures were uncommon in forward hospitals, chiefly because injuries to adjacent vital structures were usually lethal.

Mediastinal wounds included injuries of the larger hilar blood vessels, which

were usually promptly fatal; injuries of the intrathoracic trachea and major

bronchi: and injuries of the esophagus. Diagnosis, which was difficult and

confusing, was based upon the following considerations:
20 THORACIC SURGERY

1. The projected course of the missile was the most useful index of possible

damage.

2. Signs of continuing intrapleural hemorrhage were frequently, but not

necessarily, present when a large blood vessel had been injured.

3. Injuries to the trachea and major bronchi caused a rapid accumulation

of air in the pleural cavity, freqently under increased pressure. Whenever

leakage of air continued, it could be assumed that a bronchus or branch

bronchus had been injured.

4. Mediastinal emphysema of varying degrees was frequently present, as

the result of wounds of the hilar bronchi, trachea, or subglottic larynx, though

in the experience of the 2d Auxiliary Surgical Group, the air was never under

sufficient pressure to obstruct the venous return to the heart and give rise to

symptoms. It was the opinion of these surgeons that most of the symptoms

ascribed in the literature to mediastinal emphysema were more probably caused

by an unrecognized associated pressure pneumothorax. The ease with which,

in many cases, air in the mediastinum dissected into the pleural cavity was explained by the absence, in most World War II soldiers, of old pleural disease

and subsequent pleural thickening and adhesions. The most frequent clinical

evidence of mediastinal emphysema was a precordial crunch or click

synchronous with the heartbeat.

Management

Correction of the pressure pneumothorax usually stabilized the patient

sufficiently to permit whatever surgery was necessary. Only occasionally were

suprasternal incisions into the deep fascial planes necessary as an emergency

procedure to relieve emphysema.

Exploration in injuries of the mediastinum was usually carried out for

one of two reasons, suspected injury to the esophagus or continued bleeding

from large vessels or from the heart, The mere demonstration of shell fragments within the mediastinum was not considered a sufficient indication for

surgery in the absence of one or the other of these indications.

Enlargement of the mediastinum by extravasation of blood, as demonstrated by roentgenograms, was not an indication for exploration unless there

were also signs of obstruction of the superior vena cava, as shown by progressive

swelling of the cervical veins or unless progressive enlargement of the mediastinal shadow suggested continued hemorrhage. Considerable enlargement

of the superior mediastinum sometimes accompanied wounds of the neck as the

result of dissection into it of blood from a cervical vessel. It was the rule to

investigate wounds in the neck thoroughly, before proceeding with such extensive operations as removal of a part of the clavicle and the sternum, in the

hope that, even if the missile was in the superior mediastinum, the source of the

hemorrhage might be reached from above or might become accessible by exposure at the base of the neck. When a missile in this region could not be

readily removed, the area could be drained through the cervical wound.
SPECIAL TYPES OF THORACIC WOUNDS 21

•

r t

;

''lN

v." y

FIGURE 5.—Schematic showing of results of laceration of main bronchus.

This injury will always produce a Pneumothorax with leakage of large

amounts of air even under closed drainage with strong suction. Thoracotomy

is indicated.

As a matter of convenience, wounds of the trachea and bronchi and oi the

esophagus are discussed separately.

WOUNDS OF THE TRACHEA AND BRONCHI

General Considerations

Injuries of the intrathoracie trachea and main bronchi were extremely

uncommon in forward hospitals, chiefly because, if they were of consequence,

death promptly occurred on the battlefield. The few patients who survived

to reach the hospital—there were only 4 in the 2,267 thoracic and thoracoabdominal injuries encountered by the thoracic surgical teams of the 2d Auxiliary

Surgical Group—were in severe cardiorespiratory imbalance. None of them

presented a sizable intrathoracie laceration of the trachea.

Unless casualties with this kind of injury had also sustained a traumatic

thoracotomy, wounds of major bronchi were characterized by a rapid, complete

collapse of the affected lung, associated with an extreme degree of pressure

pneumothorax (fig. 5). Subcutaneous emphysema might be extreme, extend-
22 THORACIC SORCERY

ing from the scalp down to, and into, the testicles. When the trachea was the

site of a major wound, both lungs were collapsed and the patient usually died

very quickly.

These findings, combined with the location of the missile, pointed to the

diagnosis, particularly in injuries of the trachea. The only possible source of

confusion was a sucking wound at the apex of the lung anteriorly, which might

be mistaken for a perforation of the trachea.

Management

In wounds of the trachea and bronchi, immediate, adequate decompression was imperative. It was best accomplished by the introduction into the

second interspace anteriorly of a large catheter, which was connected with a

water trap. Large amounts of blood were frequently present in the pleura,

and unless thoracentesis was also carried out promptly, the patient could drown

from the sudden entrance of this blood into the tracheobronchial tree. The

diagnosis was established if the lung did not reexpand completely when these

procedures were instituted; the bubbles of air expelled during quiet expiration

could be observed in the water-seal drainage.

If bleeding was not severe, it was best to restablish the cardiorespiratory

balance before operation was undertaken. If bleeding was continuous, operation had to be performed promptly. Even if the diagnosis was only suspected,

thoracotomy was warranted, since both the bronchi and the trachea lend themselves quite well to suture.

A high posterolateral approach, preferably on the right side, provided the

best exposure for wounds of the trachea. Repair was accomplished by simple

closure with interrupted sutures of fine silk. If there was loss of substance in

the tracheal wall, mediastinal tissue, pleura! tissue, or a long-pedicled flap from

the latissimus dorsi could be used to aid in the repair. Occasionally, in high

tracheal wounds, repair was accomplished through an anterior ajDproach, with

division of the clavicle.

The diagnosis, or even the suspicion, of injury to a major bronchus was

an indication for exploration. The mere existence of damage to a bronchus was

not, however, an indication for lobectomy, though if the vein or artery to a

lobe of a lung was lacerated, resection might conceivably be necessary. Not

many such injuries were seen because they led to rapid exsanguination, and the

casualties did not usually survive long enough to reach even forward hospitals.

In contrast to the general experience, Maj. Robert II. Wylie, MC, had two recoveries after operation for injuries of major bronchi.

In one case in which serious bleeding from an upper lobe bronchus made

anesthesia hazardous, Maj. (later Lt. Col.) Lawrence M. Shefts, MC, packed

the main stem bronchus under endoscopic vision. It was then possible to

occlude the blood supply temporarily and proceed with the repair of the damaged bronchus. The procedure in this case was lifesaving.
SPECIAL TYPES OF THORACIC WOUNDS 23

Case History

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

Mediterranean Theater of Operations, U.S. Army, early predicted that no

patient with an injury to a left main stem bronchus would survive to be treated

in a forward hospital, as the anatomy of the left hilar region made it inevitable

that a missile could not pass through it without inflicting fatal damage. No

such injuries were observed. Lt. Col. W. Paul Sanger, MC, observed two casualties with, damage to the right main steam bronchus. Both survived to be

hospitalized because of the unusual tactical situation: Both were wounded

on the Anzio beachhead, in close proximity to the hospitals to which they were

admitted. One of them died early in the postoperative period because of overwhelming pleuropulmonary sepsis. The history of the other follows.

Case 2.—This casualty was hospitalized within an hour after lie had sustained a shellfragment wound of the eighth posterior interspace on the right side, presumably while

prone. He immediately became dyspneic and was unable to move the lower extremities.

When he was admitted, he was in shock and was completely paralyzed below the eighth

dorsal segment. Respiration was profuondly embarrassed, obviously because of a large

wound, 5-6 em. in diameter, in the eighth right interspace posteriorly, which was sucking

air and draining blood. It was filled with bits of clothing and bone fragments. The sucking was controlled at once with petrolatum-impregnated gauze packs. Paravertebral block

of the sixth to the tenth intercostal nerves greatly improved the respirations and permitted

the patient to cough up large amounts of blood. The blood pressure was elevated to 86/52

mm. Hg by the infusion of 25 gin. of serum albumin. Aspiration of the chest produced

800 cc. of blood, which was immediately returned to the patient by autotransfusion. Insertion of an intercostal catheter relieved the developing pressure pneumothorax.

P>y 0 hours after injury, the patient had become fairly well stabilized. Then there was

a sudden increase in the pneumothorax. Emergency surgery was performed, under endotrachcal anesthesia. The wound in the region of the eighth right rib was excised, and a

posterolateral thoracotomy incision was made in the eighth right interspace. A large,

ragged, bullet-shaped shell fragment, 12 cm. long, was found penetrating the posterolateral

wall of the right main stem bronchus, just distal to the bifurcation of the trachea. Air

and blood were pouring freely from the wound. The azygos vein was lacerated: it was

sutured, without complete occlusion. Then, with considerable difficulty, the defect in the

bronchus was approximated with interrupted silk sutures ; the closure was reinforced with

muscle. When the closure was water-tested, there was no evidence of leakage.

A transverse laceration of the upper lobe of the right lung, between 12 and 14 cm.

long, was closed with interrupted silk sutures. The lung was then reexpanded except

for the portion of the upper lobe in the area of laceration. The incision was closed in

anatomic layers.

The patient received 1,000 cc. of blood and 250 cc. of plasma during the operation

and was in fair condition at the end.

The immediate postoperative course was stormy, not because of the chest wound

but because of the distention and other complications that accompany cord transection.

Suprapubic cystostomy was done on the seventh postoperative day, and a hip spica was

applied, to facilitate evacuation.

The right lung remained expanded, but on the 12th day, the incision became infected

in the area of the original wound. Empyema followed; such an experience shows the

unwisdom of including the wounded area in the thoracotomy incision. Treatment consisted of the intramuscular injection of 25,000 units of penicillin every 3 hours for 10 days :

no sulfonamides were given.
24 THORACIC SURGERY

FIGURE G.—Thoracic: laceration of esophagus. Hydropneumothorax

produced by fluid and air escaping from esophagus (a), and through

rupture of mediastinal pleura (b). Aspiration of esophageal fluid

from pleural cavity is diagnostic (c).

Reports from the base hospital a month after wounding stated that the empyema

cavity was still from 200 to 300 cc. in volume. There was some return of sensation in the

extremities. The last report, 4 months later, stated that progress was continuing to be good.

WOUNDS OF THE ESOPHAGUS

Incidence

Wounds of the thoracic esophagus -were uncommon. In the 1,364 thoracic

wounds and 903 thoraeoabdominal wounds cared for by the surgeons of the 2d

Auxiliary Surgical Group, there were records of only 6 cases. In one of these,

the diagnosis was doubtful; the surgeon who removed the missile from the wall

of the esophagus noted that he did not think that the lumen had been penetrated.

The two other cases in which surgery was done ended fatally, and the three remaining cases were diagnosed only at autopsy. This surgical group, therefore,

with its wide experience of thoracic injuries, had no record of certain recovery

from a confirmed penetrating wound of the intrathoracic esophagus.

Diagnosis

Diagnosis of wounds of the esophagus (figs. 6 and 7) was difficult, but it

was imperative that it be made because continued spillage in an unrecognized

wound was likely to be followed by mediastinal infection (fig. 8), which was
SPECIAL TYPES OF THORACIC WOUNDS 25

a

B -

FIG i KE 7.—Cervical laceration of esophagus. A. Air and fluid spread through

deep cervical fascia! planes: Trachea (a), esophagus (h), sixth cervical vertebra

(c). and carotid sheath (d). B. Deep abscess formation, pointing to mediastinum

(a) or, less often, externally (b).

often fatal, or massive fulminating empyema. The chief diagnostic difficulty

was that neither symptoms nor signs were consistent and that suspicion was

frequently not aroused until serious complications had ensued. Another difficulty was that many of the symptoms and signs present were related to wounds

of associated struct-ares, particularly large sucking wounds and massive hemothoraces, and tended to overshadow whatever clinical picture might be produced

by lacerations of the esophagus.

Perhaps the most common symptom of esophageal injury was continued

substernal discomfort, with acute substernal pain on swallowing. True

dysphagia was not the rule. Severe pain in the back, radiating down into the

lumbar region, was pathognomonic when it was present. Typically, it was not

alleviated by large doses of morphine. The probable origin of the pain was

the inflammatory reaction in the posterior mediastinum caused by leakage from

the esophagus.

Mediastinal emphysema was often present and was sometimes associated

with cervical emphysema. Equally often, it was absent, for the opening in

the mediastinal pleura that usually was a part of such injuries permitted the

escape of air into the pleura (fig. 6). The presence of a pneumothorax was not

always helpful, for the missile which had penetrated the esophagus might very

well have penetrated or perforated the lung also.
26 THORACIC SURGERY

FIGUEE 8.—Acute suppurative meiliastiiiitis .secondary to

perforation of esophagus. Xote widening of retrotraeheal

space and air in tissues.

Projection of the track of the missile was not helpful in many cases because

a hemothorax or hemopneumothorax might obscure the path which the missile

had taken in traversing the lung. If, however, one kept in mind the exact position of the esophagus in various parts of the thorax in relation to the location

of the missile, as demonstrated by anteroposterior and lateral roentgenograms,

it was often possible to make diagnostic assumptions. This help was not available when a missile of moderate size had passed completely through the

mediastinum.

If an injury of the stomach could be ruled out, blood obtained on the passage of a Levin tube was an indication of possible esophageal injury. If roentgenograms showed a widening of the mediastinal shadow, a swallow or two of

thin barium or Lipiodol was given and additional roentgenograms taken.

Mediastinal widening was, however, a confusing finding, for it might also be

caused by injuries at the base of the neck. The aspiration from the pleural

cavity of gastric juice or of fluid containing food particles was pathognomonic

of a gastrointestinal perforation. Food particles were identified by the naked

eye. The presence of gastric juice was readily determined by the very acid
SPECIAL TYPES OF THORACIC WOUNDS 2 I

reaction of litmus paper to it. If the diaphragm was not injured, these findings

were evidence of a perforation of the esophagus.

As a practical matter, the diagnosis of injury to the thoracic esophagus was

chiefly made on suspicion, aroused by whichever of the signs, symptoms, and

roentgenologic findings just listed might be present in the particular case. It

almost always had to be confirmed by exploration, which was warranted even

if the suspicion was based on nothing more concrete than knowledge of the

course of the missile in a perforating wound or of its position in a penetrating

wound. Any rent in the posterior mediastinum or any hematoma in this region

found in the course of exploration of the chest on other indications was always

investigated, with the possibility of injury to the esophagus in mind.

Management in Forward Hospitals

The extremely high mortality of wounds of the esophagus, as just noted,

made it mandatory to perform an exploratory operation on the slightest suspicion that such an injury existed. The limited World War II experience, however, makes it impossible to make definitive statements about management.

If the patient's condition did not permit immediate operation, the best plan

was to intubate the stomach, withhold all food by mouth, and keep the patient

under penicillin protection.

When surgery was indicated, the esophagus, if the wound was in the upper

third, was best exposed from the right side, by a posterolateral transpleural

approach. If both wound and missile were on the left side, a left-sided

approach was indicated.

The margins of the esophageal wound were excised back to healthy tissue.

Then a two-layer closure was carried out, with the second layer of sutures in

the musculature. Interrupted sutures of fine silk were used. The mediastinal

pleura was left open. The pleural space was drained with two intercostal

water-seal drains.

The single patient observed by the 2d Auxiliary Surgical Group on whom

tliis total technique was used did not survive, because of other wounds, but

for the 5 days he lived after operation, there was no clinical evidence of leakage

from the esophagus or of pleural involvement. Post mortem examination, unfortunately, was not carried out.

Most surgeons of experience considered extrapleural posterior mediastinotomy both useless and harmful because it jeopardized the first objective of the

operation, complete and permanent reestablishment of esophageal continuity.

Once this was accomplished, drainage, in their opinion, would add little to the

safety of the patient and might encourage breakdown of the wound. Posterior

mediastinotomy was, in fact, an operation of limited usefulness in combatincurred chest wounds.

Postoperative management.—Gastrostomy for nutritional purposes was

not considered necessary in a forward hospital. If decompression was required,
28 THORACIC SURGERY

a Levin tube was used, either passed into the stomach, or, as advocated by

Sweet (-5) in resections of the esophagus, passed down to the site of repair.

Management in Base Hospitals

While few patients with undiagnosed wounds of the esophagus were encountered in base hospitals, it was necessary to be on the alert for such injuries.

Rapid development of a fulminating empyema and aspiration of a thin pleural

exudate with a musty odor characteristic of gastric juice were almost pathognomonic of an esophagopleural fistula. If methylene blue taken by mouth appeared in the pleural space, the diagnosis was confirmed. The site of the injury

was localized by fluoroscopy after the patient had been given a swallow of Lipiodol or thin barium solution. If a tracheoesophageal fistula was suspected,

diagnosis was made by bronchoscopy.

Once the diagnosis was made, immediate rib resection was carried out, and

a large rubber tube was inserted into the empyema cavity. For the first few

days, the tube was connected to a water-seal bottle. Gastrostomy was performed at the same operation even if the wound in the esophagus was very

small. In this sort of case, intubation was often tried, with nothing by mouth.

Full doses of penicillin were given intramuscularly.

The patient was nursed in the sitting position, to reduce the tendency to

regurgitation, which was present in practically every case. Gastric contraction

to a degree incompatible with nutritional needs was common, and the associated

pylorospasm, which was probably the result of vagal irritation resulting, in

turn, from mediastinal involvement, made continuous regurgitation almost

inevitable. Unless it could be controlled, healing of the esophagus vvas

delayed. If regurgitation was troublesome after an otherwise satisfactory

gastrostomy, jejunostomy was resorted to. In addition to preventing regurgitation. the jejunostomy served admirably as a feeding route. The gastrostomy

stoma then served as a deeompressive vent.

The criterion of satisfactory progress was closure of the esophageal fistula,

reexpansion of the lung, and obliteration of the empyema cavity. If these

results were not accomplished by this regimen, a direct surgical attack was made,

consisting of thoracotomy, decortication. and closure of the esophageal opening.

Case Histories

The following case histories illustrate the difficulties and complications of

wounds of the esophagus:

Case 3.—A paratrooper who was wounded in action on 15 September 1944 sustained

a perforating bullet wound of the right chest. The wound of exit was to the left of the

midline, just to the left of the xiphoid process. Debridement was carried out after resuscitation. There were no symptoms or signs to suggest a wound of the esophagus.

When the patient was received in a base hospital 5 days after wounding, he was

critically ill. Investigation revealed a large total empyema on the right side, with a
SPFCIAL TYPES OF THORACIC WOUNDS 29

B

FIGUUE !).—Large esophagopleural fistula with total right pyopneumothorax. A. Poslerolateral roentgenograni. Note barium at right base. B. Same, C weeks after thoracotomy with pulmonary deeortication and repair of fistula. A complete cure resulted.

large esophagopleural fistula (fig. 9A). Forty-eight hours later, the empyema was drained

under local analgesia by rib resection, and gastrostomy was performed.

The patient improved, but leakage of regurgitated material through the fistula remained

profuse, and the lung showed no tendency toward reexpansion. Four weeks after wounding,

thoraeotomy was performed, with decortication and closure of the 2-cm. longitudinal defect

of the esophagus just above the cardia. The esophagus had been pulled well to the right

by the changes consequent to injury and to subsequent infection. Operation was performed

without difficulty, and pulmonary expansion was immediate and complete. Closure was

effected in two layers, by interrupted sutures of fine silk, with inversion of the knots.

Fibrin foam was sutured over the site of the repair. The mediastinal pleura was closed,

and the usual water-seal intercostal catheter drainage was instituted.

The immediate postoperative course was uneventful, but regurgitation was troublesome, and recurrence of a small basal empyema required secondary drainage by rib resection.

Jlethylene blue given by mouth appeared in the pleural exudate at the end of 2 hours, and

iluoroseopic examination after a swallow of Lipiodol showed a very small leak at the site

of repair. After jejunostomy was performed, there was prompt relief of regurgitation as

well as rapid obliteration of the basal empyema cavity (fig. OB). When the patient left

the hospital, his condition was excellent in all respects.

Case 4.—This patient received his initial surgery in a British mobile field hospital. A

tommy-gun bullet had penetrated the neck at the base on the right side and traversed it

obliquely, emerging at the posterior margin of the left sternoeleidomastoid muscle. The

right thyroid lobe was damaged, the right lateral wall of the trachea opened, and the

esophagus almost completely transected.

At operation, a few hours after injury, the trachea was repaired and the esophagus

was closed by end-to-end suture, presumably with catgut. The wound was closed with

drainage, and gastrostomy was done.

At the end of 5 days, the neck began to swell, and on the seventh day, the anterior wound

broke down and began to discharge both purulent exudate and esophagcal secretions. When

the patient reached the 21st General Hospital, he had a large esophageal fistula, with
30 THORACIC SURGERY

considerable infection. Vomitus was aspirated into the lung when he vomited soon after

admission, and a typical aspiration pneumonia further complicated the clinical picture.

After a stormy period, the pneumonia cleared, and the cervical infection subsided. The

infection had not extended to the posterior mediastinum. When the patient was last

observed, he still had a large fistula of the esophagus, and his condition still did not

warrant barium studies to determine what type of reparative procedure would be required.

Case 5.—This patient was struck in the right shoulder and received a penetrating

wound of the neck from an explosion of an antitank shell within an M-4 tank. Eluoroscopic

examination revealed multiple foreign bodies in the base of the neck, one of them in the

region of the right lateral wall of the esophagus. Extreme dysphagia was noted soon after

the injury. The wound of entrance was debrided. No attempt was made to remove any

foreign bodies.

The diet was limited to fluids, but intubation was not done. A week after injury, there

was leakage from the wound of material taken by mouth, and when the patient was admitted to the 21st General Hospital, he had an esophageal fistula.

Intubation was immediately instituted, with high-caloric, high-vitamin feedings by

this route. Xothing was permitted by mouth. The infection cleared rapidly, and the

fistula closed with equal rapidity. Two weeks after admission, the patient's barium

studies showed a normal esophagus.

Comment.—This ease reemphasizes the importance of recognizing dysphagia as a

possible symptom of a wound of the esophagus and of resorting to intubation at once in

any instance of possible perforation.

CRUSHING INJURIES

Compression or crushing injuries of the chest observed in World War II

were chiefly of noncombat origin. They varied considerably in extent, but they

were usually relatively mild and required only conservative management.

The pathologic lesion varied according to the degree of trauma. It included simple contusion injuries of the pleura and lung; intrathoracic hemorrhage, subpleural in slight injuries and more central and more extensive in

severe injuries; hemothorax; pneumothorax; fractures of the ribs and the

sternum; rupture of viscera; and massive collapse of the lung. The so-called

contusion pneumonia which followed severer types of compression injury

and which could be extremely serious was in reality not a specific entity but the

pneumonitis resulting from factors common in thoracic trauma. These factors

included the limited respiration and cough caused by chest pain, retained bronchial secretions, and hemorrhage and edema of the lung. Together they made

up the clinical picture of wet lung (p. 207).

In simple crushing injuries, the only treatment necessary was rest and

relief of pain. In more severe injuries, the management of shock and the correction of disturbances of cardiorespiratory physiology resulting from hemothorax, pneumothorax, and emphysema were of primary importance. Surgery

was necessary when lacerations of the diaphragm were present (p. 103). Penicillin was given, to prevent infection. Late complications included pneumonia,

empyema, and lung abscess.
SPECIAL TYPES OF THORACIC WOUNDS 31

Ecchymotic Mask

Ecchymotic mask is the term used for the bluish-violet discoloration of

the face, neck, and upper portion of the chest that sometimes results from

sudden, direct compression of the chest or abdomen. In civilian practice, it is

most often seen following compression of the chest between the rear end of a

truck and a loading platform. It may also occur in sudden, direct compression

of the extremities as the result of a fall or some other accident in which the

thigh is violently flexed on the abdomen. In wartime, the casualty may be

actually crushed by falling debris from bombs.

The discoloration may also be found in the pharyngeal and retrobulbar

areas, though in these regions, true hemorrhage may have occurred. It is

ordinarily more marked at areas of pressure, such as in the neck from collarbands, around the head from hatbands, and across the shoulders from

suspenders.

The explanation of ecchymotic mask is extreme stasis in the peripheral

venous capillaries, which remain intact but become dilated. There is no

evidence of diapedesis. The proof of the theory of stasis is threefold, (1) the

intact state of the vessels; (2) the absence of extravasation of blood on microscopic examination; and (3) the absence of the usual shades of color observed as

an ordinary ecchymotic spot gradually fades.

Clinically, the discoloration begins to fade about 48 hours after the injury

and usually disappears in 2 weeks. The patients are seldom uncomfortable,

and sequelae are unusual. Ocular symptoms, which are sometimes present,

range from mildly blurred vision to total blindness. Fortunately, ocular involvement is uncommon, for retrobulbar or funcial hemorrhages may produce

permanent atrophy of the optic nerve.

When Heuer (6), as the result of a personal experience in World War I,

reported on ecchymotic mask, he was able to find 127 cases recorded in the

literature up to 1923. There were 27 deaths immediately after injury and 8

cleferred deaths. Autopsies were performed in 23 of the fatal cases. Symptoms

and signs of intrathoracic injury were common, but they were generally slight

and disappeared promptly. They included hemoptysis, pulmonary edema,

hemothorax, pleural effusion with empyema, pneumonia, and subcutaneous

emphysema.

Visual disturbances were reported in only 16 of the recorded cases, including Heuer's own case, but in 7 of these, there was permanent impairment or

complete loss of vision, in all instances associated with progressive optic

atrophy. In most of the recorded cases, there was no statement about the eyes,

but in 23 reports, it was stated specifically that the eyes were not affected, and

in 10 other cases, it can be assumed that they were not affected.

Ecchymotic mask was not often observed in World War II. It did not

occur in any of the forward cases treated by the 2d Auxiliary Surgical Group,
32 THORACIC SURGERY

which suggests that the causative factor is a product of localized, thoracic crushing rather than the result of a penetrating or a blast injury. Major Burford,

working in base hospitals, observed it only five times in 1,200 casualties. All

of these were service troops, all were injured in jeep or truck accidents, and all

recovered uneventfully.

Another textbook condition, commotio thoracis, was never observed by surgeons of the 2d Auxiliary Surgical Group, whose opinion was that it should be

dropped from the list of traumatic entities.

BLAST INJURIES

Incidence

The British experience with blast injury was entirely gained through

German bombings of the British Isles, a fact which, for a time, misled medical

officers in the U.S. Army, who believed that they would encounter the syndrome

frequently in combat. They did not. Blunt injuries of the intact chest, with

resulting contusion, were fairly frequent, but blast injuries were uncommon.

Early in the U.S. experience, the two conditions were frequently confused.

Once the differentiation was appreciated and pulmonary edema from wet lung,

injudicious fluid administration, and occasional fat embolism were also excluded, very few patients were seen in field or evacuation hospitals wdio could

be considered to be suffering from true blast injuries of the chest.

The single case of blast injury observed by surgeons of the 2d Auxiliary

Surgical Group in their 2,267 thoracic and thoracoabdominal injuries was confirmed by post mortem examination. The 8 cases observed by Maj. Frank

Tropea, Jr., MO, and Lt, Col. John M. Snyder, MC, in G03 chest injuries resulted

in 8 deaths; in 1 case, the diagnosis was confirmed by autopsy.

Capt. William W. Tribby, MC (7), in his study of 1,000 battlefield deaths

of U.S. Army troops in Italy, found 13 bodies in which there were no penetrating injuries and in which the cause of death was presumably blast injury. In

four cases, the diagnosis was confirmed at autopsy, Avhich revealed diffuse pulmonary hemorrhage in all cases and pulmonary edema in three. Because of the

advanced state of decomposition of the bodies, microscopic confirmation was

possible in only one case.

Captain Tribby believed that several other casualties might also have died

of blast injuries, for while penetrating wounds were present, they were not

sufficient, in any instance, to account for the fatality. In one body, for instance,

the only injury was a penetrating w

Touncl of the right wrist.

Data prepared by the Medical Statistics Division, Office of The Surgeon

Genera], Department of the Army, show 1,021 blast injuries of nonbattle origin

in the U.S. Army for the 1942-45 period, of which 48 were fatal (table 1). For

the same period, there were 13,200 battle-incurred blast injuries outside of the
SPECIAL TYPES OP THORACIC WOUNDS

TABLE 1.—Blast injuries of nonbattle origin in the U.S. Army, by numbers of admissions > and

deaths,"1 and by area and year, 1942-45

[Preliminary data based on sample tabulations of individual medical records]3

1942-45 1942 1943 1944 1945

Area

Admissions

Deaths Admissions

Deaths Admissions

Deaths Admissions

Deaths AdmissionsDeaths

Continental United

States..

Number

256

Number

7

Number

47

Number Number

150

Number

2

Number

34

Number

3

Number

25

Number

2

Overseas:4

Europe

Mediterranean 5__

Middle East

China-Burma325

144

4

11

128

119

20

9

18

10

2

7

4

3

3

1

22

64

3

2

16

22

12

7

1

145

52

5

1

155

25

13

8

4

27

18

4

1

1

3

5

80

70

1

Southwest Pacific.

Central and

South Pacific...

North America ß_.

Latin America

5

9

4

1

4

4

Total overseas. _ 765 41 26 149 1 255 10 335 30

Total Arm}' 1,021 48 73 299 3 289 13 360 32

i Includes an unknown, but presumably a relatively small, number of cases CEO (carded for record only), mostly

deaths. For the two years, 1943 and 1945, in which the number of CRO cases was known, CRO cases constituted 3.2

percent of the nonbattle blast injury "admissions."

2 Underlying cause of death, year of death, and area of admission.

s Complete flies of records used for deaths, 1942 admissions, and oversea admissions in 1943. Samples of admissions

were: 20 percent for 1945, U.S. 1943, and Europe 1944; 80 percent for 1944 excluding Europe.

* Includes 5 admissions aboard transports, 1 in 1943 and 4 in 1944.

5

Includes North Africa.

6

Includes Alaska and Iceland.

continental United States, of which 140 were fatal (table 2). Of the 6,284

blast injuries which occurred in 1944 and of which 76 were fatal, 493 involved

the chest, and 25 of these were fatal (table 3). Another eight injuries, one of

which was fatal, involved the thoracoabclominal region (table 3). Only 68 of

the survivors in both groups (65 with thoracic wounds, 3 with thoracoabclominal

wounds) required evacuation (table 4). A remarkable variety of agents (table

3) were responsible for these injuries, which are generally considered to be

caused only by high explosives. It must also be remembered that deaths which

occurred in blast injuries were not always due to those injuries. This was

true in 3 of the 25 deaths which occurred in 1944.

To complete the picture, it should be added that, as might have been

expected, the Navy experience with blast injury was considerably more extensive than that of the Army.
THORACIC SURGERY

TABLE 2.—Battle-incurred blast injuries in the U.S. Army, by numbers of admissions 1 and

deaths,2and by area and year, 1943-4-5

[Preliminary data based on sample tabulations of individual medical records]

1942-45 1942 1943 1944 1945

Area

Admissions

Deaths Admissions

Deaths AdmissionsDeaths Admis- JDeaths

sions [

AdmissionsDeaths

Europe

Number

9, 651

1,345

1

16

1,455

715

4

Number

106

14

Number

1

15

Number Number

8

462

Number Number

5, 405

620

1

S

176

73

Number

61

12

Number

4, 237

248

Number

45

Mediterranean 3_

Middle East

2

China-Burma-India _ 2

33

102

4

1

2

1

6

1, 236

532

Southwest Pacific

Central and South

Pacific

North America4

12

8

10

8

10

6

Latin America,

Total5

13,200 140 34 616 1 6,284 76 6, 266 63

1 Excludes cases carded for record only.

2 Among cases who reached a medical treatment facility. Underlying cause of death, year of death, and area

of admission.

3

Includes North Africa.

4

Includes Alaska and Iceland.

5

Includes 13 admissions aboard transports: 5 in 1943 ,1 in 1944, and 7 in 194.5.

Experimental Studies

The British experience with German bombings early in World War II

led them to carry out a number of experimental studies on blast injuries of

the lung, under the direction of the Eesearch and Experiments Department of

the Ministry of Home Security. The most important of these studies was

reported by Zuckerman (8) in the Lancet of 24 August 1940. In the same

issue, Dean and his associates (9) reported on the clinical aspects of these injuries, and in the issue of 19 October of the same year, Hadnekl, Swain, Boss,

and Drury-White (10) described the pathologic process as confirmed by autopsy

studies.

Zuckerman's studies on blast injury, which are now classic, were carried

out on pigeons and on animals varying in size from mice to monkeys. The experimental animals were exposed, in the open, (1) to blast from the explosions

of 70 pounds of high explosives and (2) to explosions of hydrodgen and oxygen

in balloons. Both sets of experiments produced essentially the same results.

In the experiments with high explosives, no animals were killed at distances beyond 18 feet, and none were hurt in any observed manner at distances

beyond 50 feet. When the bodies were protected by thick layers of rubber,
SPECIAL TYPES OF THORACIC WOUNDS 00

TABLE 3.—Battle-incurred blast injuries of the thorax and thoracoabdominal region, by numbers

of admissions 1 and resulting deaths 2in the U.S. Army, 1944, by area of admission and

causative agent

[Preliminary data based on sample tabulations of individual medical records]

THORAX

Area

All agents Artillery

shell

Boobytrap,

landmine,

grenade,

etc.

Bomb Small arms

fire

Other

agents 3

o

1

o

n

o o

R

o

1 1

|

Number

416

64

Number

20

5

A

J

umber

335

42

Number

14

3

Number

44

12

Number

2

1

Number

25

8

Number

2

1

Number

5

1

Number

1

A'u mber

7

1

Nit mber

1

Mediterranean 4

Middle East _ . _ _____

Chin a-Burma-India

9

4

4

3

2

1

2

! 1

Total 493 25 384 17 59 3 35 3

l

6 1 9 1 1

THORACOABDOMINAL REGION

Europe __ 5

3

1 2

2

3

1

1

|

Middle East . _ _ _

Southwest Pacific !

North America 5

1

1

Total ______ 8 1 4 4 1

i Excludes cases carded for record only.

2 Deaths occurring in 1944 among admissions in area indicated. Cause of death in 1 case (thorax, Mediterranean)

was ascribed to compound comminuted fracture of scapula; in 2 cases (thorax, Europe) cause of death was ascribed to

traumatic sucking pneumothorax.

3 Includes some few with causative agent unknown.

4 Includes North Africa.

5

Includes Alaska and Iceland.
36 THORACIC SURGERY

TABLE 4.—Battle-incurred blast injuries of the thorax and thoracoabdominal region, by numbers

of admissions 1 and resulting deaths 2in the U.S. Army, 1944, by area of admission and

evacuee status

[Preliminary data based on sample tabulations of individual medical records]

THORAX

Area

Total Evacuated Not evacuated

Admissions Deaths Admissions Deaths Admissions Deaths

Europe

Mediterranean 3

Middle East

Number

416

64

Ntimber

20

5

Number

63

2

Number Number

353

62

Number

20

5

Chinsi-Burma-India

Southwest Pacific 9

4

9

Central and South Pacific 4

North America 4

Latin America

Total 493 25 65 428 25

THORACOABDOMINAL REGION

Europe

Mediterranean 3

5

3

1 3 2

3

1

Middle East

China-Burma-India

Southwest Pacific

Central and South Pacific

North America 4

Latin America

Total 8 1 3 5 1

1 Excludes cases carded for record only.

2 Deaths occurring in 1944 amone; admissions in theater indicated. In 3 eases, not evacuated, death was ascribed

to causes other than blast injury (see footnote 2, table 3).

3

Includes North Africa.

i

Includes Alaska and Iceland.

there was either no damage at all, or minimal damage, as compared to the damage suffered by control animals. This observation, it might be interpolated,

furnishes additional evidence for the use of body armor.

None of the animals or birds had any external signs of injury. In every

autopsy, the outstanding finding was traumatic pulmonary hemorrhage, which

varied in degree according to (1) the distance of the animal from the charge

and (2) the pressure exerted against the body. The lesions were bilateral

unless the animals were so placed that one side acted as a shield for the other.
SPECIAL TYPES OP THORACIC WOUNDS ot

Then the lesions occurred on the side facing the explosion. This fact, as well

as the anatomic sites of the hemorrhage, permitted no interpretation except

that the lesions were caused by the impact of the pressure wave against the

body wall. In all instances in which the lung injury was sufficiently severe

to cause death, the lesions were detectable on roentgenologic examination, and

blood was present in the upper respiratory passages as well as in the lungs.

Mechanism

Blast may be defined as the compression and suction waves set up by the

detonation of a charge of high explosive. At every point in the neighborhood

of the explosion there occur:

1. A wave of high pressure, lasting about 0.006 second, according to

Zuckerman's studies with 70-pound charges, followed by

2. A negative suction pressure wave, lasting up to 0.003 second, produced

by the reduction of the density of the air behind the positive compression wave

to below the normal atmospheric pressure, which is about f 5 pounds per square

inch. The suction component of the blast wave is always much weaker than

its pressure component; it can never be greater than 15 pounds per square inch,

which corresponds to a perfect vacuum. It is only because of the very short

duration of both components that blast waves are not more destructive than

they are.

As hot gases are ejected by a detonating shell, they compress the surrounding air into a shell or belt, which is thrown against adjacent layers of air. The

compressed air within the belt is characterized by high pressure and high outward velocity. It is limited by an extremely sharp front, the so-called shock

front, which is less than one-thousandth of an inch and in which the pressure

rises abruptly.

The initial velocity of the shock front as it travels away from the point

of detonation is extremely high. Maj. Ealph W. French, MAC, and Brig.

Gen. George E. Callender (11) estimated it as 3,000 feet per second at 60 feet

from a 4,000-pound light-case bomb where the pressure jump is fOO pounds

per square inch. The velocity then decreases rapidly clown to the velocity of

sound, which is about 1,100 feet per second or 750 miles per hour. The velocity

of the shock front can be realized by comparing it with the velocity of gale

winds from 50 to 60 miles per hour; of hurricanes, 80 to 100 miles per hour;

and of tornadoes, in which estimated velocities range from 200 to 230 miles

per hour.

Because the pressure wave is highest in the region of the explosion and

falls off rapidly the farther it moves from it, everything in the immediate

neighborhood of a bomb explosion will suddenly be exposed to violent pressure

waves of many times atmospheric pressure, while everything 50 feet or more

awav will be exposed to only two or three times atmospheric pressure. The

T4li--fi41v- -«.", -—5
38 THORACIC SUIiCiERY

velocity and duration of a pressure wave at any given point are such that any

object as large as the human body would undoubtedly be completely immersed

for an instant in a wave of almost uniformly raised pressure.

The magnitudes of the pressure and suction components of a blast wave

are directly correlated with the amount of explosive. Zuckerman's studies

showed, however, that if a given positive pressure is caused by a given amount

of explosive at a given distance, the same degree of pressure will be experienced

at twice that distance only when the amount of explosive is increased eight

times.

Tims all objects in the immediate neighborhood of an explosion are first

subjected to violently increased wind and hydrostatic pressure, which may tear

them to pieces and blow them far from the scene of the explosion. If they are

not shattered by the pressure wave and blown along in its direction, they may

be pulled toward the center of the explosion by the weaker, but longer acting

suction wave.

Pathologic Process and Causes of Death

The pathologic process which results from the contusive ell'ect of a blast

wave on the chest arises, according to Zuckerman's (<§) experimental studies,

from the pressure component of the blast, which bruises the lungs by its impact

on the body wall. It varies from small ecchymotic areas on the lung surface

to such extensive lesions that the lung may appear hepatized.

In the 10 autopsies performed by ITadfield and his associates (10) on

civilians who died suddenly, or within a few hours, after short-range exposure

to detonation of high explosives during aerial bombings, gross traumatic lesions

were entirely absent or were trivial in all but one instance. In eight cases,

death was due to the effects of blast, though in three cases carbon dioxide

saturation of the blood was so extreme that it was considered the immediate

cause of the fatality. Two casualties who were extricated from overlying

debris without visible injuries were first thought to have died of blast. Further

examination showed that both deaths were caused by compression asphyxia.

As in Zuckerman's experimental studies, intrapulmonary capillary hemorrhage was the single gross anatomic lesion common to all cases in which deaths

were due to blast. There was free capillary bleeding over large areas, and in

these areas, the bronchioles, atria, and alveoli all showed uniform and considerable overdistention. In the fatalities due to compression asphyxia, hemorrhage was relatively slight. In these cases, the air passages contained only

a small amount of blood-stained fluid, which was not frothy, but capillary and

venous congestion and edema were striking. In the fatalities due to carbon

dioxide saturation, the pulmonary hemorrhage was of the same character as in

the true blast deaths, but the blood was fresh and pink, not dark. In both

groups, the air passages contained quantities of frothy, serous fluid. Tribby

(7) noted that in all 13 cases in which he believed death on the battlefield to

be due to blast, there was blood in the nose or mouth or in both in everv instance.
SPECIAL TYPES OF THORACIC WOUNDS 39

Subpleural hemorrhage was not conspicuous in the blast deaths studied by

Hadfield and his group (10). The only casualty in the series who showed

hemorrhagic rib markings in the pleura died from compression asphyxia, not

from blast. Bleeding into the walls of the smaller bronchioles was occasionally

observed, but there was a conspicuous absence of hemorrhage into the larger

structures. There was no suggestion that hemorrhages were grouped around

the bronchial system. Subpleural bullae, observed microscopically, had apparently been produced by detachment of the visceral pleura and its subjacent

elastic tissue from the underlying lung by air escaping from ruptured alveoli.

The most severe hemorrhages were found in two young children, one an

infant, the other 13 years of age; the possible explanation was the lesser rigidity

of the thoracic wall in youth. Bleeding was minimal in the only notably obese

casualty in the group; it may be presumed that his excess flesh protected him

from the most serious effects of the blast.

Even making clue allowance for the rapidity of the extravasation of blood

into the lungs as the result of blast, in no instance was the amount of blood

found at autopsy sufficient to cause fatal circulatory embarrassment. The

conclusion was that blast probably produces death by interference with some

vital tissue or center, in which, because of the extreme rapidity of the process,

the structural changes that occur are not detectable. Hadfield and his associates (10), however, considered the presence of hemorrhage a trustworthy

indication that the patient had been struck at close range by a wave of high

pressure.

In genera], autopsy studies on victims of blast in the Mediterranean theater

were in accord with these observations (fig. 10).

Clinical Picture and Diagnosis

Symptoms and signs.—The clinical symptoms and signs of blast injury as

observed in World War II were as follows:

1. Shoch.—This was a universal finding and was often profound. As a

rule, the degree of shock was directly proportional to the severity of the injury.

It was often increased by, or was more serious because of, associated injuries

in other parts of the body.

2. Restlessness.—This finding was often extreme and out of proportion

to the evident severity of the injuries.

3. Chest pain, tohich was of two types.—Almost all casualties from blast

complained of pain located laterally and related directly to respiratory movements. This type of pain was considered clue to contusion and hemorrhage of

the intercostal muscles, with resulting muscular spasm. The other type of pain

appeared in the more severe injuries. It was deep, central, and not related to

respiratory movements. It lasted only a few days and was considered to be

caused by mediastinal hemorrhage.
40 TIIOKACIC SURGERY

FIGI:I:K 10.—Schematic showing of pathologic physiology of blast injury (wave of positive pressure shown by solid arrow, wave of negative pressure by dotted arrow) : 1'etechial

hemorrhage, cardiac (a), pefechial hemorrhage, pulmonary (b). gross pulmonary hemorrhage (c), pleura! hemorrhage (d). engorged pulmonary artery (e). and engorged vena

cava (f).

•i. Cough, and expectoration, wliiclv were present in all hut the mildest injuries.—When the expectorated material first appeared, about 24 hours after

injury, it was thin and mucoid. Later, it became thick and mucopurulent.

Often, it was streaked with dark blood, and in an occasional case, there was free

hemoptysis. Expectoration usually lasted about 10 days. Almost all dead or

dying casualties were found to have frothy, blood-stained fluid in the nose and

mouth.

5. Ahdominal pain and rigidity.—These findings, which were present in

only a few blast injuries, were explained by extrapleural hemorrhages, which

had an irritative effect on the intercostal nerves and muscles. In an occasional

case, the persistence and prominence of these findings provided an indication

for laparotomy.

(>. J'artial fixation of the chest in the position of inspiration.—Movement,

although limited, was equal on both sides.

In the absence of complications, the percussion note was resonant. Breath

sounds were usually weaker than normal, especially at the bases, and coarse,

bronchial rales were frequently heard in both lungs.
SPECIAL TYPKS OF THORACIC WOUNDS 41

These observations are, in general, in correspondence with those reported

by Dean and his associates (9) in 27 patients whom they examined from 7 to 10

days after they had been close to bursting high explosive bombs. Three of the

casualties had been immersed. External injuries included extensive, but superficial, burns in 21 cases; fractures in 5 cases; and multiple splinter wounds of

the leg in 1 case.

There were no obvious chest injuries, and only six patients had symptoms

referable to the chest. None complained of chest pain or hemoptysis. In no

instance did the symptoms develop on the day of bombing; all appeared between

the second and fifth days. Sixteen patients had abnormal physical signs, in 15

instances the characteristic fixation of the chest just described; in 1 instance

the intercostal spaces shared the fullness.

Roentgenologic examination.—If the classical pathologic picture was

present, roentgenograms showed heavy mottling over large areas of the lung

fields, corresponding with the interstitial and alveolar hemorrhages observed,

and varying in size and density with the extent of the lesions. The roentgenologic Undings suggested those observed in patchy pneumonia. They disappeared

within a week in mild injuries but persisted for weeks in severe injuries.

Roentgenologic abnormalities were present in 11 of the 27 patients studied by

Dean and his associates.

Diagnosis.—The first consideration in a suspected blast injury was a history of exposure, which, in spite of its importance, had to be interpreted with

caution. The effects of blast were often a factor in wounds from high explosives,

but the seriousness of the penetrating wounds was likely to overshadow them.

Other diagnostic criteria consisted of the presence, of shock; the various

respiratory symptoms described; the characteristic bulging of the lower portion

of the chest, which was held almost immobile in the inspirator}- position; and

the finding of blood in the lungs and air passages. Ruptured eardrums were

pathognomonic. Roentgenologic findings were confirmatory.

The essential features of diagnosis were:

1. The absence of any significant external evidence of violence to the chest.

2. llemorrhagic lesions in both lungs, as shown by the character of the fluid

expectorated or, less often, by hemoptysis, or by autopsy confirmation.

Management

The management of blast injury was never really satisfactory. The routine

consisted of the following measures:

1. The treatment of shod'.—However deep was the state of shock and

however much associated injuries demanded intensive measures, resuscitation

had to be carried out cautiously from the standpoint of replacement therapy.

Injudicious use of any fluid, including blood, might increase pulmonary edema.

An occasional patient, in fact, in whom edema and congestion were particularly

marked, responded to venesection, which, was employed as a lifesaving measure.
42 THORACIC SüKGERY

Some medical officers, in order to reduce the amount of fluid infused, administered serum albumin in 100-cc. doses every 4 hours for three or four doses.

2. The continuous administration of oxygen.—This measure was used especially if cyanosis AY as a feature of the injury, or intermittent positive pressure

oxygen.

8. The cautious use of morphine.—Morphine was used on strict indications

and in doses of not more than gr. ys if pain could not be controlled otherwise.

i. Positioning.—Since the bases of the lungs were usually involved in the

hemorrhagic process, the best position was with the shoulders raised. In the

occasional instance of unilateral blast injury, the patient was placed on the

damaged side, to keep the blood from trickling down the bronchi into the unaffected lung.

5. Local nerve block.—This measure was employed to control pain and

permit free respiration.

G. Other medication.—The administration of adrenalin was not without

risk, but it was occasionally used to overcome a temporary spasm of the bronchioles. Atrophie was also occasionally used to diminish exudation. A sulfonamide, or penicillin when it became available, was used as preventive, measure.

If surgery was necessary for other wounds, it was postponed as long as

possible, and then was done under local analgesia or with Pentothal sodium

(thiopental sodium). General anesthesia was avoided.

Case History

The following case history concerns the only valid blast injury recorded

in the experience of the 2d Auxiliary Surgical Group :

Case 6.—This soldier was riding in the back seat of a command car when the rear

wheels ran over a landmine. "When he recovered consciousness some minnt.es later, he was

lying on the ground, beside a tree. His only complaint was a bilateral hearing impairment. Speech and cerebration were not impaired, and he had no dizziness, headache, or

blurred vision. The only external wounds were a small puncture wound anterior to the

left ear, near the temporal artery; a compound fracture of the right ankle: and a simple

fracture of the left ankle.

Wire splints, extending above the knee, were applied in a collecting station. Later,

the wound of the right leg was debrided, and plaster easts were applied to both legs.

"When the patient was admitted to the 3Stli Evacuation Hospital, 52 hours after injury,

he was in good condition, was talking rationally and normally, and had no complaints.

Both pupils were equal and regular. The toes on both sides were warm.

Four hours after admission, the pulse rate began to range between 125 and 130. A

little later, it rose to 140; at this time the respiration was 32 and the blood pressure 9S/00

mm. Hg. After 500 cc. of plasma had been given, the pulse fell to 120, and the blood pressure was OS/50 mm. Hg. The respiration was 40 and the temperature 100.4° F. The

patient was very drowsy, but he could be aroused, and he was then mentally clear.

After a brief interval, his condition rapidly worsened; the blood pressure dropped, and

the pulse rate became very rapid. After the foot of the bed had been elevated and 500 cc.

of blood and 750 cc. of plasma had been given, the systolic blood pressure was recorded at

100 mm. Hg, but the diastolic pressure could not be obtained. Shortly afterward, the

systolic pressure fell to 70 mm. Hg.
SPECIAL TYPES OF THORACIC WOUNDS 43

About this time, moderate respiratory distress developed, and the patient began to spit

up frothy blood. The breath sounds were spottedly distant, and coarse rales were

heard over the entire chest. There was considerable consolidation of both bases, with a

marked friction rub. The upper abdomen was distended, and no peristalsis could be heard.

Voiding was involuntary.

Respiratory distress increased rapidly, and the patient became slightly cyanotic.

Frothy fluid, streaked with bright red blood, was being expectorated. After the administration of two ampules of Coramine (nikethamide) and 500 cc. of blood, examination of the

chest revealed diminished breath sounds and tactile fremitns on the left, with a loud toand-fro friction rub. Oxygen therapy was instituted. The blood pressure was now 90/40

mm. Hg. The patient, although struggling for breath, remained lucid enough to answer

questions. His dyspnea did not seem of the obstructive type.

Death occurred suddenly, 72 hours after injury and 24 hours after admission to the

evacuation hospital. There was no response to artificial respiration.

Autopsy disclosed an entirely clear peritoneum and retroperitoneal space. The thoracic

cage and diaphragm were intact, as were both pleural cavities.

The lungs were expanded, and there were numerous areas of hemorrhage and crepitation. There was no blood in the pleural cavity, but when the bronchial tubes were

sectioned, they were found to contain frothy, serous fluid. The heart was grossly normal

except for a questionable auricular thrombosis. The thrombi in the pulmonary artery

were regarded as a post mortem development.

Histologie examination of the lungs showed extensive areas of intra-alveolar extravasations of red cells intermingled with varying numbers of pigmented macrophages. Occasional alveoli were filled with fluid containing a few red cells. Other alveoli, some

emphysematous, were interspersed among them. Some of the emphysematous alveoli had

ruptured walls. The bronchial lumen contained large numbers of red blood cells.

The gross pathologic diagnosis (in addition to the fractures of the lower extremities)

was possible blast injury of the lung, possible thrombosis of the pulmonary artery, and

possible thrombosis of the cardiac auricle. The histologic diagnosis was severe pulmonary

hemorrhage, ruptured alveoli, congestion of the spleen, and epicardiac hemorrhage.

Comment.—This injury was difficult to evaluate from the clinical standpoint, and the

diagnosis of blast syndrome was not made early enough for therapy to be precise and

effective. One can only speculate whether earlier recognition of the blast injury, with

intensive treatment directed toward it, would have altered the outcome.

Unfortunately, no special fat stain was used on the tissues. In some blast injuries, fat

emboli were found in the lungs, as they were in some compound fractures: they were more

often seen after traumatic amputations from landmines. The diagnosis of blast injury

of the lungs was made in this case on the basis of the ruptured alveoli.

ASSOCIATED WOUNDS

A large proportion of thoracic injuries, as pointed out elsewhere (vol. I),

were associated with injuries in other parts of the body, and these associated

injuries were frequently more serious than the chest injuries. That other injuries might exist had to he taken for granted in the approach to all chest

injuries. In other words, regardless of how specialized or restricted an injury

might seem, a total therapeutic approach was necessary. In caring for a casualty, the surgeon had to conceive of him as a total organism, not as an assembly

of individual injuries. The management of the chest injury therefore had

to he related to the management of all other injuries.
44 THORACIC SURGERY

Compound Fractures

Compound injuries of the scapula and shoulder girdle might furnish

numerous problems. A missile of high velocity that struck the scapula a

glancing blow could cause extensive damage to the heavy muscles in the vicinity, in addition to shattering and fragmenting the bone. Although there was

always considerable question as to how radical one should be in dealing with

fractured ribs, there was rather general agreement that fractures of the scapula,

especially subscapular fractures, because of the less adequate drainage possible

in this area, required more radical management than fractured ribs in other

locations. Infection invariably resulted if the initial debri dement was not

complete. Wide excision of the damaged muscles was necessary, because of

the great danger of anaerobic cellulitis in this area.

Fragments of the alar portion of the scapula, if left in situ, almost invariably led to continued suppuration. Even when the scapula itself was not damaged, it was necessary to bear in mind the possible involvement of the

subscapular space when reconstruction of the course of a missile that had penetrated the chest wall indicated this possibility. Abscesses in this area could

remain unrecognized for long periods of time.

Debridement, to be entirely adequate, would have required an incision

approaching in magnitude the incision necessary for thoracoplasty and would

also have required mobilization of the scapula, Such radical measures could

not be justified on the mere possibility that a clostridial infection might develop.

The usual procedure was to make the incisions along the track of the missile

at the vertebral and axillary borders of the scapula, then to perform as complete a debridement as the exposure permitted. Great care had to be taken

during surgery in this area not to disturb the attachment of the serratus anterior; damage to it could be followed by serious functional losses. As much

as possible of the scapula was preserved, particularly of the functionally

important upper third. Less hesitancy was felt about removing as much as

necessary of the lower two-thirds. Through-and-through Penrose drains were

inserted, and a dependent drain was placed in the subscapular space through

an incision in the angle of auscultation at the interior border of the scapula.

The patient was kept in the forward hospital in which operation had been

done for at least 6 clays after operation. The wound was examined immediately if there was a rise in the pulse rate or if he complained of local pain

or if his demeanor changed, as it characteristically does in clostridial infections.

In six cases treated by the technique just described, Major Shefts and

Capt. (later Maj.) Ernest A. Doud, MC, had no deaths. On the other hand,

Maj. (later Lt, Col.) Eeeve II. Betts, MC, and Maj. William M. Lees, MC, lost

a patient from clostridial infection after what was thought to be a very radical

debridement, It was their custom thereafter to use large paravertebral incisions in injuries of the subscapular area, even though intrapleural damage had

not occurred.
SPECIAL TYPES OP THORACIC WOUNDS 45

When fractures ordinarily treated by traction occurred in association with

wounds of the chest, some compromises in therapy were necessary. Prolonged

immobilization in traction was inimical to satisfactory progress in chest injuries. The patient had to be kept maneuverable. Precise fracture alinement

could not be achieved at the expense of thoracic crippling. Fortunately, the

orthopedic repertoire was extensive enough and flexible enough to permit the

application of a regimen that would reduce the fracture satisfactorily without

jeopardizing the outcome of the chest lesion.

Vascular Injuries

Injuries to the great vessels of the axilla and at the root of the neck were

not always recognized at initial wound surgery for chest injuries, and careful

observation was necessary in base hospitals. Otherwise, important delayed

sequelae, of the vascular injuries might be overlooked. It was particularly

necessary to bo suspicious whenever the point of entry of the missile was over

the apical region of the thorax. In one such case (p. 244), on the basis of

roentgenologic examination and the repeated aspiration of clotted blood from

the chest, the casualty, who had sustained a penetrating wound of the right

apical region 3 months before, was thought to have only a hemothorax. His

progress was satisfactory until he had a sudden attack of dyspnea and pain

in the right chest. Soon after, he went into profound shock and died promptly.

Necropsy revealed a rupture of a traumatic aneurysm of the first portion of the

right subclavian artery.

It was always necessary, when operation was undertaken for early massive

empyema or clotted hemothorax, to remember the possible presence of a traumatic aneurysm of the subclavian artery, as in the case just described, or of

the innominate artery. Ignorance of the presence of the vascular lesion could

easily result in catastrophe on the operating table.

In a case observed by Major Brewer at the 21st General Hospital, the

patient, who had a foreign body in the chest wall, was conscious of a bruit that

caused him considerable annoyance. It also made him so apprehensive that

he was afraid to perform even moderate activity. A thrill was present, but

there was no erosion of the rib and no cardiac embarrassment. A large hemothorax had previously been completely evacuated by repeated thoracenteses.

After a diagnosis had been made of aneurysm of the intercostal artery and

vein, the lesion was excised, for prophylactic reasons, and the foreign body in

the chest wall was removed. The patient was able to return to full duty. It

is believed that this is the only case of the kind to be observed in the Mediterranean theater during the war.

If ligation of the subclavian or axillary vessels had been necessary in a

forward hospital, thoracic surgeons in general hospitals had to determine

whether or not an adequate collateral circulation existed. Measures to maintain the circulation, or to increase it if it was deficient, were imperative.

74<i-!Ulv- -fiä '<>
46 THORACIC SCKCERY

The most useful measures to control edema were proper positioning of the hand

and arm; intelligently applied massage: and procaine hydrochloride block of

the inferior cervical ganglion, repeated every 24 to 48 hours as necessary.

As a rule, casualties with arleriovenous fistulas resulting from combined

tlioracic-vascnlar injuries were evacuated to the Zone of Interior for final

surgery. If, however, evacuation was delayed for an inordinately long period

and compression tests revealed a satisfactory collateral circulation, operation

was done overseas. Quadruple ligaiion with excision was the procedure of

choice.

Neurologic Injuries

Brachial plexus.—The injuries of the brachial plexus frequently associated with chest injuries constituted a neurologic problem. Careful examination in both forward and base hospitals was necessary in every chest injury,

to determine their presence or absence. It was often impossible to settle this

matter positively in the first few days after injury: during this period, the

neurologic findings present might be caused by contusion of the nerve as well

as by laceration. If the injury was only a contusion, sensation and function

would return promptly.

Head injuries.—Head injuries were frequently associated with thoracic

injuries, and patients with head injuries were particularly prone to chest complications. Atelectasis and pneumonitis were ever-present threats, particularly in patients who were deeply comatose. Chest surgery was kept to an

absolute minimum in these circumstances. Careful nursing, drainage of the

tracheobronchial tree by catheter and bronchoscope, and the administration

of penicillin were all employed to avoid serious and fatal pulmonary

complications.

Spinal injuries.—In one series of 768 chest injuries studied by the 2d Auxiliary Surgical Group, there were 23 spinal cord injuries. Fractures of the

vertebrae were also frequently associated with war wounds of the chest.

Eoentgenologic examination of the spine was routine whenever there was

any complaint of pain in the back or the cervical region. Some injuries were

detected only when the patients became ambulatory: they had fallen or been

thrown with considerable force when they were injured, and the simple vertebral

fractures they had sustained were not noticed during their initial treatment

because of the greater importance of other injuries.

Associated injuries of the chest and the spinal cord constituted one of the

most distressing complexes seen in war surgery. The close anatomic juxtaposition of the structures of the spine and thorax made it inevitable that major

injuries should affect both regions in a considerable number of cases. Casualties

with these so-called thoracospinal wounds were open to the complications

inherent in both lesions. There was a marked predilection for paralyzed

patients with chest wounds to develop infection of either the pleura or the
SPECIAL TYPES OF THORACIC WOUNDS 47

pulmonary parenchyma. Hemothoraces were much more likely to become infected than in patients without spinal cord lesions.

The most important component of management of these combined injuries

was intelligent nursing care (12). Patients were nursed in the face-down

position, whenever this was practical, and were turned at frequent intervals,

to prevent the development of decubitus ulcers. Air mattresses were used when

they were available. Coughing and breathing exercises were carefully supervised. Eepeated thoracenteses were performed, to dry up the pleural cavity

as rapidly as possible. If empyema developed rib-resection drainage was

usually employed; these patients were seldom in condition for the more radical

procedure of decorti cation.

Patients with combined spinal cord-thoracoabdominal injuries were particularly difficult to care for. Many of the wounds were tangential, a type

likely to be associated with far more pulmonary contusion and damage than

the average penetrating or perforating wound. It was impossible for the

patients to cough effectively because of paralysis of the lower intercostal and

abdominal muscles. The flared costal angle, the segmental motion of the chest

wall, the relaxed abdomen, and the feeble bechic blast were all characteristic of

these combined wounds. In many cases, tracheobronchial aspiration was necessary as often as every 1 to 8 hours. Contrary to the usual observation, support

of the abdomen and lower ribs by binders or adhesive strapping seemed to make

coughing move efficient.

It was observed in certain patients with combined injuries of the chest and

spinal cord that the level of anesthesia caused by the spinal injury seemed to

play a considerable part in the outcome from the standpoint of the chest injury.

Death sometimes occurred from intractable pulmonary edema. There was no

response to positive pressure oxygen therapy or eiidotracheal suction, even

though the chest wounds were not in themselves potentially lethal.

Analysis of a number of these fatalities led to the conclusion that the lethal

factor was paralysis of the abdominis recti muscles. Normally, the tone of

the recti in a gentle cough, or their actual contraction during a vigorous cough,

provides the diaphragm with opposing intra-abdomiiial pressure. When the

pressure was lost by reason of paralysis of the recti, the cough became ineffective; the expulsive action resulted in nothing more than bulging outward of

the abdomen; and intractable pulmonary edema was the consequence.

This chain of events was clear in two of four cases of combined spinal

cord-chest injuries treated in a field hospital in the Mediterranean theater by

Major Shefts and Captain Doud. All four patients presented a typical picture

of transverse myelitis, and all had pleuropulmonary damage of about the same

degree. The two fatalities were directly related to the level of cutaneous

anesthesia. They occurred 4 and 5 days, respectively, after debridement of

the chest wounds, from pulmonary edema that did not respond to any measures,

including positive pressure oxygen and endotracheal suction. One patient

had anesthesia from below the xiphoid process and the other from just below
48 THORACIC SURGERY

the nipples. The two patients who survived had skin anesthesia below the

umbilicus, one just below the umbilicus and the other halfway between the

umbilicus and the symphysis pubis.

While a defeatist attitude was never permitted in combined spinal cordthoracic injuries, it would have been unrealistic not to recognize their potential

lethality. In many cases, therefore, the frank objective of treatment was to

salvage these unfortunate men long enough to permit them to be returned to

the United States, so that they could spend their remaining days at home and

with their families. This was possible in many of the most apparently hopeless

cases.2

References

1. Dunham. E. K.. Stevens, E. A., Graham, E. A., and Keller. W. L. : Empyema. In

The Medical Department of the United States Army in the "World War. "Washington:

Government Printing Office, 1024. vol. XI, pt. 2, pp. 33-392.

2. Graham, E. A.: A Reconsideration of the Question of the Effects of an Open

Pneumothorax. Areh. Snrg. 8:345-303. January 192-1.

3. Brewer, L. A. Ill, Bai, A. P., King. E. L., Wareham, E. E., and Parris. J. M.: The

Pathologic Effects of Metallic Foreign Bodies in the Pulmonary Circulation. A LongTerm Experimental Study. J. Thoracic Snrg. 3S :G70-G84, 703-700, November 1959.

4. Yates, J. L.: Wounds of the Chest. In The Medical Department of the United

States Army in the World War. Washington : Government Printing Office, 1927, vol. NI,

pt. 1. pp. 342-442.

5. Sweet, R. II. : Transthoracie Resection of the Esophagus and Stomach for Carcinoma. Analysis of the Postoperative Complications, Causes of Death, and Late Results

of Operation. Ann. Surg. 121:272-284. March 1945.

0. Heuer, G. J. : Traumatic Asphyxia ; With Especial Reference to Its Ocular and

Visual Disturbances. Surg., Gynec. & Obst. 30 :G8G-090, May 1923.

7. Tribby, W. W.: Examination of One Thousand American Casualties Killed In

Action in Italy. Report to Surgeon, Fifth U.S. Army, 1944, 0 vols. [Official record.]

8. Zuckerman, S. : Experimental Study of Blast Injuries to the Lungs. Lancet

2 :219-224. 24 Aug. 1940.

9. Dean. D. M.. Thomas. A. R.. and Allison, R. S. : Effects of High-Explosive Blast on

the Lungs. Lancet 2 :224-22G, 24 Aug. 1940.

10. Hadtield. G.. Swain, R. II. A., Ross. J. M.. and Drury-White, J. M.: Blast Prom

High Explosive. Preliminary Report on Ten Fatal Cases, With a Note on the Identification and Estimation of Carboxyhaemoglobin in Formol-Fixed Material by Arthur Jordan.

Lancet 2 :47S-4S1, 19 Oct. 1940.

11. French, R. W., and Cullender. G. R. : Ballistic Characteristics of Wounding Agents.

In Medical Department. United States Army. Wound Ballistics. Washington: U.S.

Government Printing Office. 1902. pp. 91-141.

12. Medical Department. United States Army. Surgery in World War II. Neurosurgery, Volume II. Washington, U.S. Government Printing Office, 1958, pp. 31-05 : 127-191.

2 The reader is referred to chapter XI (p. 441) for long-term followup studies of the various

types of wounds described in this chapter.
CHAPTER II

Wounds of the Heart (Including Retained

Foreign Bodies), Mediterranean (Formerly North

African) Theater of Operations

Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.

INCIDENCE

In World War I, as Makins (1) pointed out, casualties with cardiac wounds

who survived to come under the care of a surgeon were hit either by relatively

small missiles or by missiles traveling with reduced degrees of velocity. The

same situation prevailed in World War II. In the 2y2 years that elapsed between the first Allied landings in North Africa on 8 November 1942 and the

end of hostilities in Italy on 2 May 1945, only 75 of the 2,267 thoracic and

thoracoabdominal wounds encountered by the teams of the 2d Auxiliary Surgical Group were instances of cardiac or pericardial injury. This is an incidence

of 3.3 percent. Of the 75 injuries, 18 were examples of pure pericardial trauma.

In the other 57 cases, the heart was involved (table 5). No single team encountered more than 10 cases.

In 1 of the 75 cases, the only stab wound in the series, the wound was selfinflicted. The remainder of the injuries were all battle-incurred, in 53 instances

from shell fragments and in 21 from small arms fire. In 2 of the 18 pure periTABLE 5.—Distribution of injuries and anatomic involvements in 56 combat-incurred cardiac

injuries l

Type of injury

Anatomic involvement

Both

Contusions

Lacerations

Contusions and lacerations

Perforating or penetrating

Embolic to heart

Total.

Right

1C 5

10 2

10 2

19 3

1

5Ü 12

Left

7

7

.5

7

1

27

Both

3

Right ! Left

1

1

Right Left

i This table doe» not include a self-inflicted stab wound, from which the patient recovered. It also does not include

IS eouihal-incurred pericardial injuries, ;i of which were fatal.

49
TIIOILinC MIKKY

A

FIGURE 11.—Fatal cardiac contusion. A. Specimen without extensive pcricardial

damage. B. Cross section showing endocardial thrombi (a). In this case, rib fragments acted as secondary missiles (b).

caixlial injuries, the damage was caused directly by rib fragments, and in at

least 1 other case, extensive contusion of the myocardium was caused by rib

fragments which acted as secondary missiles (fig. 11). In 43 cases, the injuries

w-ere confined to the chest; in the other 32 cases, the wounds were thoracoabdominal.

As these statistics indicate—75 cardiac wounds in 2,267 thoracic and

thoracoabdominal injuries—wounds of the heart were not observed with any

great frequency in forward hospitals of the Mediterranean theater. The

reason, as already intimated, is that they w-ere usually—though not always

(fig. 12)—promptly fatal. These figures take no account of immediately fatal

wounds, nor do any reliable statistics exist concerning them. In the analysis

of 1,000 battlefield deaths by Capt, William W. Tribby, MC (2), it did not

prove practical to perform routine autopsies, and even this remarkable series

therefore contributes nothing really definite concerning the number of casualties

with cardiac wounds who died on the field.

It should be remembered in reading this chapter that, as will be discussed

in more detail later, in every instance in this series, the cardiac injury was only

a single feature of the trauma. In addition to their cardiac injuries, all of these

casualties had sustained more or less extensive wounds of adjacent thoracic

structures, and the chest wounds in many instances were further complicated

by serious wounds of other parts of the body.
worxns OP THE HEAKT 51

Fiona-: 12.—Survivor of cardiac wound shortly after maehineguu slug had been removed

from his heart. He went on to complete recovery.

The data in these cases, most of which were cared for under stress of battle

conditions in forward hospitals, are remarkably complete, thanks to the special

records kept by the teams of the 2d Auxiliary Surgical Group. The preservation of essential data, including roentgenograms and electrocardiograms, was

facilitated by the peculiar and often dramatic nature of the injury, which attracted the attention of shock officers and internists as well as surgeons. Personal notes on the records, and personal comments by the medical officers who

cared for the patients, provided more information in these cases than was usually obtainable from even specially kept clinical records.

CLINICAL PICTURE AND DIAGNOSIS

Diagnostic Considerations

The preoperative diagnosis of injuries of the heart was not only difficult

in itself but was sometimes not made because examination was not directed

toward their discovery. One reason for the omission was the impression that
m THORACIC SURGERY

casulties with cardiac wounds did not live long- enough to arrive at a forward

hospital. As a result, symptoms and signs arising from the cardiac wound,

particularly anoxia, were often attributed to other injuries that were present

and that complicated the diagnosis. There is no doubt that more careful clinical examinations would have led to an increase in correct diagnosis. It is

significant that the same three medical officers made all seven observations of

arrhythmia in the 2d Auxiliary Surgical Group series. As with anoxia, the

relation of tachycardia to the cardiac wound had to be based on ruling out all

other causes for this sign. So single symptom or sign was usually sufficient to

establish the diagnosis of cardiac injury.

The patient was usually designated for surgery on the suspicion of a

thoracoabdominal wound, or the cardiac wound was found in the course of

traumatic thoracotomy or during debriclement of a large sucking wound, or

it was searched for because, of continued intrathoracic bleeding during the

course of presumably adequate resuscitation. In 15 of the 75 cases in the 2d

Auxiliary Surgical Group series, the injury was discovered at post mortem.

In a few cases, it was found, in retrospect, that the symptoms and signs recorded

on the chart should have aroused suspicion before operation or autopsy.

Symptoms and Signs

Symptoms and signs were divided into two groups, symptoms due to

anoxia and signs suggestive of cardiac dysfunction.

In this series, six patients were recorded as dyspneic, six as needing continuous oxygen, five as mentally confused or semistuporous, and three as

cyanotic. Before these findings could be attributed to a cardiac wound, however, other causes of oxygen deficiency, such as hemorrhage, hemothorax,

compression pneumothorax, and extensive peritoneal contamination, had to

be ruled out. When these conditions had been eliminated and symptoms clue to

anoxia persisted out of all proportion to visible thoracic damage, then there

was justification for regarding them as due to a cardiac lesion.

Signs suggestive of cardiac dysfunction included persistent tachycardia

(a pulse of 120 or above) in eight cases, arrhythmia in seven cases (transient

fibrillation in one and extrasystoles in six), bradycardia (a pulse below 65)

in two cases, an apical systolic murmur and a precordial friction rub in two

cases each, a paradoxical pulse in one case, and nausea and vomiting in one

case.

Both precordial friction rubs were heard for the first time 24 hours after

injury: operation was delayed 3 days in one case and 5 days in the other. Since

a friction rub or splash was noted in eight additional cases after operation, it

was concluded that a certain length of time must elapse after wounding before

this sign appears. The explanation of this phenomenon is the presence in the

pericardium of air and fluid. It was seldom seen because, in most instances,

the pericardial fluid had drained into the plenral cavitv before suro-erv.
WOUNDS OF THE HEART 53

The single instance of paradoxical pulse occurred in a patient with severe

myocardial contusion, who died in the shock ward. The persistent nausea

and vomiting noted in one case was uncommon in thoracic wounds and led

to the suspicion of a thoracoabdominal wound. Whether or not it was caused

by the cardiac wound, it was associated with it and made for further diagnostic

difficulties.

A precorclial crunch or click was occasionally heard, synchronous with

the heartbeat. It was associated with mediastinal emphysema and was not

considered related to the cardiac trauma.

In retrospect, the most important diagnostic findings were considered to be:

1. A sustained pulse of 120 or more after restoration of satisfactory arterial

tension by adequate resuscitation.

2. Continued cyanosis after recovery from shock.

3. Dyspnea out of all proportion to the evident pulmonary pathology.

In several patients with cardiac wounds in this series, oxygen had been necessary in the clearing station because of severe dyspnea and cyanosis.

4. The necessity for the early and continuous use of oxygen. These clinical

findings were, of course, in addition to:

a. The obvious presence of a precordial wound.

b. The projection of the course of a missile which might reasonably have

involved the heart.

In a number of instances, irregularities of cardiac rhythm were not apparent; abnormal cardiac sounds were not heard; and there was a notable

absence of significant symptoms and signs, or those present were so trivial

as to be misleading. Makins (1) had called attention to these observations in

his account of cardiac injuries in World War I. Generally speaking, the

safest plan was to suspect cardiac injury whenever a patient seemed generally

washed out; had a sustained, rapid pulse with transient irregularities of

rhythm; and had a persisting need for oxygen.

Adjunct Diagnostic Measures

Roentgenologic and fluoroscopic studies.—In 15 cases, there was roentgenologic evidence of the injury. In eight cases the films showed a foreign

body in the region of the heart, and in four instances the object was termed

fuzzy or double-contoured. In five cases the cardiac shadow was altered in

size or shape. In two cases the object was thought to be in the region of the

heart, but there was no definite proof. In localizing missiles within the cardiac

shadow, it was necessary to use heavy penetration (fig. 13), accomplished by

the bone techniqiie or the use of the Pottei'-Bucky diaphragm. A missile could

be completely overlooked if the chest was examined with the usual exposure.

The interpretation of roentgenologic enlargement of the heart was also open

to some question when roentgenograms were made shortly after injury, since

there is usually no appreciable stretching of the pericardium when fluid first

appears in it.
54 THORACIC XL'ROim'

>~~M

FIGUKE 13.—Foreign body in left ventricle of heart. A. I'ostei'oanterior

roeutgenogram, with massive left-sided hemothorax obscuring foreign

body. B. Same, taken with deep penetration technique, showing foreign

body in situ. C. Lateral roentsenogram.

Some cardiac injuries were not suspected until repeated X-ray studies in

a general hospital, combined with fluoroscopy, revealed their presence.

The cardiac injury also might be suspected by plotting the probable course

of the missile, using the external wounds and fractured ribs as landmarks.

Diagnosis was accomplished, or suspicion was aroused, by use of this technique

in 22 of the 75 cases in this series. On the other hand, it was easy to be misled

concerning a cardiac wound if the foreign body happened to lie free in the

pleural cavity.
WOUNDS OF THE HEART 00

*>'; ' v

i .'« i; 11 j | J ' i ! " . :

81 ' «fl

J! ai ' 9; . JiO

FKiUKi; 13.—Continued. I). Fragment after removal.

The diagnostic results might have been better if nuoroscopy had been

employed more frequently, since this method permitted observation of possible

movement of the object and also made it possible to determine -whether it was

included in the cardiac shadow in all projections. The cardiac outline was

variously described as fuzzy, blurred, enlarged, or of water-bottle shape. In

two cases in which the outline was described as blurred or fuzzy, operation

revealed hemorrhage within the pericardia! membrane and in the areolar tissues

of the lower mediastinum.
THORACIC SURGERY

ITGVKE 14.—Foreign body in wall of left ventricle near cardiac apex.

A. Postoroanterior roentgenogram. B. Right anterior oblique roentgenogran]. The electrocardiogram was consistent with mvocardial injury.

Electrocardiography.—Neither electrocardiograms nor orthodiagrams

were available in forward hospitals. Electrocardiograms were most helpful

in determining whether a penetrating wound of the chest had involved the heart

(hg. 14), particularly when the thorax was not explored at all or was incompletely explored at debridement. In numerous instances, these studies provided

assurance that the myocardium had not suffered injury. In a few- cases, progressive alterations in originally normal, tracings indicated the necessity for

removal of retained foreign bodies.

The most striking abnormalities, as reported by Lt. Col. Edward F. Bland,

MC, were observed in mvocardial injuries and involved the T-waves and S-T

intervals. The predominating pattern was the so-called anterior-apical type,

w-ith inversion of T1; T„ and T4 (fig. 15). In the posterior basal type of injury,

electrocardiograms were secured in only two cases; in both, there was inversion

of T2 and Tn. Electrocardiograms with inverted T-waves in all four leads

were obtained in five patients. In one of these cases, roentgenograms showed

foreign bodies in both the anterior and the posterior cardiac walls. There was

no explanation in the other cases for the total T-wave type of inversion.

High-grade conduction defects were not observed in any instance. Two

patients with abnormal W-shaped QKS complexes of low voltage and inverted

QRS complexes in lead four were thought to have sustained cardiac contusions.

In one case, a persistent P-E interval of borderline significance (0.2 second)

may have been normal for this part icular patient.

In some cases, in which, there was roentgenologic proof of the presence of

the foreign body in the heart (figs. IG and 17), electrocardiograms were completely normal.
WOUNDS OF THE HEART 0(

LEAD I

siili

.isa

LEAD 2

LEAD 3

LEAD 4

7 AUGUJ 1944 12 JGl 1944 19 AUGU;

sis

"SS

1944

FIGUHE 1.").—Serial electrocardiograms taken after penetrating wound of heart. Note

the anterior-apical pattern of Ti-, IV, and Ti-iiiversion encountered most often in cardiacwounds.

FIGURE 16.—Machinognu bullet in right side of heart near junction

of right auricle and right ventricle. A. Posteroanterior roentgenogram.

B. Left anterior oblique roentgenogram. The electrocardiogram

showed no abnormalities.
58 TiroiüCIC SI/KCKKY

WM

Kiiit'iiK IT.—Shell fragment in anterior wall of li<>;ut in reidon of rijdit:

ventricle. A. Ki.uiit lateral roent.üenosiram. The elect roearüio.m'am

showed no ahnornialit ies. ]!. Kiijlil anterior oblique roentsenos'rani.

CARDIAC TAMPONADE

Hemorrhage, into the restricted confines of the pericardial sac, with resulting cardiac tamponade, was the chief danger from a penetrating cardiac wound

(fig. 18). Tamponade was, however, relatively infrequent in combat-incurred

injuries, in contrast to its frequency in civilian cardiac injuries. The explanation is clear: In civilian life, small weapons, such as knives, icepicks, and smallcaliber bullets, are generally used. As a result, the wound is small, bleedingis slow, and tamponade can develop as a physical possibility. In combatincurred injuries, the wounds are large because the missiles are large, and an

outlet for drainage into the pleural cavity is therefore provided. In a few

cases, pneumopericardium occurred (fig. 10), without tamponade.

Hemorrhage into the pericardial sac was usually from the cardiac chambers but might also come from a severed branch of the coronary artery, from

a pericardial vessel, or from the myocardium itself. The thick muscular wall

of the ventricles seemed to tolerate severe lacerations, and even total penetration, without serious bleeding if the coronary arteries, especially arteries with

sizable arterial branches, were not involved. In contrast, even slight tears

of the thin-walled auricles were apt to be followed by tamponade, which

could develop within the space of a few minutes and could be rapidly fatal

if it was not promptly corrected. Most casualties in whom hemorrhage was

sufficiently rapid to produce early tamponade probably did not live long enough

to reach a hospital.
AYOUXDS OF THE HKAKT 59

-^--e

-d

lfnciuRK IS.—Schematic showing of pathologic physiology of acute

pericardial tamponarte: Collapse of superior vena cava (a), collapse of

pulmonary veins (b), collapse of inferior vena cava (ej, impairment of

diastolic lining of left and right ventricles (d), impairment of diastolic

filling of stria (e), and increase of pressure in jugular vein (f). With

these findings, the heart is silent and the pulse pressure decreased.

Diagnosis

The diagnosis of cardiac tamponade was generally based on the following

findings:

1. Lowered arterial pressure.—In Elkin's (•?) series, this finding Avas present in all cases, and in 17 of the 23, the blood pressure could not be recorded.

In all the patients who recovered, the pressure rose immediately after release

of the tamponade.

2. Increased venous pressure readings.—These readings, as Elkin (3)

noted, are of both diagnostic and prognostic value. If the venous pressure is
60 llOIÜCIC Sl'KGKRY

tm%jl:*>"~~"'

FIGURE 10.—Pneumoperieardium with retained foreign body just behind heart. A. Posteroanterior roentgenogram, shortly after injury,

showing massiye pneumoperieardium. B. Left (slight) anterior oblique,

roentgenogram showing retained foreign body. C. Posteroanterior roentgenogram 10 days later, after subsidence of pneumoperieardium.

high, the assumption is that the cardiac output is at least sufficient to sustain

life. If the venous pressure is low, or falling, the assumption is that the

heart is failing and the cardiac output is correspondingly reduced. Three of

Elkins patients who presented this phenomenon died on the operating table

or immediately after operation.

3. A quiet heart.—This finding was first described by Bigger (4) and, if

it is studied fluoroscopically, the demonstration of decreased cardiac pulsations

will be found to be extremely useful in diagnosis.

4. Engorgement of the cervical veins.—This phenomenon, which was present in a number of cases of tamponade, could readily be explained as the result

of the inability of these veins to empty into the right auricle which was com-
WOUNDS OF THE HEART 61

pressed by the tamponade. When this finding was present, it was pathognomic, since such other causes as congestive heart failure, pulmonary embolism, and mediastinal emphysema were unlikely to be encountered under combat

conditions. Absence of distended cervical veins, however, and even of a distended pericardia! sac, did not necessarily exclude continued serious hemorrhage from a wounded myocardium. In one case in this series, in which

there was continued, vigorous hemorrhage from a myocardial laceration, operation performed 10 hours after injury revealed that tamponade had been prevented by the passage of blood through the pericardial rent into the pleura!

cavity.

There were 5 instances of tamponade in the 57 cases in which the injuries

involved the heart proper. Death occurred in two because the condition was

not recognized or suspected. These cases and another case in which survival

occurred have features of special interest:

Case Histories

Case 1.—This patient was injured in the left chest, shoulder, and buttock by shell

fragments on 14 December 1944. He was not in evident shock and at a field hospital, his

condition was listed as good. Breath sounds were diminished over the left chest. He

was given 1,000 cc. of physiologic salt solution intravenously before operation, which was

performed 7 hours after injury. All wounds were debrided. An open pneumothorax was

closed without exploration. Aspiration of a hemothorax yielded 300 cc. of blood.

The patient's postoperative condition was good. The pulse was within normal range,

the blood pressure was 90/60 mm. Hg, and there was full recovery from the anesthesia.

Four hours later, he was turned in bed, at his own request. Shortly afterwards, he was

found dead. Post mortem showed the pericardium to be distended with 200 cc. of blood

and the heart to be constricted. A perforation of the superior portion of the pericardium

on the left side, about 1.5 cm. in diameter, was occluded by a fibrinous exudate. A metallic

fragment 1.5 by 1 by 1 cm. was found in the pericardial cavity. In the right ventricle was

a laceration 1.5 by 1 cm. in length and 3 to 4 mm. in depth. A small branch of the right

coronary artery was severed. Two small mural thrombi were found in the right ventricular

cavity beneath the laceration. The liver was moderately congested. The cause of death

was obviously cardiac tamponade, which had not been suspected before the post mortem

examination.

Comment.—The operating surgeon, who witnessed the post mortem, expressed the

opinion that this soldier's life could have been saved if (1) thoracotomy with control of

the coronary bleeding had been carried out, or (2) if there had been closer postoperative

observation for signs of developing tamponade, which could have been relieved by aspiration (fig. 20). It is possible that if tamponade had been relieved, hemorrhage might have

ceased spontaneously. More likely, exposure and ligation of the severed artery would have

been necessary.

Case 2.—This patient was in poor condition when he was received in a field hospital

after sustaining a bullet wound of the right lower quadrant of the abdomen. The neck

veins were swollen and the heart sounds were barely audible. Although cardiac tamponade

was suspected, no blood could be aspirated from the pericardium, and roentgenograms failed

to disclose a foreign body in or near the heart. At operation, 15 hours after injury, a

tear in the colon was sutured, and a gutter wound of the liver was drained. Left thoracotomy was then performed. The pericardium was distended with clotted blood. The

heart was constricted, and its enfeebled action soon ceased, despite vigorous efforts at
62 THORACIC SURGKRY

FIGURE 20.—Management of cardiac tamponade by aspiration: Substernal transdiaphragmatic aspiration (a), and

left lateral aspiration (b).

resuscitation. Autopsy, which was performed immediately, revealed a .30-caliber bullet

lying in the right ventricular cavity, surrounded by a foul-smelling clot. The bullet

had been deflected upward from the pelvis and had passed through the colon and the

liver before perforating the diaphragm and the right ventricular wall.

Comment.—A combination of unfortunate circumstances partly explained the fatal

issue in this case. The negative results of two ordinarily reliable precautionary measures

served to disarm suspicion. One was the pcricardial tap, which was dry because the blood

was clotted. The other was roentgenologic failure to demonstrate the missile within

the thorax, probably because it was obscured by cardiac motion. Under these circumstances, the swollen cervical veins became extremely important from the diagnostic

standpoint. They always indicated serious circulatory imbalance which demanded correction before other surgical procedures could be undertaken with safety. AVhether or not

this patient's life could have been saved by initial thoracotomy is debatable, but the fact

that he survived IS hours after wounding and withstood the added strain imposed by

an extensive laparotomy before the chest was explored is highly suggestive. Had the

operative procedures been reversed, it might have been possible to relieve tamponade,

check myocardial hemorrhage, and perhaps remove the intraventricular bullet. Even

if its removal had proved impossible, it might have migrated later to the pulmonary artery

without necessarily serious consequences, as in another case in this series (case 9, p. 82).

Case 3.—This patient sustained a penetrating shell-fragment wound of the left lumbar

region, with a fracture of the tenth rib, on S July 1944. He was received at the field hospital

in moderate shock, with a blood pressure of 90/50 mm. Hg. At operation, 8 hours after

injury, a segment of the ninth rib was resected, and 1,400 cc. of blood was evacuated from

the pleural cavity. A hole in the pericardium 2.5 centimeters in diameter was extended

to reveal a laceration of the same extent in the left ventricle, from which a small stream
WOUNDS OF THE HEART

of blood exuded with each heartbeat. The hemorrhage was controlled and the laceration

closed by two figure-of-eight silk sutures in the ventricular wall. The pericardium was

left open for a distance of G centimeters. The foreign body was found in the lower lobe

of the left lung, with a hematoma but no hemorrhage. When the diaphragm was opened

between the anterior and the posterior perforations, the spleen was found fractured

and actively bleeding. It was removed. Two perforations of the stomach were sutured.

The diaphragm and the chest wall were then closed.

The patient's immediate postoperative condition was good, the blood pressure being

110/70 mm. Hg. Ten days later, his condition was still good; he had no complaints, and

temperature, pulse, and respiration were normal. There was no fluid in the pleura, but

a pericardial friction rub was noted. The following day, the patient was transferred to

a general hospital. On 23 July, he suddenly complained of severe dyspnea and precordial

pain and became extremely cyanotic. The lungs were filled with rales. The pulse was

130. Gradual improvement occurred following the administration of morphine and oxygen,

and 4 hours later, the lungs had cleared. The medical consultant made a diagnosis of

acute left ventricular failure.

The following day, an electrocardiogram showed late inversion of Ti and Ti, with

low voltage of the QRS complexes, consistent with recent left ventricular injury and

probably pericarditis. By 25 July, the patient was much improved; the heart sounds were

good, and he had no cardiac symptoms. Electrocardiograms on 8 August and on 21 August

were still abnormal, but the inversion of the T-waves was less marked. On 11 September.

S weeks after injury, he was evacuated to the Zone of Interior in good condition.

Comment.—This case is of special interest on two counts: (1) In spite of serious injury to the heart, lungs, stomach, and spleen, this patient survived. His convalescence

was undoubtedly hastened by early and adequate surgery. (2) This is the only case in

the entire series of cardiac injuries in which delayed acute left ventricular failure occurred

(on the loth day). The precise explanation for this isolated and unexpected episode remains obscure. In this case, as in several others, cardiac tamponade was prevented by the

escape of blood through a sizable pericardial rent. It is probable that the cardiac hemorrhage accounted for the major portion of the 1,400 cc. of blood evacuated from the left

chest at operation.

PATHOLOGIC PROCESS

Cardiac injuries encountered at surgery or autopsy were classified as contusions, lacerations, lacerations and contusions, penetrating wounds of the

cardiac chambers with retained foreign bodies, and perforating (through-andthrough) wounds. Cardiac emboli were also possibilities. These injuries

were additionally classified according to the particular cardiac structure

involved.

Superficial abrasions of the epicardium and engorgement or thrombosis of

the subepicardial vessels were often found. When a major artery was badly

contused, thrombosis was a possibility.

The myocardium might show gross evidence of degeneration or actual

necrosis. Microscopically, interstitial hemorrhage varied in variety and extent.

The muscle fibers showed fragmentation, loss of striation, or advanced necrosis.

Eosinophilia, leukocytic infiltration, and beginning phagocytic removal of

necrotic muscle tissue were observed as early as 18 hours after injury.

When the endocardium was injured or there was subendocardial hemorrhage adherent mural thrombi might develop. This was observed in five cases
U THORACIC SüBGEBY

in this series, in three instances at autopsy. When extensive lesions were scattered along the acute or the obtuse margins of the heart, the hemorrhage might

involve the myocardium of both ventricles and extend into the interventricular

septum.

The high rate of energy imparted to the tissues in the track of the missile

explained why particles of tissue were thrown laterally and passed their energy

on, thus producing further damage. Attention has already been called to the

cases in which fragments of the ribs produced this sequence of events, which

was especially likely to occur in tangential wounds.

In some instances, the missile passed through the myocardium at such

an angle that the cardiac walls closed behind it.

PERICARDIAL INJURIES

General Considerations

There were 18 instances of pure pericardia! injury in this series, with 3

deaths, all of which occurred more than 48 hours after wounding and none of

which was due primarily to the pericardial injury. In 14 instances, the wounds

were lacerated; and in 5, foreign bodies were present, in 2 instances consisting

of rib fragments. One of these missiles was in the free sac.

In one case, injury of the pericardium was associated with an injury of

the myocardium; it is quite remarkable that this combination of injuries did

not occur more often, as some of the pericardial lacerations were severe. It

is also quite possible that minor lacerations of the pericardium occurred and

remained undetected. The academic question also arises as to the probable

considerable margin of safety afforded by a heart in systole as compared with

one in diastole at the moment of injury (Wood (-5) and Nicholson's "near

misses").

Management

The mere diagnosis of cardiac tamponade was not regarded as an absolute

indication for surgical intervention. In several cases, prompt recovery followed pericardial aspiration alone (fig. 20), sometimes after a single aspiration.

The general opinion, however, was that it was hazardous to depend routinely

upon this type of conservative management, especially if an irregular foreign

body with sharp margins or points was demonstrated in either the myocardium

or pericardium. Under the circumstances, if more than two satisfactory aspirations were necessary, it was considered that surgery was indicated. The possibility of infection also had to be considered (p. •»;">(>).

In urgent cases, management consisted of repeated aspiration of the pericardium until surgery could be undertaken. The needle Mas inserted in the

angle between the xiphoid process and the adjacent left costal arch and was

directed cephalad, inward, and toward the left, at an angle of about 45°.
WOUNDS OF THE HEART 65

Repair was accomplished through a curved incision exposing (he third,

fourth, and fifth costal cartilages; resection of sufficient portions of these ribs

to exposed the pericardium: incision of the pericardium: and suture of the

wound by the technique recommended by Elkin (3) and by Beck (6).

In ;") of the 18 pericardial injuries, the pericardium was sutured tightly.

In the remaining cases, drainage was instituted into the pleural cavity. In two

of these live cases, in one of which there was an associated myocardial wound,

there was massive, troublesome pericardial effusion postoperative]}-, a complication not observed in any case that was drained. Recovery in both cases followed paracentesis. All five foreign bodies were removed. In two other

cases, in which it was thought that foreign bodies might be present in the

pericardium, no attempt was made to remove them.

In one case, the pericardial sac was enormously distended with blood. It

was incised for a distance of 10 cm. from the superior to the inferior margin,

and there was no further bleeding after the first gush of blood. The pericardium

was left open and the chest was closed. Recovery was uneventful. The origin

of the tamponade in this instance was obscure, but the azygos vein, although

it is usually extrapericardial and therefore an unusual source of intrapericardial

hemorrhage, was considered the most probable source.

Pneumopericardium was observed in three of the pericardial injuries, as

the result of the entrance of air into the pericardial sac from a pneumothorax,

injured lung, bronchus, or esophagus. In two cases, the air was promptly

absorbed, without evidence of pericardial irritation. In the other case, fibrous

pericarditis developed.

"While a pericardial wound was sometimes relatively innocuous, at least

as compared to the lethal potentialities of other cardiac wounds, it could be

extremely urgent. This is clear if the pathologic process (fig. IS) be considered : With fluid in the pericardium, an obstruction exists to the filling of

the heart, and the blood is dammed up in the great venous channels of the body.

If the intrapericardial pressure comes to equal the effective venous pressure,

the blood can no longer enter the right auricle and death will occur promptly.

That is why so many deaths from this cause must be assumed to have occurred

on the battlefield and why, in some instances, the condition might be so urgent

that the time required to confirm a suspected diagnosis by roentgenologic or

fluoroscopic examination might mean the difference between life and death.

CONTUSIONS

General Considerations

The IG contusions observed in the 2d Auxiliary Surgical Group series of

cardiac wounds were similar to the contusions described by Elkin (3). Beck

(6'), and others in civilian life, as flie result of blunt trauma to the chest, steering wheel injuries, and similar accidents.
ßß THORACIC 8URCERY

There were 11 deaths in the IG eases, in (5 of which the cardiac state was

considered entirely responsible for the fatal out conic.

The diagnosis of a cardiac contusion was not particularly difficult. Most

of the patients with significant injuries of this type presented signs and symptoms indicative of oxygen want and cardiac dysfunction, that is, tachycardia

and arrhythmia. These signs and symptoms, as well as the gross and microscopic appearance of the myocardium at autopsy, Lad much in common with

the clinical and pathological picture of myocardial infarction following coronary occlusion.

Pathogenesis and Pathologic Process

In most of the battle casualties, the damage resulted from the force propagated by the passage of a small, high-velocity missile in the immediate vicinity

of the heart. In at least one instance of myocardial contusion (fig. 11), the ribs

were shattered, and their fragments apparently acted as secondary missiles,

with resultant direct blunt injury. Thrombus formation followed, and death

ensued: the- pericardium was intact.

Whether a localized blast effect resulted from the passage of the missiles

in these cases cannot be answered. Certainly, in this series, no cardiac contusion resulted from the generalized effect of a pressure wave in the atmosphere.

While it was theoretically possible for a serious cardiac injury to result from

blast, there was no confirmation at autopsy, in which the possibility was borne

in mind in the examination of patients who died of blast injuries.

Clinical and experimental studies before the war had clarified the pathologic physiology of thoracic contusions. Bright and Beck (7), as well as Warburg (8), had demonstrated that trauma to the intact chest, especially in the

young adult whose chest is far more resilient and flexible than the chest of an

older person, may be directly transmitted to the heart, whether the injury is

a direct blow over the precordial region, compression of the chest between two

solid objects, or a blow over the abdomen, with, a sudden rise in intra-abdominal

pressure.

Experimental trauma most often caused immediate rupture of one of the

cardiac chambers, with death. Contusion, with resultant petechial hemorrhage,

softening and necrosis of tissue, and eventual rupture, might involve any portion of the conduction system. Most frequently, it caused reflex spasm of the

coronary vessels, with the production of a, syndrome like the common civiliantype syndrome of coronary occlusion and infarction. It was also shown experimentally that in cases of vagosympathetic imbalance, or when the heart was

sensitized by adrenalin, cardiac irregularities and coronary spasm resulted

more readily. In the heat of battle, when the vascular system was surcharged

with considerable adrenalin, slight trauma to the chest might conceivably cause

considerable cardiac disturbance.

The pathologic process in contusive lesions consisted of scattered or confluent petechial hemorrhages involving the myocardium over various areas of

one or both chambers (fig. 21), In these IG cases, the ventricles were involved
WOUNDS OF THE HEART

»1m

»iiiiiip^

FIGUKE 21.—Scattered pctccliial and confluent hemorrhages of right

ventricle caused by the indirect force of a penetrating bullet wound

of sternum.

15 times (7 left, 5 right, 3 both) and the right auricle, once. Superficial abnasions of the epicardium and engorgement of the subepicardial vessels were sometimes observed. The myocardial hemorrhage often extended through to the

endocardium, and the muscles sometimes showed gross evidence of degenerative

changes or actual necrosis. In fatal cases, in which there had been involvement

of the entire thickness of the myocardium, mural thrombi were frequently

found attached to the endocardium (fig. 11). When extensive lesions were

scattered along either the acute or the obtuse cardiac margin, it was not uncommon to find hemorrhages extending into the myocardium of both ventricles, and

even into part of the interventricular septum. The pericardium was not necessarily injured in myocardial contusion; it was intact in 9 of the 16 cases in this

series. The pathologic pattern in the fatal cases was essentially one of subpericardial and subendocardial hemorrhage, usually petechial in distribution.

Management

A patient with a myocardial contusion was a poor risk for any kind of

surgery, especially during the first several hours after wounding. The fact

that 6 of the 11 deaths in these 16 cases were due to the cardiac lesion indicates

just how poor risks these casualties were.
THORACIC SüBGERY

The contusion itself was not a surgical lesion, but, unfortunately, numerous associated wounds often required that surgery be done promptly. Ideally,

it was postponed for 24 to 48 hours, but this was frequently impossible. Certain

wounds, such as thoracoabdorninal wounds, required prompt operation, in spite

of the fact that immediately after injury, the risk of death from irritability

of the myocardium and potentially lethal arrhythmias might be enhanced by

anesthesia or surgical manipulations. The best that could be done was to

delay surgery as long as possible, to permit some degree of cardiac recovery.

In the meantime, the patient was treated as if he were suffering from acute

coronary occlusion. Resuscitation was carried out, and surgery was then undertaken with due realization that the risk was inevitably great and the mortality would be correspondingly high. In purely thoracic wounds, in which

surgery was not mandatory within 6 to 12 hours, it was best to delay it as long

as possible.

In three fatal cases in this series, in which operation was performed, respectively, at 5, 11, and 17 hours after wounding, it was thought that further

delay might have been beneficial. Two of the wounds were purely thoracic.

The other was a high thoracoabdorninal wound, in which it was clear that only

the liver was involved. In each instance, signs of cardiac dysfunction were

prominent. During resuscitation, the patients were in poor general condition,

semistuporous, with rapid pulse, and dyspneic out of all proportion to the

visible intrathoracic damage. In each instance, the systolic pressure was elevated to 95 mm. Hg or higher, but death occurred on the operating table or

immediately after surgery was concluded.

In another case of this kind, not included in this series, the timelag was only

6 hours. Death occurred on the operating table. At autopsy, it was confirmed

that the wound was purely thoracic. There was extensive contusion of the

right ventricle and thrombosis of the anterior descending branch of the left

coronary artery.

Any of these patients might well have died, even if surgery had not been

done, but. the added burden of the anesthetic and the operative procedures cannot be ignored in assessing the outcome in seriously wounded patients.

In two other cases in this series, which may be cited in contrast, surgery

was delayed for 3 and 5 days, respectively, after wounding. Both patients

were received in shock. In one case, the pulse remained over 120 for 48 hours.

In the other, for 4 days, there were intermittent periods of cardiac arrhythmia,

associated with wet lung, pulmonary edema, and jaundice. In each instance,

the surgeon expressed the opinion that the patient might well have died if

opera! ion had been done even as late as 12 hours after wounding.

The linal conclusion was that if a cardiac contusion were diagnosed and

such indications for early surgery as continuing hemorrhage or a thoracoabdorninal wound did not exist, surgery should be deferred for at least 24 to 48

hours, to provide every opportunity for the reduction of myocardial irritability.
WOUNDS OF THE HEART 69

LEAD I

LEAD 2 ?V*

i F A D 1 SSSKB!TSS-"SKSS; A- —"^ w

LEAD 4

FIGUUE 22.—Electrocardiogram of patient

with cardiac contusion showing W-shaped

QRS complexes of low voltage and inverted

QRS-4. The same electroeardiographic phenomena were observed in another casualty

with a cardiac contusion.

Electrocardiograms in two survivors of contused wounds were identical

with respect to (1) abnormal W-shaped QES complexes of low voltage in the

limb leads and (2) inverted QKS-4 (fig. 22). This pattern was not observed

in any other type of cardiac injury. These electrocardiograms also showed the

abnormalities of T-waves and S-T intervals frequently seen after myocardial

injury.

LACERATIONS

General Considerations

Of the 20 lacerations in this series, 10 were combined with contusions of

the myocardium and 4 were detected only at post mortem. In the 10 pure

lacerations, the left ventricle was affected in 7 cases, the right ventricle in 2,

and the right auricle in 1. These 10 cases, in 2 of which there were foreign

bodies in the myocardium, comprise all the instances in the series of incised,

cleanly lacerated wounds of the myocardium in which there was no gross evidence of myocardial contusion or necrosis.

In the combined lacerations and contusions, the left ventricle was affected

five times, the right ventricle twice, and both ventricles twice. In the remain740-941'—05 7
THORACIC SURGERY

V /,

%»»,.

x

;

X

FIGUEE 23.—Technique of cardiac surgery. A. Laceration of right ventricular

wall without serious contusion. B. Direct suture of laceration of ventricular

wall with digital control of bleeding.

ing case, the right auricle and right ventricle were injured. The serious implications of contusions are again evident in this group, in which there were

five deaths, four due to the cardiac wound, against the single death due to a

cardiac lesion in the pure lacerations.

Management

An analysis of the records shows that a rather surprising number—10—

of the 16 lacerations of the myocardium were not repaired, and apparently

with no immediate ill effects. In the four lacerations found only at post

mortem, there was no evidence in any instance that the fatality was due to

failure to effect a repair.

In the six cases which Avere repaired, the laceration was completely closed

in four by suture. In the two other cases, complete approximation was impossible, and the pericardium was used to help bridge the defect; free muscle

grafts were also used (figs. 23 and 24).
THORACIC KCROERY 71

A B

•V,

NO

C

FIGURE 24.—Technique of cardiac surgery. Closure of penetrating wound of heart.

A. "Wound, of right ventricle. P.. Use of free muscle graft (greatly enlarged). C. Cross

section of sutured muscle graft.

The pericardium was either sutured over the wound or sittured to the edges

of the poorly approximated wound. In the former instance, posterior drainage

was employed.

The number of cases is too small to permit drawing any conclusions as to

the wisdom of operating in forward hospitals solely to suture cardiac lacerations.

PENETRATING AND PERFORATING WOUNDS

General Considerations

There were 19 instances of perforating or penetrating wounds of the heart

in this series, 7 involving the left ventricle, 3 the right ventricle, 2 the left

auricle, and 7 the right auricle. There were nine deaths, in eight instances clue

to the cardiac lesion. In one wound of the auricle, discovered only at post

mortem, death occurred 24 hours after wounding. In the opinion of those who

witnessed the autopsy, the fatal outcome was due to extensive wounds elsewhere

in the body. It was thought that the patient would have survived without

auricular repair. The most frequent complication, and the most important

cause of death, was hemorrhage, which could readily be exsanguinating.
72 THORACIC SüKGERI

It is of great interest that through-and-through cardiac wounds were not

always immediately fatal. In one case in this series (p. 75), recovery followed

the repair of two wounds of the left ventricle caused by a shell fragment that

divided the left phrenic nerve and the pericardiophrenic vessels, entered the left

ventricle at the apex, and made its exit on the posterior wall. Operation was

performed 14 hours after wounding.

One other patient with a through-and-through wound of the left ventricle

also survived. The three perforations of the right auricle all ended fatally.

In the experience of the 2d Auxiliary Surgical Group, no patient with a perforation of the interauricular or interventricular septum survived to reach

a forward hospital.

Management

The chief indication for immediate surgery in wounds of the cardiac

chambers was continuing hemorrhage. If bleeding caused tamponade rather

than exsanguinating hemorrhage, as it sometimes did, treatment could be more

individualized. If the tamponade developed rapidly, it was considered better

to operate at once, particularly if it was known that the missile causing the

wound was large. If the tamponade developed slowly, one or two aspirations

might be attempted (p. 64).

If foreign bodies were encountered in the course of the operation, an

attempt was made to remove them. If their presence was suspected, an attempt

was made to locate them. If, however, they were not found immediately, the

correct procedure was to control the hemorrhage and close the chest. Since

hemorrhage was the indication for operation, a long-continued search for the

missile, with blind manipulations within the cardiac chambers, could not be

considered justified. The foreign body could be removed later at the base

hospital if that proved necessary.

Complete closure of the cardiac wound was possible in 10 cases. One wound

had ceased to bleed when it was exposed, and suture was not considered necessary. In two instances, both auricular wounds, attempts at closure failed, and

both patients died of intractable hemorrhage. Attempts to plug the defect

with the finger were unsuccessful.

Case Histories

Case 4.—This 22-year-old private was wounded by an artillery shell fragment on 27

June 1944. At the field hospital, 2 hours later, he was found to be mildly shocked, but he

was conscious and in fairly good condition. Examination revealed a lacerated wound, 3

cm. long, in the fifth left intercostal space, just outside the midclavicular line. There was

no dyspnea or hemoptysis. The heart tones were normal, and no adventitious sounds were

heard. There were signs of fluid in the left pleural cavity. The abdomen was tender and

resistant to pressure.

The patient became nauseated and vomited twice shortly after admission. A Levin

tube was passed into the stomach, and 250 cc. of air and fluid were withdrawn; there was

no blood in the gastric contents.
WOUNDS OF THE HEART 73

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FIGTJKE 25 (case 4).—Repair of through-and-through wound of heart.

A. Fostcroanterior roentgeiiogram showing large left hemothorax, which

obscures lung. Shell fragment at level of ninth rib posteriorly measured 23 by 10 by 4 mm. (insert). A Levin tube can be seen faintly at

the level of the eleventh intercostal space on the left. B. Drawing depicting anterolateral laceration of pericardium with severance of pericardiophrenic artery and phrenic nerve, as follows: Incision for exposure (a),

incision for flap (b), wound of entrance (c), and wound of exit (d).

Note relation of wounds to important blood vessels.
74 TIIOKACIO SUIiGKKY

:c

V

ix \ \

D

^1

FIGXJUE 25.—Continued. C. Closure of anterior heart wound. Apex of heart held by right

hand of assistant, exposing anterior laceration.

D. Reinforcement of anterior cardiac wound by

suture of pedicled graft of pericardium.

After 500 cc. of plasma and 1,000 cc. of blood had been given over a 2

1

/2-hour period,

the blood pressure rose from S0/C0 to 130/70 mm. Hg, and the pulse fell from 110 to 90.

Abdominal signs and symptoms persisted. Roentgenologic examination (fig. 25A) showed

the shell fragment lying well posterior, apparently just within the costal cage. From

the location of the wound, the apparent course of the missile, and the persisting abdominal

signs, especially the nausea and vomiting, a thoraeoabdominal wound could not be ruled out.

Operation was carried out under endotracheal anesthesia 6 hours after wounding

and 3% hours after hospitalization. Blood transfusion was continued during the procedure.
"WOUXDS OF THE HEAKT 75

. «-..'i't---"-y'.4i$n

«M»SW

i

FIGDKE 25.—Continued. E. Posteroanterior

roentgenogram S weeks after operation, showing

clear lung fields, no cardiac enlargement, and

elevation and paralysis of left diaphragm.

Note chip fracture of fifth rib anteriorly

(arrow).

After debridement, anterior thoracotomy was performed in the fifth intercostal space

by extension of the wound of entrance. A chip fracture of the fifth rib was found, with

a small contusion of the lingula of the left upper lobe, but the diaphragm was intact.

Five hundred cubic centimeters of blood were evacuated from the pleural cavity, after

which the shell fragment was discovered lying free posteriorly. Two perforations

were seen in the pericardium. The pericardiophrenic artery and phrenic nerve had been

severed anterolaterally (fig. 25B), and a posterior laceration was found just lateral to

the reflection of the parietal pleura from the pericardium onto the mediastinum. The

pericardial sac was opened by vertical incision a few minutes after 5 cc. of procaine hydrochloride had been injected into it. Two lacerated wounds of the left ventricle, each

8 mm. in length, were found oozing blood with each systole. The wound of entrance was

at the apex and the wound of exit in the midportion of the left ventricular wall posteriorly

(fig. 2ÖB).

The apex of the heart was rotated 90° forward and steadied by the right hand of the

assistant (fig. 25C). The wound was exposed between the spread of his second and third

fingers, and bleeding was controlled by the application of two silk sutures (Xo. 0). A

small venous branch was occluded by the sutures.

The anterior laceration was irregular, and the muscle gaped slightly. Oozing continued, particularly after a suture had cut partly through the muscle. It was controlled

by suturing a small pedicled graft of anterior pericardium and pericardial fat over the

laceration (fig. 25D).

Extrasystoles were numerous while the heart was manipulated but ceased immediately when manipulations were discontinued. Crystalline sulfanilamide and penicillin

were placed in the pleural cavity, and drainage was instituted by means of two water-trap

tubes. A small mushroom catheter was used in the second intercostal space anteriorly
THORACIC SURGERY

and a quarter-inch fenestrated tube in the eighth intercostal space in the midaxillary

line. The tube was clamped off for 8 hours after operation, to permit contact of the

chemotherapeutie agents with the tissues. The incision was closed in layers, without

pericostal sutures.

At the conclusion of the operation, the blood pressure was 110/70 mm. Hg. the pulse 145,

and the respiration 32. Standard postoperative measures were employed. Recovery was

generally smooth. The blood pressure remained normal; the pulse stabilized at 100-110.

Cardiac irregularities were never evident.

Twenty-four hours after operation, a splash, synchronous with systole, was heard

over the precordium. Four days later, a loud precordial friction rub was audible for

2-1 hours; during the same time, the second sound in the pulmonic area was occasionally

reduplicated. On the sixth day, there was a slight roughening of the iirst sound at the

apex, and a poorly transmitted, soft systolic murmur was heard in this area.

When the patient was transferred to a general hospital on the 12th postoperative day,

he was afebrile, with a pulse of SS and a blood pressure of 115/00 mm. Hg. He became

ambulatory in another week. A scratching to-and-fro precordial friction rub was heard

intermittently for another 2 weeks.

Eoentgenologic examination 8 weeks after operation showed the lung fields clear and

the heart normal in size (fig. 25E). Electrocardiograms 2 weeks after operation showed

moderate inversion of T-waves with elevated S-T intervals in the first three leads and

moderate left axis deviation (fig. 20). Two weeks later there was less inversion of Ti.

Another electrocardiogram 2 weeks after the first showed Ti upright, but T~ and T3 remained

deeply inverted, and left axis deviation persisted.

Xo signs of cardiac embarrassment developed as the patient increased his activities,

and he was in excellent condition when he was evacuated to the Zone of Interior 11 weeks

after injury.

Comment.—This case is remarkable because, in spite of the through-and-through wound

of the heart, the patient survived, after early, adequate surgery. Convalescence was quite

smooth. It is noteworthy that in spite of the double wound in the ventricle, the blood

loss was minimal. It is also noteworthy that no signs of cardiac weakness ensued in

spite of the multiple wounds elsewhere, plus the necessary manipulation of the heart at

operation and the repeated intravenous infusions of blood and saline solution that were

necessary.

The serial electrocardiograms available in this case were thought to be the first on

record taken during recovery from a complete perforation of the heart. It is of some

interest that the effect of the T-waves in leads II and III of the posterior (basal) injury

appears to have overshadowed the effect of the apical wounds (leads I and II), possibly

because of the greater mass of muscle injured in the penetration of the thicker basal wall

of the ventricle.

That this patient survived his original wound seems due to a happy and unusual

chain of circumstances. The fragment must have struck end-on and passed through

the heart without revolving. It also seems probable that the perforation occurred during

diastole, so that the chamber was traversed by the missile without irreparable damage to

the papillary muscle.

As this case also demonstrates, there may be few if any localizing signs or symptoms

in spite of a serious cardiac wound. The nausea and vomiting were probably cardiac

in origin; these symptoms do not usually occur in pure thoracic injuries. With the shell

fragment free in the pleural cavity, the course of the missile was misleading, and the wrong

conclusions concerning it were drawn. Had the missile come directly from the front,

it could not have failed to penetrate the diaphragm. It came, however, from the left,

passed through the heart, and then fell free in the pleural cavity, almost opposite the

wound of entrance in an anteroposterior plane.
WOUNDS OF THE HEART Ct

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78 THORACIC SURGERY

Case 5.—In another ventricular injury, the patient died in the shock ward of a field

hospital 6 hours after he had received a penetrating wound of the left chest, before operation

could be performed. Autopsy revealed that a single shell fragment, 1 by 1 by 1 cm., had

entered the chest through the left scapula, fractured the third and fourth ribs posteriorly,

and then perforated the wall of the left ventricle, to become embedded in the opposite

ventricular wall. Death was caused by hemorrhage from the heart into the left chest.

The rent in the pericardium had permitted the escape of blood and thus prevented

tamponade.

Comment.—The comment of the medical officer who performed the autopsy was that

this man had lived for 0 hours with a hole in his heart and that his life might have been

saved if adequate blood had been available and if the chest had been opened at once.

MIGRATORY FOREIGN BODIES

General Considerations

The intravascular migration of projectiles and other foreign bodies to the

heart and pulmonary circulation from distant wounds by way of the great

veins is so uncommon as to constitute a true medical curiosity.1 Although still

rare, these migratory objects were recognized more frequently in World War II

than in the past. The need for their removal was still the subject of some

disagreement. Some objects remained asymptomatic for long periods of time,

but others, because they served as foci of infection or caused damage to the

myocardium, caused death from embolism. Early removal in a base section

center was considered the wisest plan if cardiac disability or other clinical signs

and symptoms were present, Otherwise, the policy was to return the patients

to the Zone of Interior.

If the fragment entered the pulmonary circulation from the right heart,

it was theoretically possible for it to serve immediately as a fatal embolus.

Removal of a missile from the pulmonary vessels could be attended with great

difficulty and might require the sacrifice of an essential artery, perhaps with

lobectomy or pneumonectomy. In one case in the 2d Auxiliary Surgical Group

experience, surgery was not carried out for this reason (case 9, p. 82).

Migratory foreign bodies were not necessarily fatal. Three of five patients

observed in the Mediterranean theater are known to have recovered, and at

least one of the two deaths was not caused by the presence of the foreign body,

while the same comment is possibly applicable to the other case. The case

histories follow.

Case Histories

Case 6.—A soldier who sustained a penetrating shell-fragment wound of the right

cervical region on IT June 1944 was treated conservatively. Roentgenograms revealed a

1 Although only one instance of migratory foreign body seems to have been reported in World War

I (fl), undoubtedly others occurred. In the reported case, a shell fragment buried in the liver was

left in situ at operation. The patient died of peritonitis 0 days later. At necropsy, the metal fragment was found covered with fibrin and enmeshed in the columnae carneae. Examination of the liver

disclosed the track of the fragment into its point of entry into a large hepatic vein and its subsequent

intravascular passage to the heart.
WOUNDS OF THE HEART 7&

foreign body in the right mid lung field, with no evidence of pulmonary injury. He was

discharged to duty on 21 July but on 9 August was readmitted to the hospital, complaining

of dyspnea and a vague pain in the right chest on effort. Kocntgenograms showed the

foreign body in the same position as at the first examination. At exploratory thoracotomy

on IS August, the missile was found in the right inferior branch of the pulmonary artery.

It was palpated through the wall of the artery but was not removed. On 10 October, when

the patient was evacuated to the Zone of Interior, he was ambulatory but was still mildly

dyspneic, and he continued to complain of vague chest pains on effort.

Comment.—When this patient was first admitted to the hospital, it was thought that

the missile had entered the thorax directly from the cervical wound. In the light of the

findings at operation, however, it must be assumed that it penetrated the right subclavian

vein, migrated to the right side of the heart, and thence passed to the right pulmonary

artery. No infarction resulted, and it was considered unlikely that it would cause serious

trouble at its present site."

Case 7.—This man sustained penetrating wounds of the right flank on 11 October 1944,

with a resulting perforation of the colon and another of the left chest, with hemothorax.

f

;

'

;

^

:

: . ..«Mit

FIGUISE 27 (case 7).—Migratory intravascular foreign

body. Lower portion of inferior vena cava showingwound of entry and superimposed metal fragment that

had passed as embolus to branch of left pulmonary

artery.

2 As already pointed out (p. 17 fn), postwar experimental studies by Dr. Lyman A. Brewer III and

his associates showed that metallic foreign bodies in the lobar branches of the pulmonary artery are

usually well tolerated, provided that the bronchial arteries remain intact. Those occluding the main

pulmonary arteries cause serious pulmonary changes and should be removed.
80 THORACIC SURGERY

The following clay, laparotomy and eolostomy were performed, and the chest wound was

closed. On 25 October, he died from an intraperitoneal hemorrhage. Necropsy revealed

multiple penetrating wounds, including a puncture wound, 0.8 cm. in diameter and surrounded by necrotic tissue, on the posterior wall of tlve inferior vena cava just above its

formation. An embolic shell fragment 1.5 by 0.6 by 0.4 cm. was found in the inferior branch

of the left pulmonary artery, with no evidence that it had entered through the lung parenchyma (tig. 27). There was no associated pulmonary infarction. The anatomic cause of

death was massive hemorrhage secondary to the abdominal wound.

Comment.—The metallic einbotus to the lung found in this ease at autopsy was a

complete surprise. There had been no signs or symptoms suggestive of its presence before

death, and roentgenologic study had not seemed justified because of the patient's continued

precarious state. It is entirely probable that he would have recovered from the vascular

injury had he not succumbed, 2 weeks after wounding, to the secondary complications of

his severe abdominal injuries.

Case 8.—This patient sustained penetrating wounds of the right shoulder and the right

lumbar region on 2 October ]!)44. Though laparotomy revealed that a foreign body had

entered the abdomen, it could not be found. Subsequent roentgenograms suggested that

it was on the right side and lying in the psoas muscle. On 7 October, the roentgenograms

were repeated because the patient had continued to run fever and had developed rales on

the left side. The film was hazy, and the foreign body seen in the first film on the right

side now appeared to be above the diaphragm on the left side.

Two days later, the temperature rose to 104° F. Other findings included a rapid pulse

(from 140 to KiO) ; a blood pressure of 95/50 mm. Ilg; a variable systolic sound of unusual

character over the heart to the left of the lower sternum, somewhat suggestive of a friction

rub; and pulmonary rales. There was no venous distention. Roentgenograms revealed

the foreign body apparently lying anteriorly and interiorly in the pericardium and slightly

blurred by motion. On 12 October, the patient continued to have fever, pulmonary rales

were still present, and the superficial systolic "noise" persisted. His condition deteriorated

progressively, and he died before a definite diagnosis was made, though the pyrexia was

thought to be due to malaria.

At autopsy, when a penetrating wound in the right flank was explored, a track was

found which indicated that the foreign body had entered the inferior vena cava. Continued exploration revealed it lying free in the right ventricle (fig. 2SA). The entrance

of the missile into the inferior vena cava was represented by an oval defect 1.5 by 1.5

by 5 cm. in the posterior wall above the bifurcation (fig. 2SP.). The defect was surrounded

by numerous thrombi, some of which appeared to have become detached. The fragment

found in the right ventricle near the apex was large and irregularly oblong. It measured

2.3 by 1 cm. and weighed 10.35 grams. There was slight discoloration of the adjacent

endocardium, but no thrombi were found. Careful examination of the heart and vena

cava revealed no evidence of penetration, and there was no doubt that the metal fragment

had entered the vascular system through the wound in the lower vena cava. Both lungs

showed widespread areas of infarction, and multiple emboli were demonstrable in the

pulmonary arterial branches. In addition, there was massive intraperitoneal hemorrhage

(1,500 cc.) from an omental vessel.

Comment.—In spite of the size and weight of this jagged fragment, it had apparently

churned about in the right ventricle for over a week without causing serious injury to

the cardiac wall. Although it was apparently too large to pass through the pulmonary

orifice, at no time did the patient exhibit acute seizures suggesting a ball-valve effect, and

at no time were the cervical veins distended. The persistent fever and downhill course

were adequately explained by the recurrent pulmonary emboli from the mural thrombi in

the lower vena cava, but these phenomena were probably unrelated to the presence of the

foreign body in the right ventricular cavity.
WOUNDS OF THE HEART 81

. ' «Hi

V

V.]

<#.

v

A

FIGURE 28 (case 8).—Migratory intravascular foreign body. A. Large oblong

shell fragment free in chamber of right ventricle. B. Lower portion of inferior

vena cava showing wound of entry surrounded by thrombi just above bifurcation. Fragment in ventricle is shown above.
THOBAOIC SUEGEßY

A

FIGUKE 20 (case 0).—Migratory intravascular

foreign body. A. I'osteroanterior roentgenogram showing shell fragment in left hilar region.

B. Left lateral roentgenogram localizing foreign

body to intrahilar pulmonary area. The foreign

body could not be found in this position or elsewhere at operation.

Case 9.—When this soldier was wounded in action on 12 April 1944, he sustained multiple severe penetrating wounds of the right thorax, right leg, and both feet. Initial

roentgenologic study showed a large metallic foreign body in the left lung. The wounds

were debrided.

On 28 April, when he was transferred to a thoracic surgery center, his condition was

good except for moderate dyspnea, which continued after cardiorespiratory disequilibrium

had been treated by adequate thoracentesis and nerve block. Localization studies showed

the fragment to be in the hilar region of the left lung (fig. 29A and 29B). Fluoroscopy

on 9 May showed it to be in the root area on this side.

At thoracotomy the following day, the foreign body could not be found, and the chest

was finally closed after a long and fruitless search for it. Roentgenograms taken immediately after operation revealed it lying in the right hilar region (fig. 29C).
WOUNDS OF THE HEART

FiGUiiE 2'.).—Continued. C. 1'osteroanterior

rcentgenogram immediately after left thoracotomy showing foreign body in right hilar region.

I). Right lateral roentgenogram showing fragment again localized in root area of lung. At

operation immediately afterward, it was found

in the lumen of the main right pulmonary artery,

where it was left in situ.

After operation, the patient remained more dyspneic than seemed warranted by the

findings in the chest. The only change noted on electrocardiography was a moderate sinus

tachycardia.

On 9 July, a right-sided thoracotomy was done, after repeated roentgenograms and

fluoroscopy immediately before operation had shown the fragment still in the right hilar

region (fig. 29D). The missile was found impacted within the lumen of the main right

pulmonary artery. A palpable thrill was felt over it and for a short distance into the

artery distally. The pulmonary circulation was entirely adequate. Complete dissection

of the hilar structures did not achieve sufficient mobilization of the artery to warrant an
84 THORACIC SURGERY

attempt to remove the missile, since the involved segment of the artery lay directly beneath

the superior pulmonary vein anteriorly and upon the right stem hronchns posteriorly.

Since there was no evidence of aneurysmal dilatation of the artery or of inadequacy of the

pulmonary circulation, it was decided not to sacrifice the posterior pulmonary vein in order

to remove the foreign body.

Convalescence was uneventful except for a disproportionate degree of dyspnea for a

few days following operation. The patient was transferred to the Zone of Interior on IG

August, ambulant and in good condition. In October, a followup letter from the United

States reported that he had continued well, with no symptoms other than dyspnea when

he walked rapidly. Xo further roentgenologie studies and no operative procedure had

been carried out.

Comment.—This case might be fairly termed unique in medical annals. The opportunity for adequate roentgenologie study and for complete exploration of both hihir regions

by a competent chest surgeon left no doubt that the large metal fragment had migrated,

against the blood flow in the pulmonary circuit, from its original position in the left

pulmonary artery to its subsequent lodgment in the right pulmonary artery, without

causing serious symptoms or recognizable complications. The exact mechanism of the

migration is difficult to explain. It seems unlikely that it was accomplished by gravity

alone. It may have been the result of manipulation during the exploration of the left

hilar region, but no definite statement can be made on this point.

It is a matter of special interest that during a review of this case shortly after the

first thoracotomy, the operating surgeon stated that the missile had probably entered a

major lobar radicle of the right pulmonary artery and had progressed from there.3

Case 10.—This patient sustained a maehinegun bullet wound which penetrated the

right chest, just below the middle third of the clavicle, on 31 ilay 1944. On 4 June, he

was transferred from a field hospital to a general hospital. He was then in fair condition

except that his temperature was 102° F., the heart sounds were distant, and the veins of

the neck were distended. Roentgenograms showed an enlargement of the heart shadow

and a foreign body 1.7 by 1 cm. inside the left cardiac border. In the right chest was a

moderate collection of fluid. On 7 June 1044, there was considerably increased distention

of the neck veins, and the venous pressure was 210 mm. H~0. Electrocardiograms showed

QRS complexes of low voltage, rericardicentesis produced 750 cc. of old. bloody fluid.

The patient showed prompt improvement but had a pericardial friction rub for the next

3 days. Roentgenograms showed a smaller heart shadow, together with a surprising shift

of the foreign body, which now lay just inside the right border of the heart. By 20 June,

the patient was ambulatory. His improvement was progressive and satisfactory except

that he complained of a dull pain running from the sternum to the cardiac apex «hen he

walked. Roentgenograms showed the foreign body now lying behind the cardiac apex

just inside the left border. On 2 August, the foreign body, which was embedded in dense

pericardial adhesions behind the apex, was removed, with considerable difficulty. On 2

October, the patient was evacuated to the Zone of Interior fully ambulatory and complaining only of slight substernal ache on effort.

STAB WOUNDS

The single stab wound in the series, which was self-inflicted, was similar

to the same type of injury observed in civilian practice. Emergency surgery,

16 hours after injury, was required to control hemorrhage from a small punc3 This patient was seen again in 1048, at which time he was perfectly well. In April 1950, he

suffered profuse hemoptysis because the foreign body had eroded through the right pulmonary artery

into the right bronchus intermedius. Pneumonectomy was necessary, from which he made a good

recovery. He has remained in good health to date (October 1900).
WOUNDS OF THE HEART 85

ture wound of the left ventricle near the left descending coronary artery. A

laceration of the myocardium was also sutured. The postoperative electrocardiograms showed inversion of T,, T2, and T4. The patient was evacuated

to the Zone of Interior in good condition 8 weeks after operation.

INJURIES OF THE GREAT VESSELS

Since lacerations and penetrations of the great vessels were apt to be

quickly fatal, it is not surprising that the experience of the 2d Auxiliary

Surgical Group included only two such injuries. The first patient died on the

operating table, from cardiac tamponacle. The pericardium was distended by

hemorrhage from a small laceration of the superior vena cava, and the fragment

was recovered free in the pericardia! sac.

The second patient was of interest because of the retained foreign body

which rested in close apposition to the ascending aorta and moved vigorously

with each cardiac pulsation (fig. 80). The vessel wall was presumed to have

escaped injury, and the patient was returned to the Zone of Interior without

operation overseas.

That this patient was likely to continue well was evident in the case history

of another soldier observed in the Mediterranean theater, who had harbored a

.38-ealiber bullet directly against the ascending aorta for the past 20 years

(fig. 31). On fluoroscopy, the bullet was seen to move vigorously with each

pulsation of the aorta. In the interim, he had had no symptoms of any kind,

and he was returned to the Zone of Interior not because of the presence of the

bullet but because of bronchial asthma.

MANAGEMENT OF CARDIAC WOUNDS

Official Policies

The infrequency of wounds of the heart susceptible to surgical management

is implicit in the scant attention paid to them in the instructions for wound

management issued during World War II. They are not mentioned in the

circular letters published in either the Mediterranean or the European theaters

or in the "Manual of Therapy" published in the European theater just before

D-day. They are also not mentioned in War Department Technical Bulletin

(TB MED) 147, which was published in March 1945 and which dealt Avith the

care of battle casualties in the light of the wartime experience to date.

In fact, the only detailed instructions for management of wounds of the

heart appeared in the thoracic surgery section of the military manual on neurosurgery and thoracic surgery published in 1943 under the auspices of the Committee on Surgery of the Division of Medical Sciences of the National Research

Council (10).
M THORACIC SUBGEKY

Mil

mm.-

j

-B-* C

FJGUKE :-SO.—Retained shell fragment in close apposition to ascending

aorta. It moved vigorously with each pulsation. A. Posteroanterior

roentgenogram. P>. Right anterior oblique roentgenogram. C. Lateral

roentgenogram.

Policies in the Mediterranean Theater

Although foreign bodies within the heart were not a major problem in base

installations in the Xorlh African campaigns or later in the Italian campaigns,

it early became necessary to establish a policy concerning their management,

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

theater surgeon, with the thoracic surgeons in the theater led to the establishment of the following principles:

1. Only foreign bodies in the heart that were causing significant clinical

symptoms or giving rise to significant clinical signs were to be removed in over-
WOUNDS OF THE HEART 87

FIGURE :il.—Retained .3S-ealiber bullet

lying directly against ascending aorta, in

which position it had been for the past 20

years. All hough it moved vigorously with

each pulsation of the aorta, the patient had

never had symptoms referable to it. A.

Posteroanterior roentgenogram. B. Lateral

roentgenogram.
88 THORACIC SURGERY

sea base installations. All such casualties were to be sent to chest centers, for

management by qualified thoracic surgeons.

Two groups of objects were believed likely to give trouble. The first was

composed of missiles, particularly low-velocity fragments, lying in the myocardium, without complete penetration of the chambers. These, it was thought,

would give rise to continuing intracardiac bleeding or to nonhemorrhagic pericardia 1 effusion or to both. A number of such cases were managed successfully

by surgery. The second group was composed of intramyoeardial foreign bodies

impinging on major coronary vessels, which might give rise to symptoms of

coronary arterial insufficiency. Two such cases were treated, with complete

relief of anginal symptoms after removal of the objects.

2. It was not be! ieved that so-called chamber foreign bodies; that is, foreign

bodies lying in an auricle or ventricle, would be a problem in an oversea theater.

On the basis of long-term followup reports it was thought that patients in this

group could be safely evacuated to the Zone of Interior for such surgery as

might be necessary. On the other hand, if a chamber foreign body migrated

intravaseidarly to the pulmonary vessels, removal in the oversea theater was

considered indicated.

Experience confirmed the validity of this policy. Only a small number

of true chamber foreign bodies were observed, none of which migrated to the

pulmonary vessels or gave rise to difficulty during the period of observation

overseas.

Surgical Timing

When a patient with a suspected cardiac wound was encountered in wartime, the decision as to its management could not be based, as in civilian life,

solely upon the presence of the wound and the patient's status. In wartime,

the heart wound frequently represented only one of several injuries, and both

the diagnosis of the cardiac wound and the timing of surgery for it were

complicated by the presence of these multiple injuries. As already noted,

only half of the cardiac injuries in this series were diagnosed before operation

or post mortem, but, in view of the difficult circumstances, the percentage of

diagnoses is gratifying rather than otherwise.

Decision as to surgery rested upon two considerations, the type of injury

and the presence or absence of a foreign body in the heart or pericardium.

Three questions had to be answered:

1. Could the cardiac lesion itself be corrected by surgery?

2. What was the effect of the patient's cardiac status on his ability to

withstand surgery for other wounds?

3. Should the surgery be performed at a forward hospital, at the base,

or in the Zone of Interior?

When the heart was exposed for any reason at initial wound surgery in

a forward hospital, suture of the laceration was best accomplished at the forward hospital. Efficient repair was unlikely in the base section after 10 days
WOUNDS OF THE HEART 89

or more had elapsed after the injury. After this lapse, retraction of the edges

of the myocardial defect and induration from proliferation of fibroblastic

tissue combined to defeat good approximation.

Foreign bodies, however, presented a different problem. When it was

certain that a foreign body identified by roentgenologic examination was just

within the myocardium or had merely penetrated the pericardium, it was best

to postpone surgery for 7 to 14 days and to evacuate the patient to a base

center unless there were early and continued episodes of bleeding or cardiac

dysfunction. Continued bleeding from a cardiac wound was always an indication for prompt thoracotomy. Otherwise, surgery was seldom an emergency. The dearth of diagnostic facilities and the lack of time for unhurried

study in forward installations made accurate localization in them difficult or

impossible.

Specifically, indications for delayed removal of foreign bodies included

cardiac pain, arrhythmia, abnormalities in previously normal electrocardiographs, and suspected intrathoracic hemorrhage.

Preoperative Management

Resuscitation of patients with recognized cardiac wounds followed standard principles. Originally, in accordance with the work of Beck (6), it had

been thought that if tamponade existed or was suspected, it would be of no

value to give blood or any other fluid intravenously, since it could not reach

the heart. The experimental work of Cooper, Stead, and Warren (11) shortly

before the war had shown that rapid intravenous infusion, with the subsequent increase in blood volume, enabled dogs to withstand considerably higher

intrapericardial pressure than when this measure was omitted. Elkin (3) had

also shown its clinical value. Rapid blood transfusions were therefore

strongly recommended as part of the preoperative routine.

TECHNIQUE OF CARDIAC SURGERY

When a cardiac wound was considered in need of surgical repair or when

such a wound was suspected, adequate exposure through an elective approach

was mandatory. The tragedy of inadequate exposure was well illustrated by

a case in the 2d Auxiliary Surgical Group experience in which exsanguination

occurred from an unsuspected wound of the right auricle. The surgical incision, a low posterior thoracotomy, was intended for a thoracoabdominal

wound and was not suitable for control of auricular hemorrhage.

Surgeons of the 2d Auxiliary Surgical Group believed very strongly that

extrapleural techniques should not be employed, however desirable they might

be in civilian life. In the Duval-Barasty type of extrapleural surgery, both

auricles and ventricles were exposed simultaneously, and the argument was

advanced that with such exposure, there was less possibility for missiles to
% THORACIC SUEGEEY

%

c

- 'HnLfi

FIGURE 32.—Technique of cardiac surgery. A. Left anterolateral transpleural

incision to expose left ventricle. 15. Exposure of right ventricle aided by transaction

of sternum.

migrate from one chamber to the other. Exposure for posterior lesions, however, was not satisfactory by the extrapleural technique. Such operations

always took longer than operations performed by the transpleural technique,

and there was no time for them in the busy wartime operating room. Finally,

the intrapleural damage and hemothorax almost always present in these battleincurred wounds made extrapleural techniques so difficult that they were entirely impractical.

Surgical Approach

An anterior transpleural approach (fig. 32A) was generally most suitable.

An intercostal incision was always employed unless the rib in the involved area

was badly fractured. The third or fourth intercostal space provided the best

exposure for wounds of the auricle and the fifth or sixth interspace for wounds

of the ventricle. In general, more of the right ventricle could be exposed

through a left-sided than through a right-sided thoracotomy (fig. 32B).

The incision was carried to the sternum, and the internal mammary vessels

were ligated and divided. When it proved necessary, an increase in vertical

exposure could be obtained by transverse section of the sternum at the level

of the intercostal incision.

Usually, according to the suggestion of Beck (<5), fO cc, of 5 percent procaine hyclrochloride was injected into the pericardial sac several minutes before

the heart was exposed. This practice materially cut down the incidence of

ectopic beats while manipulations were in progress.
WOUNDS OF THE HEART 91

As a rule, the pericardium AY as found tense, with the cardiac pulsations

weak or even imperceptible. If the pericardial wound was found, it was enlarged as necessary. If it was not found promptly, the pericardium

was opened between stay sutures. Once intrapericardial pressure was relieved,

bleeding became more profuse and cardiac contractions increased in force.

The heart wound was occasionally located before blood and clots were removed

and before the heart began to beat actively. Suture was simple under these

conditions. More often, the wound was not located until free blood and clots

had been removed by suction.

Control of Hemorrhage and Rotation of Heart

111 ventricular wounds, if the left index finger was placed over the wound,

bleeding was usually controlled sufficiently to permit the passage of a suture

directly under the finger. The suture, which was left untied, was held in the

left hand, so that hemostasis could be secured by traction while other sutures

were placed and tied. If the wound was on the diaphragmatic surface, on

the posterior aspect of the heart, or behind the sternum, a stay suture was

sometimes passed through the apex, by Beck's (6) technique, so that the heart

could be rotated into a favorable position for suture of the wound.

Surgeons of the 2d Auxiliary Surgical Group found that the hand of the

assistant (fig. 25C) made a better retractor than any suture. By this means,

the apex of the heart could be rotated forward at least 90°, and cardiac movement was considerably dampened. Spreading the fingers provided a sliding

type of retractor which permitted exposure of any portion of the cardiac wall.

If the lesions were anterior, the palming method (Sauerbruch grip) had

advantages. By this technique, the third, fourth, and fifth fingers of the surgeon's left hand were passed behind the heart, The index finger was anterior,

and the thumb was used as necessary for hemostasis. This technique provided

excellent control of both the heart and the bleeding area.

Suture Techniques

Much of the wartime knowledge of actual cardiac suture techniques was

owed to the prewar work of Beck (C), Elkin (-5), and Bigger (4), in particular

(fig. ?>">). The general techniques which they had promulgated pointed to the

direction, and furnished the background, of most cardiac surgery.

Some lacerations in this series were deliberately not sutured, for two reasons: Some were considered too slight to require repair, and some were so

located, or were of such a character, that it was thought that attempts at

suture might lead to additional difficulties. Among the wounds left unsutured

were (1) superficial lacerations of the myocardium 1 or 2 mm. in depth, which

were not bleeding, particularly if the left ventricle was involved; (2) round or

oval lacerations left after removal of foreign bodies, especially in the apical

region; and (?>) lacerations near a major coronary artery, in which the risk of
THORACIC SURGERY

FiouiiE 33.—Technique of cardiac surgery. A. Closure of perforating wound of left

auricle by modified. Beck technique. B. Closure by modified Elkin technique. Occlusion

of wound with rubber-shod forceps.

nonrepair had to be weighed against the chances of thrombus formation.

Wounds of the coronary vessels were not necessarily fatal. If small branches

were bleeding, very careful ligature or suture of the individual branches was

highly satisfactory.

"Wounds which had penetrated the cardiac chambers were always sutured,

even though they were plugged by blood clots and were not bleeding when they

were exposed. If they were not sutured, secondary hemorrhage was always a

possibility.

In general, it was easier to repair lacerations of the auricle on the right

side than on the left. Since the right wall is thinner than the left, repair of

wounds in this area was always necessary, on the ground that after repair,

the wall was thicker, and the scar from the sutured laceration stronger, than

a naturally healed wound. Complete suture or some other type of repair was

considered mandatory if the depth of the laceration felt thin or if there was

any myocarclial bulging. Without adequate suture, aneurysm of the myocardium might develop later. Cases of this kind were reported by Loison (cited

by Lilienthal (12)).

Large wounds of the auricle deserve special mention. Even wounds as

large as 3 cm. might not be exsanguinating because the lung had collapsed

against the wound or a clot had formed. The maneuver of covering the defect

with the finger in penetrating wounds, as practiced in ventricular wounds, was.
"WOUNDS OF THE HEART 93

however, not practical in wounds of the auricle because of the thinness of the

auricular wall. If sutures could not be placed immediately, the best plan was

to grasp each edge of the laceration with line forceps, which were then approximated, or to use temporary ligatures until sutures could be properly introduced,

If the wound was at the edge of the auricle, it would be completely occluded

with rubber-shod forceps.

Perforating through-and-through wounds of the chambers could be repaired successfully if both wounds were superficial. No method of exposure

was practical for repairing a wound of the posteromesial surface of the right

auricle. The oiilj' two patients in the 2d Auxiliary Surgical Group series

with this type of wound both died of exsanguination, caused by hemorrhage

from the free wounds. If the cardiac wound could have been repaired, the

mediastinal perforation might have sealed off.

A needle with a small eye or an atraumatic needle was used. Sutures were

interrupted and were usually of braided No. 00 or No. 000 silk, preferably

oiled or waxed. They were placed as close as possible to the wound edges but

did not include them, if this could be avoided (it could not always be avoided

in auricular wounds), because of the possibility of thrombus formation. In

myocardial defects, sutures were taken into the epicardium and superficial myocardium. No sutures included the endocardium (fig. 23). Great care was

taken in the placing of sutures, since necrosis of the wound edges, particularly

when the cardiac chambers were involved, could lead to fatal necrosis and

secondary hemorrhage. Sutures were tied during systole when possible and

always without tension.

Some lacerations, because of loss of substance as the result of the necrosis

and contusion of surrounding tissues, were difficult if not impossible to suture

completely. Then considerable ingenuity had to be exercised to secure closure,

particularly when the laceration extended into a cardiac chamber. Free muscle

grafts Mere useful, and probably should have been employed more frequently

than they were. They could be laid in the defect, where they were held in

place by fine sutures (fig. 24B). They helped to fill the defect and were also

instrumental in checking hemorrhage or myocardial oozing.

As a further reinforcing mechanism, the pericardium was sutured over

the area of repair, after establishment of drainage for the pericardial sac into

the pleural cavity by a cruciate incision. The edges of the pericardium could

be either approximated or imbricated (fig. 2IC). This technique, combined

with the use of a muscle graft, provided solid repair. A flap of pericardium as

an extra layer was also useful when bleeding had not been completely controlled

bj- myocardial suture.

Drainage was provided into the pleural cavity by closing the pericardium

so loosely that fluid was able to escape. In the two cases in which this

precaution was omitted, pericardial effusion occurred (p. 65).

The chest wall was sutured with careful approximation of the anatomic

lavers.
94 THORACIC SURGERY

ANALYSIS OF CASES

Management

Lacerations and perforations.—Twenty-nine cardiac injuries were visualized at operation and managed as follows:

Complete repair was accomplished in four lacerated wounds (one of the

left ventricle, two of the right ventricle, and one of the right auricle and right

ventricle).

Partial repair was accomplished in two lacerations of the left ventricle.

Complete repair was accomplished in 10 perforating or penetrating wounds

(6 of the left ventricle, 1 of the right ventricle, 1 of the left auricle, and 2 of

the right auricle).

Repair was attempted but proved impossible in two perforated wounds

of the right auricle.

Xo repair was attempted in 11 wounds, including 10 lacerations (8 of the

left ventricle, 1 of the right ventricle, and 1 of the right auricle), and 1 perforating wound of the right ventricle.

Foreign bodies.—It was the policy in the Mediterranean theater to be extremely conservative about the removal of foreign bodies in forward hospitals

or, indeed, in any oversea hospital. Of the 29 retained missiles in the 75

cardiac wounds in the 2d Auxiliary Surgical Group experience, only 9 were

removed, as follows:

Four (of four) were recovered from the pericardium.

One (of three) was recovered from the pericardial sac.

Three (of ten) were recovered from the myocaridum; five others were

found at autopsy.

One (of four) was recovered from the cardiac chambers; three others

were found at autopsy.

The majority of fragments not removed were small, 0.5 cm. or less in

diameter. In some cases, the condition of the patient did not warrant an

extended search for them. The two foreign bodies not removed from the

pericardial. sac were not identified positively, but from the roentgenologic

evidence and operative findings, it was considered highly likely that they were

present.

Of the eight, foreign bodies found only at autopsy, the missile was directly

responsible for one death, because of an embolus to the heart (case 7, p. 80)

and possibly for a second death (case 8, p. 80).

Postoperative Observations and Complications

Certain cardiac abnormalities were observed in some of the patients who

survived surgery:

Eight developed friction rubs, some of which were audible for as long as

3 weeks.
WOUNDS OF THE HEART 95

Two patients had apparent myocardial accidents, presumed to be infarctions. One occurred in the single stab wound in the series (p. 84). The other

patient developed a typical coronary occlusion 24 hours after operation, with

transient auricular fibrillation, precordial pain, and circulatory collapse. This

patient had presented extrasystoles before operation, and at operation, it was

necessary to ligate a small bleeding terminal branch of the anterior descending

artery. In addition, he had a clean superficial laceration of the cardiac apex,

which was not repaired.

One patient had a transient pneumopericardium.

One patient developed hemiplegia after repair of a laceration of the left

ventricle. One may speculate -whether mural thrombi formed after operation.

Two patients developed massive pericardia! effusions. In neither instance

was the pericardium drained at operation. Both did well with pericardicentesis,

and there were no apparent sequelae.

Four other patients had delayed pericardial effusions between 2 and 6

weeks after injury, for no apparent reason. All recovered under conservative

management. The clinical course suggested an irritative phenomenon rather

than a fiareup of latent infection. British observers in the Mediterranean

theater, who observed a few similar cases, accepted this development as an

indication for removal of any retained foreign bodies as soon as the acute

reaction subsided. The limited U.S. experience, as well as theoretical considerations, suggested a more benign interpretation, which remained for the

future to clarify.

Fibrinous pericarditis developed in four cases and quite likely was present

in others in which it was not clinically apparent. The removal of dressings

and bandages to establish this fact would not have been justified. In the

affected patients, electrocardiograms usually exhibited the expected changes

in the QBS complexes (low voltage), with lesser degrees of alteration in the

T-waves and S-T intervals.

Purulent pericarditis occurred in one case in the series in which the diagnosis of pericardial injury was missed at first:

Case 11.—This patient sustained a severe penetrating shell-fragment wound of the

epigastric region on 3 June 1944. Debridement revealed no pleural penetration, and no

foreign body was visualized. Laparotomy revealed no intra-abdominal injury.

Five days after wounding, the patient became increasingly dyspneic, and cardiac enlargement was noted. Digitalis was administered, on a diagnosis of myocardial insufficiency. When ho was admitted to a thoracic surgery center on 11 June, 600 cc. of dark,

bloody fluid, without odor, was removed from the pericardium, with prompt relief of

dyspnea. Systemic penicillin therapy was begun. Five days later, only 15 cc. of fluid

was obtained on pericardial aspiration, but 2 days later, 1,000 cc. was obtained. The

patient became progressively more febrile, and on 17 June, the fluid removed (400 cc.) had

an offensive odor, showed early purulent transition, and on direct smear was found to be

teeming with organisms.

Pericardiostomy was performed immediately, by removal of segments of the fourth

and fifth costal cartilages. A large metallic foreign body, surrounded by a large piece

of cloth, was found in the posterior recess of the left pericardial sac; it had driven
Oß THORACIC SURGERY

FIGURE 34 (case 11).—Suppurative pericarditis. A. Posteroanterior roentgenogram showing extent of accumulated Jlukl in pericardium. Aspirated

fluid showed early purulent transition and had a foul odor. B. Same, 3 weeks

after pericardial drainage.

itself partly through the pericardium and into the left pleural space. The missile, with

its cloth investment, was removed, and the pericardium was emptied by suction and was

tacked to the pectoral fascia to keep it widely open. No other provision for drainage was

made. Cultures were reported positive for protcolytic clostridia.

The patient made a very rapid recovery, and the pericardial cavity was rapidly obliterated. There were no episodes of recurrent dyspnea or paradoxical pulse. The fever

subsided promptly, and the patient was up and about 18 days after operation.

Comment.—The foreign body in this case was not visualized (fig. 34A) by roentgenogranis because of the superimposition of the heart shadow and the density of the fluid

in the pericardium. Its presence in the pericardium was suspected because of the failure

to visualize it elsewhere and the nature of the wound. The patient's rapid convalescence

is explained by the fact that drainage was instituted early, before the pericardial fluid

became thick and intensely purulent. As a result, there was no recurrence of dyspneic

episodes and no irregularities of the pulse. There was also prompt obliteration of the

pericardial sac (fig. 34B). Fibrinous deposition of exudate on serosal surfaces is an important factor in delayed convalescence in such cases and furnishes an urgent reason for

early drainage.

Fatalities

There were 30 deaths in the 75 cardiac injuries managed by the surgeons of

the 2d Auxiliary Surgical Group, 3 among the 18 pericardial injuries and

27 among the 57 myocarclial injuries.

All three deaths in the pericardial group occurred 48 hours or more after

operation, and none could be attributed to the cardiac wound per se. Of the

27 deaths in the myocarclial injuries, 20 were, however, directly attributable to

the cardiac wounds. The seven remaining fatalities were variously attributable

to associated wounds or to shock, bronchopneumonia, and anuria.

Ten cardiac wounds were seen only at autopsy, as follows:
WOUNDS OF THE HEART 97

Four lacerated wounds, including one of the left ventricle, one of the right

ventricle, and two of both ventricles.

Six perforated wounds, including one of the left ventricle, one of the

right ventricle, one of the left auricle, and three of the right auricle.

Causes of death.—Exclusive of the 3 deaths in the 18 pericardia! injuries,

the 27 deaths in the 57 wounds of the heart proper were distributed as follows:

Eleven deaths, six clue to cardiac causes, in sixteen pure contusions. Three

of these cardiac deaths were due directly to myocardial lesions and usually

occurred suddenly, from infarction or arrhythmia. In the three other cases,

the heart wound played an essential contributory part in the fatality but was

not the only cause.

Five deaths, four due to cardiac causes, in the ten lacerations associated

with contusions.

One death, clue to the myocardial lesion, in the ten pure lacerating wounds.

Nine deaths, eight due to cardiac causes, in the nineteen perforating or

penetrating wounds. In four cases, the fatality was due to exsanguinating

hemorrhage from the cardiac wounds, and in two cases to tamponade.

One death, in a myocardial lesion, clue to a cardiac embolus.

An analysis of the cardiac deaths (table 6) shows that 15 of the 20 followed

wounds of the ventricles.

Time of death.—The distribution of the 27 deaths in the series in relation

to the time of the fatality was as follows:

Two before operation, both as the result of the cardiac wound.

Ten, including four in thoracoabdominal injuries, before surgery was completed or immediately after operation. Eight were considered due to the

cardiac wound.

Four, including three thoracoabdominal wounds, between 1 and 5 hours

postoperative. Three were considered due to the cardiac wounds.

TABLE 6.—Distribution of 27 deaths in 56 combat-incurred car Hoc inj tries 1

Xumber

of eases

Number of deaths Anatomic distribution of cardiac deaths

Cardiac Other Ventricles Auricles

16

10

10

19

1

6

1

4

8

1

5

High/

2

Left

3

1

1

2

Both

1

High/ Left

1

1

1

1

1

2

Perforating or penetrating 4 1

Total. ______ . __ 56 20 7 5 7 3 4 1

i This table does not include a self-inflicted stab wound, from which the patient recovered. It also docs not include

18 combat-incurred pericardia! injuries, 3 of which were fatal.
TIIOIÜCIC SUKGEM

Two between 6 and 12 hours postoperative. Xeither was due directly to

the cardiac wound.

Six, including one thoracoabdominal wound, between 12 and 21 hours

postoperative. Four were considered due to the cardiac wound.

Three, including two thoracoabdominal wounds, after 2-i hours. All were

considered due to the cardiac wound.

Of the 20 deaths considered directly due to the cardiac wound, 2 occurred

before operation, 8 during or immediately after operation, 3 within 5 hours

after operation, d within 13 to 24 hours postoperative, and 3 after 21 hours

postoperative.

Responsibility for cardiac fatalities.—In 20 deaths attributed to wounds

of the heart, either surgery was not done at all, or corrective surgery was not

completed. An analysis of these cases indicates that in eight, surgery would

probably have benefited the patients and that in one other case, it might possibly

have been beneficial. In the other 11 cases, smgery would not have been useful,

or more extensive surgery than was carried out would have been useless. Of

these 11 casualties, i were in such poor condition when they were first seen thai

they died promptly, either before or during operation. Another, thought to be

in good condition, died suddenly during operation, and three others, also

thought to be in good condition, died suddenly soon after operation. The other

three patients in this group died after operation, soon after symptoms of myocardial infarction had become evident.

When the analysis of the possible benefits of surgery, or of more complete

surgery, is made in these 20 cases from the standpoint of the causative lesion,

the following facts emerge:

1. The six casualties with contusions could not have benefited by operation.

This is not a lesion which is ever benefited by surgery, nor is it a condition in

which early operation for other causes, however necessary it may be, is well

tolerated.

2. Surgery would not have been useful in the single fatal lacerating wound

uncomplicated by other cardiac damage. The patient had a pericarditis produced by contamination with gastric contents, though the exact role of the

infection in the fatal outcome cannot be stated precisely.

3. Operation would not have been useful in four cases of myocardial lacerations and contusions in which it was omitted, nor would additional surgery

have been beneficial in a fifth case in which the laceration was repaired. Damage was lethal in all four of these cases. In three, the anterior descending branch

of the left coronary artery presented a traumatic thrombosis for at least half

its length, and the fourth patient had an early pericarditis produced by contamination from gastric contents. A fifth patient, with a myocardial laceration

and contusion, might possibly have been helped by surgery. He died suddenly,

4 hours after debridement of the thoracic wound. At autopsy, a shell fragment

15 by 10 by 10 mm. was found in contact with the sternum, lying in a shallow,

contused, lacerated wound of the right ventricle at the base of the pulmonary
WOUNDS OF THE HEART 99

conus. It is possible that the continued presence of this missile was responsible

for propagating fatal ectopic stimuli. The pericardium contained 150 cc. of

liquid blood, but the sac was not tense, and the mode of death did not suggest

that pressure from tamponade played any part in the fatal outcome.

4. Operation would probably have been useful in the fatal case in which the

foreign body became embolic to the heart.

5. The largest group of cases in which surgery might have been beneficial

consisted of seven penetrating or perforating wounds of the cardiac chambers.

Eepair of the defect would probably have succeeded in six of these cases and

might have helped in the seventh. Four of the patients died of exsanguination,

one in the shock ward, two on the operating table, and the other of an unrecognized perforating wound of the right auricle. In this case, original hemorrhage had apparently ceased when debridemont of the thoracic wall was done,

but rapid exsanguination occurred before additional surgery was performed 3G

hours after the injury.

There were two instances of tamponade in these seven cases. One was entirely unsuspected until autopsy. The second was recognized too late for

control, though it is doubtful that the patient could have survived, in view of

the severe associated thoracoabdominal wounds.

The mode of death in the remaining (seventh) case in this group is not

entirely clear. Death occurred suddenly and was considered due to myocarclial

dysfunction. The patient had a through-and-through wound of the left auricle,

and there was approximately 100 cc. of blood in the pericardium, without any

evidence of tamponade. It is speculative that repair of the defects might have

been successful but quite obvious that a man with such injuries could not survive

veiyTlong without surgery.

References

1. 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, 1922, vol. I, pp. 431—175, passim.

2. 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.]

3. Elkin, D. C.: Wounds of the Heart. Ann. Surg. 120: 817-821, December 1944.

4. Bigger, I. A. : Heart Wounds. A Report of Seventeen Patients Operated Upon in

the Medical College of Virginia Hospitals and a Discussion of the Treatment and Prognosis.

J. Thoracic Surg. 8 : 239-253, February 1939.

5. Wood, Paul. : War Wounds of the Heart. Proceedings of the Conference of Army

Physicians, Central Mediterranean Forces, held at the Istitulo Superiore Di Sanita Viale

Regina Marguerita. Rome, 29 Jan. to 3 Feb. 1945, pp. 23-25.

6. Beck, C. S.: Further Observations on Stab Wounds of the Heart. Ann. Surg. 115:

G9S-704, April 1942.

7. Bright, E. F., and Beck, C. S.: Nonpenetrating Wounds of the Heart; A Clinical

and Experimental Study. Am. Heart .T. 10 :293-321, February 1935.

8. Warburg, E.: Myocardial and Perieardial Lesions Due to Non-Penetrating Injury.

Brit. Heart J. 2 :271-2S0. October 1940.
100 THOKÄCIC SUEGEEY

9. 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, passim.

10. Neurosnrgery and Thoracic Surgery. Prepared and edited by the Subcommittees

on Xeurosurgery and Thoracic Surgery, Committee on Surgery, Division of Medical Sciences,

National Research Council. Philadelphia and London : W. B. Saunders Co., 1943.

11. Cooper, F. W., Jr., Stead, E. A., Jr., and Warren, J. V.: The Beneficial Effect

of Intravenous Infusions in Acute l'ericardial Tamponade. Ann. Surg. 120 :S22-S25. December 1944.

12. Loison, cited by Lilienthal, Howard : Thoracic Surgery—The Surgical Treatment

of Thoracic Disease. Philadelphia and London : W. B. Saunders Co., 1925, vol. I. p. 441.
CHAPTER III

Thoracoabdominal Wounds

Lyman A. Brewer HI, M.D.

GENERAL CONSIDERATIONS

Definition.—The term "thoracoabdominal wound" was reserved in World

Whir II for a wound in which a single missile was responsible for damage to

structures of the chest and the abdomen. In approximately 90 percent of all

cases, the missile entered the chest and passed into the abdomen. As a rule,

the term "thoracoabdominal injury" implied a perforation of the diaphragm.

Occasionally, a missile that entered the chest could transmit sufficient force

through an intact diaphragm to produce an abdominal injury, but this was most

unusual. A wound of the so-called bare area of the liver produced by a

fragment that entered the chest and perforated the diaphragm was considered

a true thoracoabdominal wound.

The term "thoracoabdominal wound" should never have been used, as it

occasionally was, for wounds in which both serous cavities were injured by

separate missiles. The distinction is important. The management of a combined thoracic and abdominal wound inflicted by separate missiles and without perforation of the diaphragm differed considerably from the management

of a thoracoabdominal wound in which the injury of both cavities was produced

by the same missile and in which perforation of the diaphragm was a factor.

Thoracoabdominal and combined thoracic and abdominal wounds resembled

each other in one respect, however, that both carried very high mortality rates.

Incidence.—There was not complete agreement as to the incidence of these

wounds.1They accounted for about 5 percent of all admissions for battleincurred wounds in Seventh U.S. Army hospitals. Maj. (later Lt. Col.)

Lawrence M. Shefts, MC, and Capt. (later Maj.) Ernest A. Doud, MC, who

had a representative forward experience, found that thoracoabdominal wounds

represented about a quarter of their intrathoracic wounds. The 903 thoracoabdominal injuries treated by the 2d Auxiliary Surgical Group amounted to

almost 40 percent of the 2,267 intrathoracic injuries which they encountered.

Management in field hospitals.—About a quarter of the battle-incurred

injuries treated in held hospitals in the Mediterranean theater were thoracoabdominal injuries. Since casualties with these injuries were always nontransportable, practically all were treated in these forward hospitals. The

1 Official statistics for thoracoabclominal injuries appear in the first volume dealing with thoracic

injuries (chapter II, tables 8-11).

101

740-941*'—05 i)
m THORACIC SUEGEBI

occasional casualty treated in an evacuation hospital had an injury that had

escaped recognition in the field hospital. The management of thoracoabdominal injuries in base hospitals consisted of the management of complications

and the care and closure of colostomies.

As a group, casualties with thoracoabdominal wounds presented the severest injuries of all battle casualties; furnished a high proportion of the admissions to field hospitals, where, as just noted, most of them were treated; and

had the highest case fatality rate of any group admitted to them.

These wounds furnished the most important single indication for surgery

of thoracic injuries in a field hospital, for two reasons, (1) that resuscitation

was not complete without surgical repair of the intraperitoneal damage, and

(2) that in this type of wound, immediate surgery was necessary to prevent or

control intraperitoneal contamination. In thoracoabdominal wounds, whether

the diagnosis was established or merely probable, surgery was indicated as soon

as cardiorespiratory stability permitted.

Attention has been called elsewhere to the necessity for thoracic surgeons

assigned to field hospitals to be able to do intra-abdominal surgery (vol. I).

The large number of thoracoabdominal wounds that had to be handled in these

installations was further proof of the need for this dual ability. Even though

the majority of casualties with injuries limited to the thorax could be evacuated

to the evacuation hospitals after resuscitation, if not before, a single team could

not handle the remainder of the casualties in this group plus all of the casualties

in the thoracoabdominal group. Thoracoabdominal injuries were practically

always very serious, and a great deal of time was consumed in resuscitation and

at operation. A desirable plan, when available personnel permitted its use,

was to assign a senior thoracic surgeon to a field hospital and place two teams

under his direction. In this way, he could supervise the management of all

serious thoracic and thoracoabdominal wounds without attempting the usually

impossible task of managing them all personally.

PATHOLOGIC PROCESS

The wound of entrance in thoracoabdominal wounds was in the thorax in

the great majority of cases. In the 903 such wounds encountered by the 2d

Auxiliary Surgical Group, the missile entered through the chest 837 times and

through the abdomen 66 times.

Thoracic injuries.—In most instances, the entering missiles caused fractures of the ribs; the level of the fractures tended to correspond with the zone

of the diaphragm. In only 3 of the 903 wounds just mentioned was the site

of the costal fracture above the sixth rib posteriorly or the fourth rib anteriorly. The paucity of wounds in the upper chest is probably to be explained

by the smaller size of the target and by the lethal effect of missiles which entered

the thorax in a cephalad direction; these patients did not survive to reach a

hospital.
THORACOABDOMINAL WOUNDS 103

Pulmonary damage varied according to the site of injury. When a costophrenic angle was crossed, damage was usually minimal. If the wound of

entrance was elsewhere, there was usually a perforation or a laceration of the

lung. Contusions were less frequent. Hemorrhage was present along the

track of the missile and for 1 to 3 cm. beyond it. In an occasional case, a

segment of the lung was found amputated.

The mediastinum was injured 30 times, the heart 14 times, and the pericardium alone 13 times in these 903 cases. There was only one injury of the

esophagus.

In most cases handled by the 2d Auxiliary Surgical Group, on whose

material all of the following statements are based, the pulmonary wound was

in the peripheral portions of the lower lobes because the missiles most often

entered through the lower chest in the zone of the diaphragm. Injuries of the

middle lobe and of the lingula of the left upper lobe were much less frequent.

Diaphragmatic injuries.—Injuries to the diaphragm (fig. 35) fell roughly

into three categories:

1. Small single or double perforating wounds.

2. Large lacerated wounds.

3. Avulsion of the diaphragm from its attachment to the chest wall.

The wounds were almost equally distributed between the right (435 cases)

and the left (448 cases) sides. In 20 cases, the diaphragm was perforated

bilaterally.

Herniation of abdominal contents through the diaphragm was recorded

57 times. In 17 instances, only the omentum protruded. The explanation of

evisceration was the physiologic fact that pressure is normally lower within

the chest than within the abdomen. As a result, the spillage of gastric and

intestinal contents into the chest was always a possibility when the diaphragm

had been wounded.

Intra-abdominal injuries.—The liver took the impact of missiles which

entered on the right side. It was involved in 407 of the 435 right-sided injuries.

In the order of frequency after w

rounds of the liver (table 7) were wounds of

the right kidney, colon, stomach, small bowel, and gallbladder. On the left

side, the spleen, stomach, and colon took the impact of most missiles entering

on that side. In the 448 left-sided wounds, the spleen was injured 272 times,

the stomach 167 times, and the colon 145 times.

There was no evidence of involvement of the thoracic duct in these 903

cases. The assumption is that casualties with such injuries seldom survived

long enough for their condition to be recognized.

Tension pneumothorax of peritoneal origin.—In the 55 thoracoabdominal wounds encountered by Lt. Col. John M. Snyder, MC, and Maj. Frank

Tropea, Jr., MC, 24 of wdiich were left-sicled, there were 2 instances of tension

pneumothorax of peritoneal origin. This condition, it was thought, had not

previously been described. In each instance, the wound of entry was in the

lower left chest, and in each, there was a large perforation of the anterior wall
104 THORACIC SURGERY

T"

C D

\

,*•*"

A

/

N

'' /

7

/

r

FIGUKK 30.—Types of wounds of diaphragm possible from penel rating or

perforating missiles. A. Through-and-through wound of lower chest. On

inspiration, the wound may bo purely thoracic. B. Same type of wound,

which may be thoracoabdominal on expiration. C. Thoracoabdominal

wound with, as usual, missile entering chest first. D. Thoracoabdominal

wound with missile entering abdomen first.

of the stomach, with a resultant outpouring of a large amount of air through

the lacerated diaphragm. In the first case, the diagnosis was not made, and

death occurred in the course of laparotomy. In the second, in which the condition was recognized several hours after the patient was first seen, closed drainage was instituted, and recovery was uneventful.

Theoretically, there seems to be no reason why tension pneumothorax of

peritoneal origin should not be possible under the circumstances described,
THORACOABDOMINAL TVOt'XI)S 10a

TABLE 7.—Frequency of wounds and ease fatality rede in 903 llwraroabdominal wounds

according to combinations of viscera

Combinations of organs Cases Deaths

Case

fatality

rate

Liver alone —

Liver and kidney

Liver and stomach

Liver and small intestine! —

Liver and spleen

Liver and right colon

Liver and left colon

Liver, stomach, and colon

Liver, kidney, and right colon

Liver, stomach, and biliary tract

Liver, stomach, and spleen _ _

Liver, small intestine, and left colon

Stomach and spleen

Stomach, spleen, and left colon

Stomach, spleen, and kidney

Stomach, spleen, and pancreas

Stomach and left colon

Stomach, small intestine, and colon^

Stomach and kidney

Spleen alone

Spleen and kidney

Spleen and left colon _ _ . ..

Spleen, kidney, and left colon

Spleen and small intestine

Kidn py alon e

Left colon alone

Left colon and small intestine

Peritoneal cavity (penetration only)

All other combinations 1

297

59

30

9

6

11

6

4M

S

19

12

9

11

IS

6

26

ii 5

oo

14

11

1

O

4

1

5

4

4

18

4

1

10

4

4

6

0

4

11. 7

23. 7

36. 6

11. 1

42. 8

57. 1

33. 3

62. 6

80. 0

66. 6

/. J,

S3. 3

41. 8

50. 0

33. 3

66. 6

25. 0

25. 0

25. 0

10. 5

14. 8

21. 0

50. 0

36. 6

OO. o

50. 0

11. 5

63. 4

When five organs or more were injured, the case fatality rate was 100 percent.

though before autopsy established it in the fatal ease, some doubt had been felt

about it. A tension pneumothorax of peritoneal origin could scarcely occur in

a thoracoabdominal wound on the right, but the possibility of what might be

termed an internal sucking wound could reasonably be considered on (lie left

side. In this variety of wound, small quantities of air and intestinal contents

could be aspirated into the chest during the act of respiration, and the repeated

aspiration of small quantities would alter the intrapleural pressure and lead lo

pulmonary collapse unless the sucking was promptly corrected.

During the laparotomy for a left-sided thoracoabdominal wound, an injury

that originated as an internal sucking wound would become an external sucking

wound as soon as the peritoneum was opened. This is apparently what happened in the faial case in this series. Next to the control of active hemorrhage,
106 THORACIC SURGERY

therefore, closure of the lacerated diaphragm was the first duty of the surgeon

who operated on a thoracoabdomhial wound through a laparotomy incision.

On the right, the liver usually sealed off the diaphragmatic wound.

In the early days of the war, many laparotomies were performed without

endotracheal anesthesia, and as a result, when the abdomen was opened, a tension pneumothorax developed through the perforation in the diaphragm. This

complication ceased to be a problem after endotracheal anesthesia was in general use and surgeons became aware of the possibilities of tension pneumothorax

of this origin.

DIAGNOSIS

In general, if the patient had a single wound of the thorax and a single

wound of the abdomen, the diagnosis was obviously a combined thoracic-abdominal wound. If both wounds were in the abdomen, there was little possibility

of diaphragmatic injury unless the costal cage was involved. If both wounds

were thoracic and if one was below the level of the fourth rib anteriorly, a

thoracoabdomhial injury might or might not be present.

Since not more than 10 percent of the missiles in thoracoabdomhial wounds

entered the body via the abdomen, the chief difficulty from the diagnostic standpoint was in determining the presence or absence of abdominal injury in a

patient with a known thoracic wound, in every one of which penetration of the

abdomen had to be considered as a possibility until the injury was excluded.

There was no problem when roentgenologic examination showed the retained

foreign body to lie within the chest or showed that it had entered the abdomen.

The diagnostic difficulties were posed by the missiles that perforated the chest

in the so-called diaphragmatic zone or penetrated it and lodged in the vicinity

of the diaphragm.

Anatomic and Physiologic Considerations

The most practical method of diagnosing a thoracoabdomhial wound was

to keep constantly in mind that the diaphragm might be involved in any thoracic injury, most particularly in any injury occurring in the area bounded

superiorly by the anterior end of the fourth rib and posteriorly by the level of

the seventh rib, down to and including the twelfth rib at its inferior level

(fig. 36).

Both physiologic and anatomic facts had to be borne in mind in making

the diagnosis. It could be assumed that the pleural reflection follows, with

reasonable accuracy, the outline of the periphery of the ribs and the costal cartilages. For diagnostic purposes, the thickness of the diaphragm could be ignored, and the peritoneum could be assumed to be in contact with the diaphragmatic surfaces of the pleura. The diaphragm, however, is not an immobile

structure which forms a perfectly horizontal partition between the chest and
THORACOABDOillXAI, WOUNDS 107

FicuiiE 3C—Schematic showing of maximum expiratory excursion of diaphragm.

In deep expiration (a), it can reach as high as the superior border of the fourth

rib anteriorly. Note depth of costophrenic sulcus on inspiration (b) draws the

diaphragm down to the sixtli rib.

the abdomen. In these circumstances, diagnosis would be much simpler. Instead, the variables caused by its uneven configuration and the distance through

which it can move, tremendously increased its susceptibility to injury, and, m

turn, the susceptibility of abdominal organs to involvement in the wound.

Because of the movement of the diaphragm, any wound of the entire lower

left hemithorax might penetrate the division between the thorax and the abdomen (fig. 36). Any wound below the seventh interspace posteriorly or the

fourth rib&anteriorly might injure the diaphragm if the patient was in the

expiratory phase of respiration at the time. Since the pleural reflection extends

down to the attachments of the diaphragm to the ribs and the costal arch, any

wound at the level of the twelfth rib or above posteriorly, or any wound that

involved the costal arch or above anteriorly, had to be considered a possible

thoracoabdominal injury.

If the range of motion of the diaphragm on deep inspiration and expiration were kept in mind, the cavities and organs involved in a wound of the chest

might reasonably be predicted by lining up the wounds of entrance and exit

if the injury were perforating, or by lining up the wound of entrance with the

point at which the missile was lodged within the body if the injury were penetrating. Any missile, therefore, which passed through the area extending from

the level of the twelfth rib posteriorly to the level of the fourth rib anteriorly

might or might not have entered both the pleural and the peritoneal cavities.
108 THORACIC SURGERY

Since many wounds were inflicted while the soldiers were prone, the increase in

intra-abdominal pressure created by this position further raised the upper limits

of the diaphragm.

If the patient was in deep expiration at the time of wounding, the diaphragm, with the spleen and stomach, might rise high enough into the thoracic

cavity to be injured by a missile that had entered the chest at the fourth

interspace. If the wounding had occurred during the expiratory phase of

respiration, the anatomic position of the wounds in the chest wail might be

quite cephalad and yet there might be a tear in the diaphragm and damage to

the peritoneal organs. In one casualty, for instance, in whom the wound of

entrance was in the fourth interspace just medial to the left nipple and the

wound of exit was in the seventh interspace in the left midaxillary line, the

diaphragm was perforated and the spleen was injured.

Projection of Course of Missile

The most reliable and most helpful information in thoracic injuries in

which involvement of the abdomen was not evident by clinical means was obtained by projecting the probable course of the missile. Boentgenologie examination was therefore essential in every penetrating wound of the chest, no

matter how insignificant it might seem, if only because the location of the

wound of entrance was occasionally extremely misleading in relation to the

course of the missile within the body.

Both anteroposterior and lateral films were made, with overexposure for

both abdomen and chest. They were preferably made in the sitting position.

Patients in severe shock, who could not tolerate the upright position, were

examined by anteroposterior exposures made in the prone position.

When the information derived from films in hvo planes was correlated

with its point of entrance, the course of the missile could be projected and a

decision made concerning the possibility of intra-abdominal damage.

Missiles tend to travel in a straight line if they are not deflected. The

experience of most surgeons who treated large numbers of war wounds was,

as pointed out elsewhere (vol. I), that stories of missiles which entered at one

point and caromed around at a tangent before making their exit or Jodjrinsj at

some point within the body were the exception. There were occasional instances in which, the course of the missile was bizarre because it had struck a

bony structure tangentially, but these injuries, again, were exceptional. Many

superficially bizarre pathways could also be explained by investigation of the

position that the casualty was occupying when he was injured. Inquiry on this

point was made whenever the patient was sufficiently oriented to furnish the

information.

On the other hand, an occasional thoracoabdominal injury diagnosed for

the first time at a general hospital made it clear that exceptions to these generalizations sometimes occurred. In one such injury, reported by Lt. Col. John

Burke, MC, and Maj. Theodore T. Jacobs, MC, for instance, a wound of
THORACOABDOMINAL WOUNDS 109

entrance in the region of the light scapula and a wound of exit in the right

groin were considered to be individual wounds. They proved to be from the

same missile. Fortunately, the delay in operation was not attended with

serious consequences.

Clinical Considerations

Part of the diagnostic confusion in some thoracoabdominal wounds was

caused by the overshadowing of symptoms and signs referable to the abdominal

injury by the more urgent symptoms and signs of the chest injury. The thoracic component of the injury could give rise to pain in the chest wall, hemoptysis, hemothorax or hemopneumothorax, dyspnea, cyanosis, and wet lung.

Since thoracic wounds that did not involve the abdomen were frequently

associated with pain and spasm of the upper abdomen (vol. I), these phenomena

did not furnish a reliable indication of abdominal injury. Abdominal tenderness and rigidity were also often present; in such cases, a useful differential

point was that deep tenderness and rebound tenderness were never elicited in

chest wounds. If time could be spared, a differential diagnosis was sometimes

clarified by paravertebral or intercostal block. The results were not always

conclusive, but, when there was prompt relief of pain, abdominal involvement

could usually be excluded. Pain in the shoulder was not a universal symptom.

When it was present, it pointed to an injury of the diaphragm.

Although nausea and vomiting sometimes occurred in thoracic injuries,

they were not common, and their presence lent strength to the possibility of

abdominal involvement. The demonstration of active peristalsis suggested

that if abdominal injury had occurred, a hollow viscus was not involved.

Most surgeons, however, could recall casualties in whom peristalsis had been

observed even with wounds of the colon. Peristalsis frequently persisted when

the injury was limited to the spleen, liver, or kidney. Wounds of all of these

organs were associated with a paucity of symptoms and signs referable to the

abdomen.

If a hollow viscus was injured, prompt surgery was imperative, but it was

important to remember that injuries of solid viscera could also be extremely

serious. A casualty might bleed to death from a damaged spleen, or grave or

even fatal, bile empyema might be the consequence of an overlooked wound of

the liver.

Other Diagnostic Aids

The presence of blood in gastric contents, whether vomited or aspirated,

was suggestive of abdominal injury, though it was not conclusive, since it might

have originated from a wound of the lung.

Examination of a voided or catheterized specimen of urine was part of the

diagnostic routine. The absence of blood in the urine was not conclusive, but

its presence furnished valuable information as to the course of the missile in

relation to the urinary tract.

74G-!>41V—Go 10
110 THORACIC SURGERY

Such diagnostic refinements as pneumoperitoneum were not practical in

forward hospitals.

EXPLORATION

Indications

The final diagnosis of a thoracoabdominal wound was based on the

following considerations:

1. Inspection of the wound or wounds.

2. The projection of the suspected course of the missile from the wounds

of entrance and exit if the injury were perforating or from roentgenologic

localization of its position if the injury were penetrating.

3. Such information as could be obtained from the history and from the

general clinical picture.

If a positive diagnosis of a thoracoabdominal wound could not be made

with reasonable promptness and the suspicion persisted that the diaphragm

might have been perforated, prompt exploration was the ride. A positive

preoperative diagnosis was naturally desirable, but if it could not be made, a

reasonable suspicion that such an injury existed was sufficient indication for

exploration. In many instances, a somewhat enlarged traumatic thoracotomy

provided adequate exposure to determine whether or not the diaphragm had

been perforated.

The only suspected thoracoabdominal injuries in which exploration was

not regarded as mandatory were minor penetrations of the liver. If a foreign

body was only 2 or 3 mm. in diameter, and if roentgenologic examination made

it unmistakably clear that it lay entirely within the liver, expectant treatment was considered permissible in certain selected cases. Not more than 1

percent of all thoracoabdominal injuries fell into this category, and many surgeons considered the risk of biliary empyema too considerable to warrant expectant treatment in any case at all. Whenever the foreign body was over

3 mm. in diameter, regardless of its location, it "was always best to determine

surgically the exact damage that had occurred.

Negative Explorations

A rather large number of exploratory thoracotomics had to be performed

because of the difficulty of making an accurate diagnosis of wounds around the

diaphragmatic sulci. For this and other reasons, a significant number of negative explorations were carried out in all field hospitals. In the 2,267 penetrating and perforating wounds of the chest cared for by thoracic surgeons of

the 2d Auxiliary Surgical Group, there were 903 proved thoracoabdominal

injuries, almost 40 percent. Teams from this group, however, performed 122

exploratory thoracotomies in which no abdominal involvement had occurred.
THORACOABDOMINAL WOUNDS 111

These 122 negative explorations represent 28 percent of all thoracotomies done

by these teams in forward hospitals.

To snrgeons without experience in combat wounds, this figure may appear

high. It is certainly high compared with the 41 explorations (1.3 percent)

performed by surgical teams of the group in 3,154 abdominal wounds in which

no intraperitoneal damage of any consequence was found (1). On the other

hand, it is significant that well over half of these 41 negative explorations (28)

were in thoracoabdominal wounds. In these 28 explorations, as in the 122

negative explorations performed for suspected thoracoabdominal wounds in

this series of thoracic injuries, the indication was the same: Injuries of the

abdominal viscera are so highly lethal if they are not treated surgically that

no chance of overlooking them could be taken.

A practical consideration in the diagnosis of thoracoabdominal wounds

was the echelon of medical care in which surgery was done. Casualties with

thoracoabdominal wounds in which the diagnosis was clear cut were not transportable; surgery was done in field hospitals. Casualties in whom thoracoabdominal wounds were suspected also had to be cared for in field hospitals.

Exploration could not be delayed until they reached an evacuation hospital.2

If an abdominal injury were positively excluded, surgery for the chest injury

could usually be deferred until an evacuation hospital was reached. Unnecessary exploration put an added strain on the space, facilities, and personnel of

the field hospital, but it could not be omitted in any doubtful case.

RESUSCITATION AND PREOPERATIVE PREPARATION

General Considerations

Certain concessions to the realities of the situation had to be made in the

resuscitation and preoperative preparation of casualties with thoracoabdominal injuries. The exigencies of the abdominal emergency were sometimes met

at the expense of the most ideal preparation of the casualty from the point

of view of cardiorespiratory stabilization.

From the standpoint of pure thoracic injuries, the length of time required, within reasonable limits, to restore thoracic casualties to as nearly

normal status as possible before operation was not of primary importance.

If the injury was limited to the thorax, the casualty frequently was benefited

by a short period of stabilization after cardiorespiratory abnormalities had

been corrected and shock controlled.

In casualties with thoracoabdominal wounds, the situation was entirely

different. Time was of great importance. They had to be resuscitated as

expeditiously as possible and operated on as soon as it was thought that they

2

In certain military situations, evacuation hospitals served as the most forward hospitals in the

area and acted in the capacity of field hospitals. In these circumstances, they operated on all nontransportable casualties.
112 THORACIC SURGERY

could tolerate surgery. 11 a patient continued to have a low blood pressure,

rapid pulse, and associated signs of shock alter correction of the disordered

thoracic physiology, supplemented by adequate replacement therapy, immediate, surgery was indicated. Many patients who presented such a picture

were found at operation to be bleeding seriously or to have massive pleural or

peritoneal contamination from a perforated stomach or intestine. Their condition was frankly dangerous with immediate surgery, but entirely hopeless

without it.

Patients with thoracoabdominal injuries were examined in the shock tent

to determine their status in respect to shock and their cardiorespiratory status

as manifested by respiratory restriction due to pain, embarrassment of respiration by hemothorax or pneumothorax, cyanosis, and excessive accumulations

of blood and mucus in the tracheobronchial tree. In 669 thoracoabdominal

injuries in the 2d Auxiliary Surgical Group records in which information is

available, on this point, 145 patients were not in shock but 75 were in mild

shock, 174 were in moderate shock, and 275 were in severe shock.

Routine of Resuscitation

When thoracoabdominal casualties were received in the held hospital from

the division clearing station, measures to combat shock and maintain respiratory equilibrium would already have been instituted. Sucking wounds of the

chest would have been closed by occlusive dressings. Pain would have been

relieved by morphine if it was indicated, or by intercostal nerve block. Plasma

transfusions would also have been given as necessary. The 2d Auxiliary Surgical Group records in which information is available on this point show that

144 casualties had received no plasma, but 455 had received an average of 525

cc. each.

The records also indicate that while (iO casualties received no blood in

the shock tent, 019 had an average ol 1,100 cc. each. It is known that 252

casualties received no plasma in the shock tent and that 408 received an average of 500 cc. each. The usual, practice was to begin the administration of

plasma in the shock tent while waiting for blood to be crossmatched.

While plasma and blood were being administered, measures were instituted to correct the disordered cardiorespiratory physiology, including the

administration of oxygen through a nasal catheter or mask (vol. I) ; intercostal

nerve block if it had not already been carried out (vol. I) ; aspiration of air

ami blood from the pleural cavity (vol. I) ; and catheter or bronchoscopic

aspiration of the tracheobronchial tree (p. 227). As a rule, the effect of these

measures upon the cardiorespiratory imbalance and on the state of shock to

which it was contributing was most gratifying.

As pointed out already (vol. I), a patient with a thoracic injury had to

be. treated judiciously in respect to replacement therapy because of the grave

danger of overloading the already damaged cardiorespiratory system and pre-
THORACOABDOMINAL YVOUXDS 1K-5

s

cipitating pulmonary edema. The same precautions had to be observed m

thoracoabdominal injuries. However much the casualty might need blood

from the standpoint of the abdominal component of his wound, there was serious risk from the standpoint of the thoracic component in giving large amounts

and in giving them too rapidly.

An important step in preoperative management was the introduction of

a Levin tube, to aspirate the gastric contents and thus eliminate the risk of

vomiting during surgery (vol. I).

It was a general policy to transport the patient from the shock tent to

the operating table on the litter on which he had been placed originally, to

operate on him on the same litter, and to move him to the recovery tent on it.

Casualties with abdominal and thoracoabdominal wounds, particularly those

who had been in serious shock, did not tolerate movement well, and this plan

eliminated it while at the same time saving the time and eil'ort of busy

personnel.

Priority of Surgery

Unless severe infra-abdominal hemorrhage, which was not usual, demanded priority of treatment, the necessary intrafhoracic surgery took precedence of the abdominal surgery. The importance of this sequence is evident

in 15 deaths analyzed by Maj. (later Col.) Howard E. Snyder, MC, Consultant

in Surgery, Fifth U.S. Army (2). In only one of seven cases in which laparotomy preceded chest surgery was there any indication for performing it

first, and there seemed no doubt that the unwise order of precedence played

a part in more than one of the fatalities.

ANESTHESIA

The anesthesia of choice in thoracoabdominal wounds was endofracheal

ether and oxygen in a closed circuit, with induction by nitrous oxide and

oxygen. In a small number of cases, Pentothal sodium (thiopental sodium)

was used for this purpose. In 1942 and part of 1943, open drop ether was used

in many operations because of the limited number of anesthetic machines.

This technique was discarded as soon as these machines became generally

available.

It was impossible to overemphasize the value of endotracheal anesthesia

in thoracoabdominal surgery or of the services of an expert anesthesiologist.

Such an anesthesiologist appreciated the value of frequent and thorough aspiration per catheter of the tracheobronchial tree throughout the operation; of

bronchoscopy in selected cases at the end of operation; of replacement therapy

during operation ; and of positive pressure anesthesia when the thoracic cavity

was open as well as during closure, of the chest, when reexpansion of the lung was

necessarv.
114 THOMCIC SUBGEBY

Replacement therapy was carried out during surgery, the use of whole blood,

plasma, or glucose or physiologic salt solution depending upon the needs of the

individual patient. The records of the 2d Auxiliary Surgical Group that are

complete in this respect show that 116 patients required no fluids on the operating table, 639 had an average of 1,000 cc. each of blood, 166 an average of 575

cc. each of plasma, and 78 an average of 1,000 cc each of 5 percent glucose in

physiologic salt solution in addition to the plasma and blood they received.

The casualties operated on by teams of the 2d Auxiliary Surgical Group

were kept under anesthesia on an average of 2y2 hours.

SURGICAL APPROACH

General Considerations

At the beginning of the fighting in North Africa, it was generally thought

that the transdiaphragmatic approach to the abdominal component of thoracoabdominal wounds would be of only limited usefulness. At that time, and to a

certain extent throughout the war, the decision as to the surgical approach

depended not only upon the findings in the particular case but also upon the

preference of the surgeon for the abdominal or thoracic approach. This

preference usually depended, in turn, upon his experience, or lack of experience,

in chest surgery. The experienced chest surgeon was able to select the single

approach or the combined approach which best met the needs of the patient.

Surgeons not widely versed in thoracic surgery found it safer to repair the

hitraperitoneal damage through a laparotomy incision after handling the

thoracic damage and closing the diaphragm through the chest.

By the end of the war, it was the opinion in the Mediterranean theater—

an opinion shared by the more experienced of the thoracic surgeons in the

European theater—that whenever it was practical, thoracotomy with transdiaphragmatic repair of all accessible abdominal injuries was infinitely the

procedure of choice. If total repair was not possible by the transthoracic approach, the best plan in left-sided wounds was to correct the intrathoracic

damage, care for any damage readily accessible in the left upper quadrant of

the abdomen, close the diaphragm, reexpand the lung, close the chest wall

tightly, and then proceed with the repair of hitraperitoneal injuries not accessible through the diaphragm. The same general principle was applicable to

wounds of the upper right quadrant of the abdomen, but the extent of surgery

possible in this quadrant was, for anatomic reasons, much less than on the

leftside.

When the thoracic and abdominal wounds were separate, transdiaphragmatic surgery was not indicated because it subjected the pleura to contamination

which did not already exist, In these cases, the chest wound was given priority unless profuse intra-abdominal bleeding or massive evisceration made

laparotomy necessary as the primary procedure.
THORACOABDOMINAL WOUNDS 115

Advantages and Disadvantages of the Transthoracic Approach

No hard-and-fast rule, covering all casualties, could be laid down for the

approach to a thoracoabdominal wound. There were advantages and disadvantages to both the thoracic and the abdominal approaches, and each

casualty had to be individualized.

In favor of the transthoracic approach were the following arguments:

1. If there was extensive thoracic damage, the chest injuries could not be

repaired from below the diaphragm.

2. Certain wounds of the upper abdomen were more easily handled through

the diaphragm than through a laparotomy incision. These included wounds

of the spleen, the dome of the liver, both kidneys, the upper portion of the

stomach (especially if the posterior surface was injured), and the splenic flexure

of the colon. There was real danger of overlooking wounds of the posterior

wall of the stomach and of the retroperitoneal portion of the splenic flexure,

as well as wounds of certain areas of the spleen, when the approach was by

laparotomy.

3. Injuries of the diaphragm, whether on the right or the left side, especially if they were extensive, were more readily repaired transthoracically.

If the wound was small, it could as well be repaired from below as from above.

Injuries over the dome of the liver, however, as well as such large defects as

resulted from tearing of the diaphragm from the costal margin, especially

posteriorly, were much more readily repaired from above.

4. The transthoracic approach permitted exteriorization of the transverse

or splenic flexure of the colon through a subcostal gridiron incision at a greater

distance from the surgical incision than was possible if laparotomy had been

done. Wound infection was thus reduced to a minimum.

5. If considerable pleural contamination had occurred from spillage of

gastric or intestinal contents, it could be reduced by copious pleural lavage with

physiologic salt solution, a procedure possible only through the chest.

6. There was no validity to the objection, sometimes raised, that wounds

of the gastrointestinal tract should not be dealt with through the chest because

infection of the pleural cavity might result. For one thing, considerable

damage to the intrathoracic organs might exist without being evident before

the chest was explored. For another, potential infection existed whenever the

diaphragm had been iDerforated by the missile. If hollow organs in the abdomen had been perforated, feces and gastric contents had been sucked into the

pleural cavity before the surgeon ever saw the casualty.

7. If the chest was long and narrow, with an acute angle at the costal arch,

subdiaphragmatic repair was often technically very difficult.

8. Blockage of the intercostal nerves, for anatomic reasons, was much

easier when the transthoracic approach was used. These nerves lie underneath

the ribs and course downward diagonally to supply the upper abdomen. When

they were blocked at operation, both thoracic and abdominal pain was decreased. As a result, after operation, the patient coughed willingly, and as
116 THORACIC SURGERY

a further result, the lungs were more adequately aerated and bronchial secretions were raised more completely.

0. Since abdominal relaxation was not necessary when the transthoracic

approach was used, the patient could be carried in a lighter plane of anesthesia.

10. If the transthoracic approach revealed intra-abdominal injuries that

could not be repaired from above, it was a simple matter to perform the necessary chest surgery, close the diaphragm and chest wall, and then perform the

necessary intraperitoneal surgery through a separate laparotomy incision. As

already emphasized (p. 113), in the absence of compelling reasons for reversing

the order, chest surgery was always done first, in order to restore normal

cardiorespiratory conditions as promptly as possible.

Against these multiple advantages of the transthoracic approach were the

following arguments for repair of intraperitoneal damage through a laparotomy

incision:

1. Certain wounds of the small bowel and colon could not be exposed adequately through the diaphragm and had to be repaired by laparotomy. These

included wounds of the terminal 18 inches of the small intestine and all wounds

of the colon except wounds of the transverse portion, the splenic flexure, and

the proximal portion of the descending colon.

± When thoracic damage was minimal, an abdominal approach avoided

unnecessary entrance into the plenral cavity. This was not a sound argument.

When the abdomen was opened, all but the most minimal perforations of the

diaphragm constituted, in effect, sucking wounds, which carried all the risks

of sucking wounds of the chest wall (p. 105). Not infrequently, patients developed pulmonary embarrassment wiiile the abdominal repair was in process

because of aspiration of air into the chest through the diaphragmatic opening.

If the situation was unrecognized and uneorrected, serious results could follow,

including aspiration into the plenral cavity of intestinal and gastric contents

free in the peritoneal cavity. If the abdominal approach was used, repair of

the diaphragm was necessarily the first step of the procedure, to avoid these

dangers, instead of the last before wound closure, as in the transthoracic

approach.

INCISION

^ Four types of incisions, in addition to separate thoracic and abdominal

incisions, were employed in thoracoabdominal wounds :

1. Limited thoracotomy, accomplished by an extension of the original

wound (traumatic thoracotomy). This was often a satisfactory incision when

injuries were confined to the chest. It was not usually satisfactory in thoracoabdominal wounds unless the original injury in the chest waif was large

enough to supply adequate exposure, which was essential for exploration of the

upper abdomen and repair of damaged infra-abdominal viscera. If the original wound was below the tenth rib, and especially if the missile had gone

through, the eleventh or the twelfth rib, traumatic thoracotomy was entirely
THOKACOABDOMINAL WOUNDS 117

impractical. Even resection of one or more ribs did not provide satisfactory

space for maneuvers. Wide exposure was essential. If there was any reason

for inspection of the interior of the thorax, there was every reason for adequate

investigation.

2. Thoracotomy in the area of the original wound.

3. Thoracotomy outside the area of the original wound. The majority of

thoracotomies fell into either this group or the second group. The formal

approach was usually posterolateral and usually through the ninth intercostal

space or the bed of the ninth rib. Injuries of the mid or anterior portions of

the diaphragm were often approached through the eighth interspace or the bed

of the eighth rib. A small number of thoracotomies were performed laterally,

in the region of the sixth or seventh ribs, more often through the intercostal

spaces than through the bed of the ribs. It was always best, if it was anatomically feasible for good exposure, to resect a rib that was not involved in the

wound of entrance or exit, in order to reduce the chances of postoperative

wound infection with involvement of the diaphragm.

4. Thoracolaparotomy, an incision in which the thoracic incision was extended through the costal arch onto the abdomen. This was not a popular

incision because of the resulting instability of the chest wall and the increased

morbidity if infection occurred in the costal cartilages. It was used only six

times in the 903 thoracoabdominal wounds cared for by the 2d Auxiliary

Surgical Group. In two of these injuries, the rib margins had been destroyed

by the original wounds, and this approach was used as a matter of expediency.

In one of the four other cases, in all of which the incision was elective, the

wound broke down and the resulting infection was fatal. Most chest surgeons

believed there was nothing to be said in favor of this approach as an elective

procedure.3

TECHNIQUE

Management of the Thoracic Component

The thoracic component of the thoracoabdominal wound was treated in

much the same manner as if it were the only M'ound. The principal difference

was that, because of the abdominal element and the transthoracic approach,

many chest wounds M'ere treated by thoracotomy in field hospitals that otherwise would have been treated in evacuation hospitals and only by debridement

and thoracentesis. Once the thoracic cavity was entered, there would have

been no point to not removing intrapulmonary foreign bodies and bone fragments, though a prolonged search for small missiles was not warranted. Pulmonary lacerations of more than 4 or 5 cm., as well as any lacerations which

demonstrably leaked air, were repaired with interrupted sutures.

3 The long vertical abdominal incision introduced by Duval in World War I does not seem to hare

been employed in World War II. It was used by Wangensteen after World War I, and it was employed by Norwegian surgeons in a forward hospital during the Korean War.—F. B. B.
118 THORACIC SURGERY

Management of the Abdominal Component

Standard practices were also followed in the management of the abdominal

component of the wound. In brief, wounds of the stomach were sutured.

"Wounds of the small intestine were treated by suture or by resection and

anastomosis, according to the indications. Wounds of the colon were exteriorized or managed by colostomy. Wounds of the spleen were treated by splenectomy. Wounds of the pancreas were treated by suture and drainage or by

drainage alone. Wounds of the kidney were preferably treated by drainage;

nephrectomy was performed only when the pelvis was definitely involved or

when hemorrhage was intractable. The management of all of these wounds

is described in detail in the volume on general surgery devoted to abdominal

injuries (1).

Wounds of the liver.—Wounds of the liver require special mention. Even

if only a small fragment had penetrated the liver substance, it was conservative management to explore the wound, since it was not possible to determine

from the size of the missile the precise site of the diaphragmatic laceration or

the extent of hepatic damage. In some instances, particularly when a rib had

been fragmented, a surprising amount of diaphragmatic and hepatic damage

was caused by the passage of a small missile.

Experience in World War II soon showed that any wound of the liver that

warranted exploration also required drainage. A wound too small to demand

drainage was almost never encountered. It is quite true that bile did not drain

after operation in some cases, but there were no criteria by which the injuries

in which this would happen could be identified at operation. The size of the

missile was not the deciding factor. If a small missile cut across a main bile

passage, drainage was more profuse than it might be after a more superficial

hepatic wound of greater extent. The larger bile radicles were frequently involved in wounds that looked innocent.

If drainage was omitted and infection developed, the resulting draining

sinus often took weeks to close. In other cases, the diaphragmatic repair broke

down, particularly if the perforation was over the bare area of the liver over

which there is no peritoneum. The pooled blood and necrotic material from

the damaged liver readily broke through the unfortified diaphragmatic suture

line, The resulting biliary pleura! fistulas were difficult to treat, and there was

more than a casual relation between them and pleura! empyemas.

The use of gauze packs was abandoned early in the war as both inefficient

and hazardous. They gave rise to subphrenic, subhepatic, or pelvic collections

of bile, often with associated abscess formation. Since the diaphragm was

perforated in all thoracoabdominal wounds, bile and exuded fluids, whose external discharge was prevented by the pack in the liver, tended to force their

way through the sutured diaphragmatic wound, no matter what the technique

of suture, with resulting biliary fistulas and bile empyemas. In some instances,

the thoracotomy incision broke down, and pleurocutaneous fistulas developed.
THORACOABDOMINAL WOUNDS 119

In two cases, in which the lung was adherent to the suture line in the diaphragm,

a serious problem was created when the bile eroded into a bronchus.

Other disadvantages connected with the use of gauze packs concerned their

removal, which was usually painful and was often followed by secondary

hemorrhage. In one such case in the experience of the 2d Auxiliary Surgical

Group, the granulation tissue that had invaded the meshes of the gauze bled so

profusely when the pack was removed that the patient was exsanguinated

before surgical intervention could be undertaken. Autopsy showed vascularization of the liver bed as a reaction to the presence of the pack.

Complications associated with the use of gauze packs were so numerous

and so troublesome that their use was eventually discontinued, and Penrose

drains Mere substituted for them. These drains, however, were satisfactory

only when the drainage incision was of adequate size not only on the surface

but through all layers of the drainage tract. It was also essential that they

be placed under direct vision when the abdomen was still open.

Adequate drainage implied (he proper placing of two or three large, soft

rubber drains to the site of the liver damage through an adequate anterolateral

subcostal incision. The incision was not adequate unless it was at least 3 inches

long. A tract was established extraperitoneally by blunt dissection until the

upper surface of the liver was reached; then the peritoneum was broken

through. The drains were placed precisely, under direct vision, before the

diaphragm was closed. Often both anterior and posterior drainage was desirable. Drains to the liver were never brought to the surface through the

thoracotomy incision or the laparotomy incision. This would have been an

invitation to wound infection and disruption.

There was a significant reduction in the complications caused by inadequate

drainage of wounds of the liver as the principles of drainage became more

clearly understood and the proper techniques were put into effect. Constant

emphasis upon both principles and practices was, however, necessary throughout the war.

Closure of the Diaphragm

The rent in the diaphragm was repaired as securely as possible to forestall

the development of bile empyema on the right side and of diaphragmatic

hernias, which were more of a threat on the left than on the right side. When

thoracotomy and laparotomy had been done as separate procedures, the diaphragm was preferably repaired from above, through the thoracotomy. Closure from below was much more difficult and much less satisfactory.

The anesthesiologist had much to do with the ease with which the diaphragm was closed. If he initiated a period of controlled respiration, thus

securing complete diaphragmatic relaxation and immobility, closure was

greatly facilitated. Relaxation was particularly important when the closure

had to be effected in a site that would not have been the site of election : in war

wounds, the surgeon had no choice.
120 THORACIC SURGERY

Several techniques were used to close the diaphragm, a 2-hiyer closure

being generally regarded as most satisfactory. It was accomplished either by

imbrication of 2 cm. of diaphragmatic tissue or by simple approximation of the

wound edges, reinforced by a second layer of inverting mattress sutures.

Neither of these techniques was practical through an abdominal approach.

Crushing of the phrenic nerve was practiced only when there had been

actual loss of muscle tissue, so that closure under tension would otherwise be

necessary.

Silk or cotton sutures were used, sometimes combined with chromic catgut.

Silk was used in ?>7?> of the 636 cases in which 2d Auxiliary Surgical Group

records have information, on this point, Sutures were always interrupted.

Special techniques were necessary for special wounds. An apparent defect

in the lateral costal margin of the diaphragm, which was the result of contraction or avulsion after severance of its attachments, was corrected by suturing

the diaphragm to an intercostal muscle one or more spaces higher than its

original attachment, Eeattachment was important, for the original site of

attachment was usually in the area of the chest wall wound, with its accompanying fractures, and this structure was no longer stable enough to permit efficient

diaphragmatic action.

"When the diaphragmatic crura had been torn from the vertebral column,

the first layer of sutures had to be passed through the superior surface of the

liver. A sufficient number of these sutures always held to fix the liver against

the undersurface of the diaphragm and thus prevent herniation.

Pleural Lavage

Before the chest wall was closed, all blood was suctioned out of the hemithorax. and it was adequately flushed with physiologic salt solution (vol. I).

This measure was particularly important if there had been soiling of the cavity

by gastric or intestinal contents.

Drainage

"Whether to institute drainage of the pleural space at operation or to rely

upon keeping it empty after operation by thoracentesis was a matter of prime

importance in securing reexpansion of the lung. The decision depended upon

a number of considerations, including the extent of pulmonary damage; the

magnitude of the laceration in the diaphragm; the size of the defect in the chest

wall; and, most important, whether or not the pleura had been grossly contaminated through the diaphragm from a perforated abdominal viscus.

Unless the defect in the thoracic wall was small, pulmonary and diaphragmatic injuries minimal, and gross contamination of the pleural and

peritoneal cavities absent, it was not safe to omit water-seal intercostal drainage

and to rely upon postoperative thoracentesis to keep the pleural cavity free of

blood and air. When water-seal drainage was employed, the chances of pleural
TIIÜKACOABDOHINAL WOUNDS 121

infection were reduced, and, if if did occur, the process was limited and localized

because there was no plenral dead space.

According to the records, closed water-trap intercostal drainage was instituted in 326 of the 903 thoracoabclomiiial injuries cared for by teams of the

2d Auxiliary Surgical Group. The practice was to use either a large fenestrated catheter or a tube of equal caliber; both were rigid enough not to collapse.

The site of drainage was a separate intercostal stab wound, usually in the

posterolateral or lateral aspect of the lower chest, A small additional catheter

was sometimes placed in the second interspace anteriorly, for the escape of air

trapped in the upper pleural cavity.

Closure of the Chest Wall

Closure of the thoracic cage was accomplished by approximation of adjacent ribs or of the intercostal musculature, depending upon whether thoracotomy had been performed through the bed of a rib or through an intercostal

space. If there were large defects in the thoracic wall, contiguous musculature

was utilized in layers. In closing the posterior aspect of the pleural incision,

it was often useful to pull the paraspinalis muscle over the suture line for

additional reinforcement. The muscular layer was always closed, but the

subcutaneous tissue and skin were usually left open for subsequent closure.

SPECIAL SURGICAL CONSIDERATIONS

Special surgical conditions in the management of thoracoabclomiiial

wounds depended upon (1) which side they were located, and (2) whether they

were penetrating or perforating.

Right-Sided Wounds

Perforating wounds.—When the wound on the right side was low in the

costal margin or in the region of the tenth, eleventh, or twelfth ribs posteriorly,

possible injury of the gallbladder, liver, duodenum, colon, and kidney had to

be borne in mind. Exploration by the transdiaphragmatic route was often

not satisfactory in injuries in these locations because the liver blocked vision

and prevented adequate exploration.

Debridement of the wounds of entrance and exit and investigation of the

status of the diaphragm through a traumatic thoracotomy sometimes revealed

that only the diaphragm and liver, or sometimes the kidney, had been damaged.

If the thoracotomy was as low as the tenth interspace posteriorly, the liver

could be drained or the kidney sutured or removed through the diaphragm.

Wounds of the diaphragm no higher than the eighth interspace and no

farther posterior than the posterior axillary line could be exposed and sutured

from within the abdomen. The condition of the patient determined whether

lacerations of the diaphragm in other areas should be repaired at this time.
122 THORACIC SURGERY

Failure to repair a laceration of the diaphragm might lead to a biliary pleural

fistula, but the possibility of this complication was not of major importance in

a patient in such poor condition that he could not tolerate further surgery.

Early surgical intervention "was imperative when the right lobe of the liver

continued to bleed into the pleural cavity or when the spleen lay shattered in

the left pleural cavity. The situation was evaluated on the basis of the location

of the wound of entry, the position of the fragment, and the lack of response

to shock therapy. It was often necessary to operate without delay in spite of

persistent hypotension.

It was also possible to drain a wound of the liver through a traumatic

thoracotomy in this location. The most satisfactory plan was to lay Penrose

drains over the rent in the liver and exteriorize them subcostally by breaking

through the lateral reflection of peritoneum over the right lobe. Whatever

the technique used, drainage was essential.

When there was no urgent indication for laparotomy before thoracotomy,

the first attention was given to the chest wound. After debridement, closure

of the chest wall, insertion of an intercostal tube, and aspiration of all blood

and air in the pleural cavity, it was surprising to find how often the patient's

condition had improved and how much better he tolerated extensive intraabdominal surgery. The intercostal tube was drained into a water-trap bottle,

and it was thus possible to check on the amount of hepatic bleeding. The

drainage of blood into the pleural cavity, which would otherwise have occurred,

might have considerably lowered the already impaired vital capacity by the

time laparotomy was concluded.

An extrapleural approach was used in an occasional thoracoabclominal

injury low on the right side posteriorly, but only if the thoracic injury was not

severe and if it was quite certain that the liver was the only abdominal organ

injured. The eleventh or twelfth rib was resected, and the reflection of the

pleura was dissected up. The pleural defect, being thus exposed, was then

repaired, after which, the liver was approached either through the perforation

in the diaphragm made by the missile or through the bed of the resected rib.

The operation was performed exactly as drainage for a subphrenic abscess

would be instituted. In selected cases, this was a safe and simple way of

draining wounds of the liver.

Penetrating wounds.—When a penetrating wound was on the right side,

it was necessary to investigate whether the missile had passed through the

right lobe of the liver or had entered the peritoneal cavity. As a general rule

the laparotomy approach was best when roentgenologic examination showed

the missile to be in the peritoneal cavity. If roentgenologic examination indicated that it had stopped in the liver, the procedure was the same as for rightsided perforating wounds; that is, drainage of the suprahepatic space and

repair of the diaphragm. If the fragment was readily accessible, it was removed, but protracted exploration for a buried intrahepatic foreign body was

not wise, for it often resulted in considerable hemorrhage. Drainage, as al-
THORACOABPOMINAL WOUNDS 123

ready pointed out (p. 118), was mandatory to guard against subphrenic space

infection and bile empyema.

Left-Sided Wounds

Perforating wounds.—Possible injury to the left diaphragm was always

in itself a sufficient indication for thoracotomy. It was a simple matter, in the

process of handling a sucking wound, to enlarge the wound and determine the

status of the diaphragm. Since the chest wall is relatively thin in the lower

thoracic cage, most wounds were sucking.

Penetrating wounds.—Accurate localization of the missile was important

in left-sided penetrating wounds in order to determine the surgical approach.

Any damage done to intraperitoneal organs by a missile that entered the left

upper quadrant of the abdomen and remained in it could easily be reached and

remedied through a transdiaphragmatic approach, with greater technical ease,

in fact, than was possible at laparotomy. If, however, the missile had passed

into any other quadrant of the abdomen, laparotomy was necessary.

The left transdiaphragmatic approach had many technical advantages.

Through it the following procedures (fig. 37) were readily performed:

Splenectomy; exploration and repair of the entire stomach from the esophago-

<rastric junction to the duodenum; examination and mobilization of the colon

from the hepatic flexure to the first portion of the sigmoid loop; examination

of the hepatic flexure itself, by blindly taking down the hepatocolic ligament;

repair of the colon, or subcostal or midline exteriorization of either loop, or

spur colostomy; examination of the small bowel from the ligament of Treitz to

within a few inches of the cecum, with resection or anastomosis as necessary;

and visualization and removal of the left kidney.

The abdominal approach was required for repair of wounds of the lower

ileum and cecum and of wounds of the colon from the hepatic flexure to the

upper sigmoid. These structures could not be adequately exposed through

the diaphragm.

The abdominal approach was also wisest when thoracic damage was so

slio-ht that no intrathoracic surgery was necessary. If the diaphragm could

be repaired from below in these cases, it was best not to enter another serous

cavity.

When the foreign body was in the left upper quadrant of the abdomen and

the wound of entrance was not sucking because the missile had traversed the

chest wall obliquely, it could be assumed that pleura! contamination had not

occurred. The decision then had to be made whether to perform laparotomy

or to employ a transthoracic approach, with the possible risk of pleural contamination. Many surgeons, on the basis of their personal experience, thought

the minimal risk justified because of the greater technical ease of repair of

intraperitoneal structures through this approach. The chances of infection

were small with an experienced surgeon, who bore in mind the importance of
124 THORACIC SURGERY

Fiona; 37.—Technique of transdiaphragmatic operation for left-sided thoraeoabdominal wound. A. Exposure of yustric perforations after excision of ninth rib and opening

of diaphragm. P. Field after splenectomy and closure of gastric perforations. G. Large

laceration in splenic llexure of colon. J). Subcostal exteriorizafion of splenic flexure as

loop (a), or spur colosfomy (b). In general, spur colosfomy was indicated when more

than half of the diameter of the bowel had been transected or when the wound was on the

mesenteric side and the blood supply was questionable.

a fully expanded lung-, a dry pleural cavity, and proper attention to pleura!

la vage and pulmonary expansion during closure of the thoracotomy.

The, following technique for left-sided thoracoabdominal wounds was

reported by Major Shefts and Captain Doud:

After the patient had been anesthetized, he, was placed on his right side,

with a folded blanket under the lower lateral aspect of the right costal margin.

A long strip of adhesive placed over the left hip and attached to the litter

anteriorly and posteriorly helped to hold the position. The left leg was flexed

at the hip and knee, and a pillow was placed below the knee. With the right

leg extended, the great, saphenous vein anterior to the medial malleolus or at

the middle border of the tibia was available if the administration of fluids

during the operation should prove necessary.
THORACOABDOillXAL WOUNDS 125

The rib chosen for resection varied with the habitus of the patient and

could be determined during debriclement of the wound. The best approach

was usually through the bed of the resected ninth rib. Resection stopped

short of the costal cartilage, to prevent the chondritis possible if contamination

should have occurred. When the diaphragm was opened, the perforating

wound was included in the incision whenever that was possible.

When it was necessary to explore the stomach, access to the posterior wall

was obtained by opening the gastrocolic omentum. For exposure of injuries

in the region of the esophagogastric junction, especially those on the side of

the lesser curvature, it was necessary to cut the left triangular ligament and

mobilize the left lobe of the liver.

When splenectomy was indicated, the lateral reflection of peritoneum over

the spleen was cut and the spleen delivered into the opening in the diaphragm.

The operation was technically easier if, after the spleen had been delivered, the

surgeon and his assistant changed sides. The assistant maintained the spleen

in position, with his left hand, while the surgeon passed his Angers beneath the

splenic pedicle. With this maneuver, the risk of injury to the greater curvature of the stomach and the tail of the pancreas was greatly decreased.

To expose the left kidney, the lateral peritoneal reflection of the upper

portion of the descending colon was cut, together with the lienocolic ligament,

and the, colon was retracted mesially. Xephrectomy was readily performed

through this approach.

POSTOPERATIVE CARE

In general, the postoperative care of the casualty with a thoracoabdominal

wound consisted of the care that would be given to him if he had a chest wound

only (vol. I) plus the management of an abdominal wound only. The routine

of the postoperative care of casualties with abdominal wounds is described in

detail in the volume of this series dealing with these wounds (1) and need not

be repeated here.

As a general rule, the absence of an abdominal incision made for a smoother

convalescence because abdominal discomfort and distention were less. Since he

was more comfortable, the patient was likely to be more willing to cooperate

in the measures necessary for promoting pulmonary expansion and keeping

the tracheobronchial tree clear.

Routine of Management

Measures directed to the respiratory system.—Before a patient with a

thoracoabdominal wound was removed from the operating table, the tracheobronchial tree had been cleared by aspiration or, if necessary, by bronchoscopy.

Bronchoscopy was employed in 110 of the 903 thoracoabdominal operations

done by surgeons of the 2d Auxiliary Surgical Group. If the patient showed

any cyanosis or respiratory difficulty, oxygen was administered at once.
126 THORACIC SURGERY

As soon as the patient was conscious, lie was given instructions for deep

breathing, frequent coughing, and turning from side to side. If he could not

or would not cough voluntarily, intercostal nerve block was carried out if it

had been omitted at operation.

Tracheal aspiration by catheter was also begun and was repeated as frequently as necessary as long as there were detectable amounts of blood or mucus

in the tracheobronchial tree. Often after the first tracheal aspiration, the

patient coughed voluntarily and without protest and kept the air passages clear

by his own efforts. If he could not or would not cooperate, or if catheter aspiration was unsatisfactory, bronchoscopy was resorted to promptly. It was performed after operation in 12 of the 903 thoracoabdominal wounds cared for

by members of the 2d Auxiliary Surgical Group. Atrophie gr. 1/100 was

given intravenously from 10 to 15 minutes before it was begun, to eliminate

the risk of vagovagal reflex. Bronchoscopy could be performed quickly and

easily on the ward because most members of thoracic surgical teams—surgeons,

assistant surgeons, and anesthesiologists—were all trained to perform it.

If the ward was busy and repeated observation was not practical, it was

the best plan to use an oral or nasal airway to maintain patency of the respiratory passages. At least one thoracoabdominal casualty is known to have died

of strangulation 3 hours after operation because this precaution was omitted

on a busy postoperative ward.

Replacement therapy.—Replacement therapy was continued after operation according to the indications. The amount of blood and plasma administered depended upon the hemoglobin, hematocrit, and serum protein

determinations. Between 2,000 and 3,000 cc. of 5 percent glucose in physiologic

salt solution was given daily. This amount was not usually exceeded because

it was still possible to overload the circulation and produce pulmonary edema.

Gastrointestinal decompression.—All patients with thoracoabdominal

wounds were treated by nasal intubation and gastric siphonage for 3 or 4 clays

after operation, the removal of the tube depending upon the time at which

satisfactory peristalsis was reestablished. The use of the tube beyond this

period was undesirable, for it might mask an intestinal obstruction and delay

its recognition and correction. An accurate record of the daily intake and

output was necessary during the period in which nasogastric suction was in use.

General measures.—If morphine was indicated for pain, it was given in

small doses, preferably gr. % and never more than gr. 14.

Patients were encouraged to get out of bed promptly if other wounds did

not contraindicate ambulation. If drainage had been instituted, ambulation

usually had to be delayed until the water-seal catheter was removed, but these

patients were encouraged to sit on the side of their beds.

The sulfonamides and penicillin were used according to the routine described for thoracic wounds (vol. I).

Vitamins B and C were given routinely in the postoperative period to

improve the nutritional status.
THORACOABDOMINAL WOUNDS 127

The roentgenograms ordinarily taken in chest injuries 4 or 5 clays after

operation were usually deferred until after the first week in thoracoabdominal

wounds. Clinical signs provided a satisfactory guide to management.

Drainage

The care of water-trap drainage in the postoperative period required constant vigilance on the part of the surgeon and a thorough knowledge of the

method plus conscientious attention on the part of the nursing and other staff

members of the forward hospital. Serious errors might result when untrained

personnel were entrusted with this phase of the patient's care.

The catheter was connected with the water-seal bottle as soon as the patient

was returned to the ward. If two tubes were used and penicillin had been left

in the pleural cavity, the posterolateral tube was kept clamped for 3 to 4 hours,

to give the penicillin time for bacteriostatic action. The patient was watched

closely and the tube was undamped immediately if pneumothorax or hemothorax seemed to be developing.

The water-seal bottle was kept at least 18 inches below the most dependent

part of the pleura. The tube was clamped off whenever the bottle had to be

emptied. It was the general practice to continue water-trap intercostal tube

drainage for 48 to 72 hours unless the tube became sealed off earlier; this sometimes occurred within 24 hours.

After the tube had been removed, and earlier if drainage had not been

instituted, aspiration of blood and air from the chest was carried out as indicated. Daily aspirations were sometimes necessary. Often a pocket of air

was evident anteriorly, even when drainage had been instituted by lateral or

posterolateral intercostal drainage. It was aspirated at once.

The proper removal of drains down to the liver was as important as their

initial placement, They were gradually shortened, usually beginning on the

fourth or fifth day. Manipulations had to be cautious and gentle. If the

drains were withdrawn too far and too fast, fluid collections were likely to

become pocketed in the hepatic region.

The amount of drainage through tubes placed clown to the liver was generally, though not always, related to the amount of hepatic damage. The period

of drainage was unpredictable, but it was seldom shorter than from 10 to 12

clays, which meant that the final removal of drainage tubes was usually the

responsibility of the surgeon in the base hospital.

MANAGEMENT IN BASE HOSPITALS

Of the patients who survived to reach base hospitals after surgery for

thoracoabdominal wounds, about half would have had involvement on the left

side and would have undergone, variously, splenectomy; repair of gastric

lacerations; exteriorization of a segment of the colon, usually the splenic flexure
V2b THORACIC SURGERY

or descending colon: nephrectomy in a small number of cases; or various combinations of these procedures.

Of the patients with right-sided injuries, the majority would have had

injuries of the liver as the only intraperitoneal injury. The remaining patients

with injuries on this side would have had thoraeotomy with inspection of the

abdomen, repair of the diaphragm, and laparotomy to deal with injuries inaccessible from the right hemithorax.

Except for the closure of traumatic wounds and of elective incisions in

which the skin and subcutaneous tissues had been left open, the chief responsibility of surgeons in base hospitals in respect to thoracoabdominal wounds was

the management, and sometimes the closure, of colostomies and the management of complications.

Management of Colostomies

The management of colostomies in thoracoabdominal injuries was the

responsibility of general surgeons in base hospitals. In many cases, perhaps

most cases, the patient had recovered entirely from his chest injuries long before

the closure of his colostomy was undertaken. Many patients with thoracoabdominal injuries had to be evacuated to the Zone of Interior because the

colostomy could not be closed within the permitted holding period of the theater

or because, for other reasons, closure could not be attempted overseas.

There was no standard surgical technique for the management of wounds of

the colon in the Mediterranean theater, but all the techniques employed were

based on three general principles (1) :

1. Exteriorization of the wounded segment of bowel to prevent intraperitoneal leakage at the suture line. The damaged exteriorized segment could

be used as the site of colostomy on appropriate indications.

•2. Diversion of the fecal stream away from wounds of the distal or lower

colon and rectum. Colostomy was always performed for perforation of the

rectum and was supplemented by adequate posterior drainage through the

fascia propria.

o. Incomplete diversion of the fecal stream, which was a temporary measure, designed for purposes of decompression as well as to bring the bowel to

the surface, so that a diversional colostomy could be performed.

As might be expected, when so many different surgeons had operated on

so many patients under such widely different circumstances, with only principles to guide them, the colostomies that had to be closed represented every

known technique. Closure therefore had to be accomplished by a corresponding

variety of techniques. Both intraperitoneal and extraperitoneal methods were

found satisfactory. Careful preoperative preparation was a criterion of

success.

Techniques of the closure of colostomies and the management of complications associated with them are presented in detail in the volume on general surgery devoted to abdominal injuries (?).
TIIORACOABDOMIXAL- WOUNDS 129

Complications

As might be expected in the circumstances of war, the records of complications of wounds were always incomplete and were particularly fragmentary in

respect to (he Jess severe and nonfatal types. Many postoperative processes

which in civilian practice would be regarded as complications were so frequent

in battle wounds that the)- came to be accepted as routine and were not made a

matter of record.

These, statements are all applicable to the 903 thoracoabdominal wounds

cared for by the 2d Auxiliary Surgical Group. In 529 instances, the records

bear no indication that complications occurred, which naturally is incredible.

There is only one recorded case, for instance, of postoperative pulmonary edema.

The largest numbers of complications were recorded for atelectasis, 21 cases;

empvema, 19 cases, 2 of which where associated with bronchopleural fistula;

subphrenic abscess, 15 cases; and pneumonia, 12 cases. Ten disruptions of the

abdominal wound were recorded, in three instances with evisceration.

Postoperative complications were remarkably few, considering the character of the wounds, but individual surgical experiences often included more

than these presumably total figures indicate. Maj. Thomas H. Burford, MC,

for instance, in 98 lacerations of the liver treated at base hospitals, collected

14 subphrenic abscesses (fig. 38), 5 bile empyemas, and 6 iutrahepatic abscesses

(fig. 39).

Eight-sided thoracoabdominal injuries gave rise to a higher percentage

of complications than left-sided injuries because of the almost universal involvement of the liver on this side. It was estimated thattransdiaphragmatic biliary

fistulas, with bile empyema, developed in about 3 percent of the lacerations of

the liver in right-sided wounds. The incidence of hepatic abscesses was put

at about 1 percent.

Almost without exception, patients with left-sided injuries did well if they

survived the first week. Complications arising within the abdomen were significantly less than on the right side, though an occasional left-sided subphrenic

abscess required drainage.

Bile empyema.—Bile empyema resulting from the intrapleural, transdiaphragmatic drainage of bile was always serious. The complication was not

usually lethal, but it invariably showed a troublesome predilection toward

chronicity, which was attributed to the presence of bile in the pleural cavity.

Attempts at decorticatioii of the lung, with excision of the fistula and tight

diaphragmatic repair, failed consistently when they were undertaken as late as

6 or S weeks after injury. At this stage, it seemed impossible to achieve complete pulmonary immobilization and total pulmonary reexpansion. On the

other hand, early surgical attack, within 3 or i weeks after injury, gave gratifying results (p. 130). An important phase of the operation was the provision

of adequate extrapleural, extraperitoneal drainage for the bile leakage. This

was accomplished by placing the rubber tissue drains exactly at the point of
130 THORACIC SURGERY

FIGURE 38.—Thoracoabdominal wound requiring later

drainage of anterior subphrenic abscess following laceration of liver.

hepatic injury while the diaphragm was still open and bringing them out

through a generous subcostal wound.

Subphrenic abscess.—Subphrenic abscesses were almost universally of the

anterior type and most frequently developed from an inadequately drained

transdiaphragmatic abscess of the liver (fig. 40). They were treated by adequate drainage, which occasionally necessitated resection of a segment of the

tenth rib below the pleural reflection. Most patients showed satisfactory progress toward healing of the underlying biliary fistula by the time they were

evacuated to the Zone of Interior. In one instance, a left-sided subphrenic

abscess ruptured through into the left lower lobe bronchus. Adequate drainage

below the diaphragm resulted in prompt and complete cure.

In an occasional case, a bile empyema and a subphrenic abscess coexisted:

Case 1.—This patient sustained a penetrating shell-fragment wound of the right chest

on 14 April 1045. Exploratory thoraeotomy on the same day revealed a penetrating wound

of the right half of the diaphragm and a laceration of the liver. Subcostal drainage was

instituted, and the diaphragm was closed with interrupted cotton sutures. The immediate

postoperative course was uneventful. The subcostal drains were loosened on the fourth

postoperative day and removed on the seventh day.
THORACOAHDOAUXAL WOUNDS 131

V

FIGURE 30.—Thoracoabdominal wound requiring later drainage of large

intrahepatic abscess.

When the patient was received in the chest center at the 70th General Hospital,

Pistoia, Italy, the following day, there was considerable bile-stained fluid in the right

chest. The fluid rapidly became purulent and showed persistently large percentages of bile.

Later, roentgcnologic examination revealed a right subphrenie abscess (fig. 41A).

In preparation for surgery, the patient was given 1,500 cc. of blood in 48 hours, which

restored the hematocrit value to 40. He was also given penicillin systemically. Exploration on 28 April, 2 weeks after injury, revealed a large subphrenie abscess and an extensive

bile empyema. The one-stage operation performed consisted of drainage of the subphrenie

abscess, decortication of the lung, excision of the fistula, and closure of the diaphragm

with interrupted silk sutures. Decortication was accomplished without difficulty, and

pulmonary reexpansion was prompt and complete. The fistulous opening in the diaphragm,

at the site of the previous repair, was excised. With the diaphragm open, the cluster of

rubber tissue drains that had previously been placed were carried down to the wound in

the liver. The diaphragm was closed in two layers, with interrupted sutures of fine silk.

The chest was closed tightly after irrigation of the pleural cavity with physiologic salt solution and the introduction of anterior and posterior intercostal catheters. Penicillin (25,000

units) was instilled into the pleural cavity and left in situ for 6 hours.

The wound healed promptly (fig. 41P»), and recovery was uncomplicated and complete

(fig. 41C).

Other complications.—Bronchobiliary fistulas were infrequent. One patient with this complication died of unexplained, massive retroperitoneal

hemorrhage while he was being prepared for surgery.

Complications of left-sided thoracoabdominal wounds were sometimes

bizarre. In one instance, a soldier with a previously unrecognized congenital

diaphragmatic hernia received a chest wound. The colon was perforated, and

what amounted to a traumatic colostomy developed; 3 clays after wounding,
132 THORACIC SURGERY

B

FIGURE 40.—Management of subphrenie abscess

secondary to laceration of liver. A. Posteroanterior roentgenogram showing abscess on right.

B. Detail posteroanterior roentgenogram showing

fluid level, air cap, and elevation of right hemidiaphragm.
THORACOABDOMINAL WOUNDS

c

1ÜGU1SE 40.—Continued. C. Lateral roentgenog'i'aii! showing abscess in characteristic anterior

position.

feccs were found pouring- out through the broken-down tlioraeotomy wound.

Two patients were observed with gastropleural fistulas. In each instance,

the gastric repair had broken down and had caused the breakdown of the

diaphragmatic repair. Both fistulas were difficult, to close because the skin was

so badly excoriated from irritating gastric secretions.

An extremely troublesome complication, which fortunately was uncommon,

was the so-called plastic type of peritonitis. Presumably, it was caused by

the slow leakage of bile into the general peritoneal cavity. The plastic, nonpurulent exudate that resulted matted the loops of intestine together and gave

rise to intermittent bouts of partial intestinal obstruction. Prompt decompression by the TVangensteen or Miller-Abbott technique was the usual treatment.

Operation was required only in an occasional case.

CASE HISTORIES

The following case histories are illustrative of various aspects of thoracoabdominal wounds:

Case 2.—This soldier was operated on in a field hospital, under endotraeheal ether

anesthesia. H hours after sustaining a severe perforating gunshot wound of the left chest,

with abdominal involvement. The chest was entered through a left-sided tlioraeotomy; an

S-inch segment of the ninth rib was resected.

The chest cavity contained the entire stomach, which was tremendously dilated; a

portion of the jejunum; the omentum ; the transverse colon with the splenic flexure; and

the spleen. The stomach, jejunum, colon, and kidney were found to be intact. The badly

lacerated spleen was removed. Insertion of a stomach tube reduced the stomach to 40

percent of its original size. The left gastroepiploic artery, which was torn near its termination, was ligated. A tear in the lesser omentum was repaired. After the herniated

746-941v—65 11
13-1 THORACIC SURGERY

-m-

"it

A

"Wh

.%fe

'^I§§fl'»

B

FIGTJKE 41.—Coexistent bile empyema and subiihrenic abscess. A. Posteroanterior roentgenogram showing right-sided snbphrenie abscess and bile empyema.

B. Same, 10 days after one-stage operation consisting of thoracotomy, drainage

of snbphrenie abscess, decortication of lung, and closure of biliary fistula in

diaphragm. C. Patient 1 week after operation.
THORACOABDOJIINAL WOUNDS 135

organs were replaced in the peritoneal cavity, the diaphragm was closed in two layers with

interrupted silk sutures. The tip of the lower lobe of the left lung, which was badly torn

and bleeding, was resected, and the wound sutured with fine catgut on a swaged needle.

After an intercostal catheter was inserted, closure was effected with pericostal sutures

and suture of the muscle layers. The patient was evacuated to a base hospital on the

12th day in excellent condition.

Comment.—This case history typifies the multiple character of left thoraeoabdomina]

injuries because of the close proximity of the organs in the left upper quadrant of the

abdomen to each other. The history also demonstrates their ready accessibility through a

transthoracic approach. When the diaphragm is opened, they actually rise into the

pleural cavity.

Case 3.—This soldier sustained a penetrating shell-fragment wound of the tenth left

interspace in the posterior axillary line. The wound was explored at a forward hospital,

which came under shellfiro during the operation. Closure was therefore hurriedly effected

after suture of the diaphragm. When the casualty was received at an evacuation hospital

24 hours later, his record contained a note from the forward surgeon that he "thought a

laparotomy should be done." The man was in great pain, and his abdomen was considerably

distended.

When the abdomen was opened through a left rectus incision, the peritoneal cavity

contained fresh blood, but all viscera appeared intact.

Thirty-six hours after operation, the thoracotomy wound became erepifant and edematous, and a foul odor was noted. When the wound was explored, a typical clostridial

myositis of the superficial muscles was found. The muscles were already neerotic. Death

occurred 12 hours later. Autopsy confirmed the diagnosis of clostridial myositis of the

chest wall and also revealed a perforation of the splenic flexure of the colon.

Comment.—The injury of the retroperitoneal portion of the splenic flexure was not

identified at laparotomy in this case. It would probably have been found, and could have

easily been handled, had a transthoracic approach been employed.

Case 4.—This soldier was admitted to a field hospital with a rigid abdomen shortly

after sustaining a penetrating wound of the right lower chest. Thoracotomy was performed, with resection of the tenth rib, and a laceration of the lower lobe of the right

lung was sutured. The diaphragm was perforated and the liver lacerated; the missile lay

in the tear. Inspection of the duodenum, hepatic flexure, and kidney revealed no further

damage. The wound in the liver was drained subdiaphragmatically before the diaphragm

was closed with two layers of interrupted silk sutures. The patient was in good condition

when he was evacuated on the sixth postoperative day.

Comment.—This case is one of 17 right-sided thoraeoabdominal lesions, 12 of which

were handled satisfactorily by the transthoracic approach.

Case 5.—This soldier was received in a field hospital with a blood pressure of 90/50

mm. Hg and a pulse of 110, after having sustained a gunshot wound of the left chest and

abdomen. He had received 500 cc. of plasma before admission. No respiratory difficulty

was apparent, and breath sounds were present, though somewhat diminished on the left.

The abdomen was spastic and moderately tender. He complained of suprapubic pain.

The wound of entrance, which was 1.5 cm. in diameter, was in the seventh interspace

anteriorly, 2 inches from the midline. The ragged wound of exit, 7.5 cm. in diameter, was

in the ninth interspace, just medial to the posterior axillary line. Aspiration of the left

chest produced about 30 cc. of blood and a small amount of air.

After a plasma transfusion of 500 cc. had been given, a blood transfusion was started

and ether-oxygen anesthesia induced. A subcostal laparotomy incision was made. Exploration revealed approximately 800 cc. of blood, mixed with gastric contents, in the

peritoneal cavity. The stomach was greatly distended. The lesser peritoneal cavity was

not involved. The spleen was lacerated, and a perforating wound was found in the cardia.
136 THOIUCIC SUEGEBY

The wounds of entrance and exit in the eardia were closed in two layers with chromic

catgut by the inverting technique. When the spleen was delivered, a 0-cin. sucking laceration of the posterior portion of the diaphragm became evident. It was closed with difficulty

after the spleen had been removed. Another nonsneking laceration of the diaphragm was

easily repaired. The abdomen was closed in layers.

The patient's condition was not satisfactory at any time during the !)0-minute procedure,

and he died while the skin sutures were being inserted. At no time did the blood pressure

rise above !.)0/(i() mm. IIg, in spite of the continuous administration of blood, and there was

a gradual decrease in pressure during the last 30 minutes of the operation.

Comment.—The first error made in this case was failure to have an endotracheal tube

in place before the abdomen was opened. The large sucking perforation of the diaphragm

was not apparent until the lacerated spleen was delivered and its tamponade effect on the

diaphragm was lost. Except for the application of an ineffective gauze pack, the diaphragmatic laceration had to be ignored until splenectomy was completed. Most of the operating

time was spent in accomplishing a difficult diaphragmatic closure. The sudden collapse

of the left lung was more than an already shocked patient could tolerate. Had endotracheal anesthesia been used, with facilities for maintaining positive intrapulmonic pressure

during operation, pulmonary collapse would not have occurred. The major error of management was not to employ the transtboracic approach, through which the entire procedure

could have been carried out with a great reduction in risk.

EXPERIENCE OF THE 2D AUXILIARY SURGICAL GROUP

The World War II experience of the 2d Auxiliary Surgical Group in the

Mediterranean, theater included 903 thoraeoalxlominal wounds, 2-17 of which

were fatal. These wounds were encountered chiefly during 1944 and 1045, but

OS wounds, 25 of which were fatal, were observed in 1943. During- the same

1943-45 period, the teams of this group encountered 1,364 thoracic wounds.

Thoracoabdominal wounds thus accounted for almost 40 percent of all wounds

of the chest.

Certain data concerning these 903 thoracoabdominal wounds have been

cited in the preceding- pages. Additional data, and certain conclusions which

can be drawn from them, follow.

General Data

The great majority of these casualties were U.S. Army infantrymen, with

Wehrmacht, prisoners of war accounting for the next largest, group. The figures also cover some British and French, soldiers and a few civilian casualties.

The age factor was of little significance, as the great majority of the

patients were young, healthy males. In the 702 cases in which the aye was

recorded, there were only 4 patients over 40 years of age. There were 190

casualties 20 years of age and under; 297 in the 21- to 25-year group ; 176 in the

26- to 30-year group; and 95 in the 31- to 40-year group.

Artillery and mortar fire was responsible for 590 of the 903 wounds, and

rifle, machinegun, and pistol fire for 245. The remaining wounds were caused

by bombs, mines, and grenade fragments.
THORACOABDOMINAL WOUNDS 137

In 887 cases, the missiles entered the abdomen through the thorax. In the

other 66 cases, they entered the abdomen and then penetrated the diaphragm.

In 418 cases, the wounds were on the right side and in 119 on the left side. In

20 cases in which both diaphragms were perforated, the wound of entry was

on the right in 7 and on the left in 13. No information is available on this

point in the remaining 46 cases.

Timelag

There was no record of the timelag in 49 cases, 11 of which were fatal.

In the 854 cases in which information on this point is available, it varied from

less than an hour to more than 30 hours (table 8).

At first glance, the high mortality rate in the group in which the timelag was

shortest might seem to invalidate the concept that the earlier a casualty with

a thoracoabdominal wound could be operated on, the better were his chances.

It does not. The high rate reflects the fact that the nearer the frontline a field

hospital is set up, the more casualties will be brought to it who will die there

rather than on the battlefield. This was particularly true on the Anzio beachhead, when both field and evacuation hospitals were very far forward because

the sector occupied was too small for them to be placed farther back. On the

beachhead, one patient, died of an injury of the portal vein, and five died of

injuries of the vena cava, in hospitals. If the evacuation distance had been

longer, they would not have reached them alive.

There were 8 deaths in the 34 casualties who came to operation 30 hours or

more after wounding. Two had wounds of the liver, three wounds of the spleen,

and one a wound of the kidney. In the two remaining cases, the missile penetrated the peritoneal cavity without, damage to any viscera.

Surgical Approach

The transthoracic approach was used in 448 of these 903 thoracoabdominal

injuries (table, 9). In 86 patients in this group, surgery was limited to thoracotomy, exploration, removal of foreign bodies, or simple retroperitoneal

TABLE S.—Case fatality rate according to timelag in 854 thoracoabdominal injuries l

Timelag Cases Deaths Percent

To 6 hours

To 12 hours

221

400

122

54

23

34

64

9G

39

20

9

8

28. 9

24. 0

To 18 hours 31 9

To 24 hours __________

To 30 hours

Over 30 hours

37. 0

39. 1

23. 5

Total. _ _ _ 854 236 27. 6

1

In 49 of the 903 cases in this series, there was no record of the timelag. There were 31 fatalities in this group.
138 THORACIC SURGERY

TABLE 9.—Case fatality rate according to surgical procedure in 903 thoracoabdominal wounds

Procedure Percent

Transdiaphragmatic laparotomy

Laparotomy

Thoracotomy and laparotomy.

Laparotomy and thoracotomy

Transdiaphragmatic laparotomy and laparotomy

Thoracolaparotomy 1

Xo surgery

Death during surgery

Total

1

In this technique, the thoracic incision was extended onto the ahdomen over the chondral arch.

91 20. 3

77 38. 1

36 25. 0

26 35. 1

7 35. 0

3 50. 0

1 33. 3

6 100. 0

27.4

drainage. In the remaining 3G2 cases, the entire abdominal procedure, -which

involved surgery on 31 different combinations of organs, "was performed through

the chest incision.

In 202 other cases, the entire procedure was abdominal.

A comparison of the case fatality rates in the injuries handled by the transthoracic approach and those handled by the abdominal approach, 20.3 percent

versus 38.1 percent, might suggest the far greater superiority of the transthoracic approach. These data should not be so construed. The results in the

individual case depended upon the magnitude of the abdominal and thoracic

problems (table T). Generally speaking, however, the results were better if

the thoracotomy approach was used for perforating wounds in the upper zone

of the left diaphragm or penetrating wounds in which roentgenograms showed

that the missile lay within the area of the dome of the diaphragm.

Factors of Mortality

General considerations.—The gross case fatality rate for the 903 thoracoabdominal injuries cared for by surgeons of the 2d Auxiliary Surgical Group

was 27.4 percent (247 deaths). These figures are for first priority hospitals,

in which the postoperative stay, though it varied from a few days to as long

as 18 days, was usually from 7 to 10 days.

Conditions in theaters of operations made it extremely difficult to determine the end results of forward surgery. Reports from evacuation and base

hospitals were all to the effect that patients operated on in field hospitals did

well after they reached hospitals farther to the rear. It is probable, therefore,

that a more complete followup would not have materially altered the case

fatality rates in forward hospitals.

There was an interesting and probably significant decrease in the case fatality rates of thoracoabdominal injuries as time passed:

In 1943, there were 25 deaths in 68 cases, 36.8 percent.
THORACOABDOMINAL WOUNDS 139

Between January and June 1944, there were 84 deaths in 243 cases, 34.6

percent.

Between July and December 1944, there were 98 deaths in 392 cases, 25.0

percent.

Between January and the first week in May 1945, when the war ended,

there were 40 deaths in 200 cases, 20.0 percent.

The decreasing case fatality rate in the latter half of 1944 and 1945 coincided with the introduction of penicillin. Antibiotic therapy undoubtedly

played a part in the improvement. Another explanation of the improvement

is applicable to the first half of 1944, the establishment of a theater blood bank

and the increasingly liberal use of whole blood.

Surgeons in the theater, however, believed that the improvement in the

case fatality rate could reasonably be assumed to be a reflection of their greater

knowledge and experience in dealing with these wounds; a greater appreciation

of the implications of the thoracic component and the complications which

could arise from it; a greater facility on the part of individual surgeons and

anesthesiologists (the so-called learning curve) ; and a keener appreciation of,

and greater attention to, details of resuscitation and of preoperative and postoperative, care.

Effect of thoracic and abdominal components of wound.—When the

mediastinum was injured, the case fatality rate was 54 percent. Otherwise,

it was impossible to discover, from a study of these cases, exactly what effect

the chest component of the wound had, beyond the far-reaching influence of

cardiorespiratory disturbances that were not promptly corrected.

With these exceptions, there was no doubt that the most lethal part of the

wound was the abdominal component. The precise organs injured and the

number of injuries below the diaphragm were reflected in the mortality rates

(table 7). Wounds of hollow viscera carried a much higher rate than wounds

of solid viscera, though an occasional fatality was caused by an overlooked

wound of a solid viscus.

The number of organs injured also played an important role. Wounds of

five or more viscera were universally fatal. These subjects are discussed in

more detail in the volume in this series devoted to abdominal injuries (1).

Anatomic considerations.—The side on which the injury was located

played a part in the mortality rate, for anatomic reasons. The figures are as

follows:

Perforations of the right diaphragm, 435, with 103 deaths (23.6 percent).

Perforations of the left diaphragm, 448, with 136 deaths (30.8 percent).

Bilateral perforations, 20, with 8 deaths (40 percent).

Anatomic reasons are also connected with the case fatality rates for herniation of the abdominal viscera into the chest cavity. In the 5 instances of

evisceration into the right pleural cavity there were 2 deaths, against 13 deaths

in 35 herniations through the left diaphragm.
140 THORACIC SURGERY

Time of death.—The day of death was recorded in 234 of the 247 fatalities:

1. There were 154 fatalities in the first 48 hours, including- 49 deaths

on the operating- table (40 from shock, 4 from hemorrhage, 3 from atelectasis,

and 1 each from cardiac tamponade and vagovagal reflex during bronchoscopy). All but 13 of the 130 deaths from shock occurred within this period.

The case fatality rate could be directly related to the degree of shock in which

the casualties were received:

Xo signs of shock, 145 patients, 8 deaths (5.5 percent).

Mild shock, 75 patients, 10 deaths (13.0 percent).

Moderate shock, 174 patients, 31 deaths (17.5 percent).

Severe shock, 275 patients, 164 deaths (59.0 percent).

There is no record of the degree of shock in the remaining 234 cases, in

which there were 34 deaths (14.5 percent).

In addition to shock, chiefly clue to blood loss, deaths early in the postoperative period were caused by uncorrected (occasionally irreversible) disturbances of cardiorespiratory physiology, overwhelming contamination and

infection of the peritoneal and pleural cavities and retroperitoneal space, and

massive tissue destruction.

2. There were 28 deaths between the third and fifth days. Of these, 13

were due to renal failure, as evidenced by oliguria and anuria (vol. I) ; peritonitis and pneumonia were the next most frequent causes.

The 22 deaths from peritonitis occurred between the day of operation and

the 10th postoperative day. The fact that 17 had occurred by the end of the

third day is evidence of the catastrophic effect of the so-called contamination

type of peritoneal infection, with sudden, massive soiling of the cavity.

3. There were 10 deaths from pulmonary embolism, all between the day

of operation and the 11th postoperative day; 6 occurred within the first 72

hours.

Other occasional causes of death included missed perforations of hollow

viscera, mismatched blood, blast injury, mediastinitis, empyema, fat embolism,

pressure pneumothorax with broncbopleural fistula, liver death, clostriclial

myositis, disruption of the diaphragm, morphinism, and meningitis.

Associated wounds.—Wounds in other parts of the body accounted for

some of the 247 deaths in this series or played an important part in the fatality.

Of the 385 associated wounds. 101 were classified as mild, and the 34 deaths in

this group (21.1 percent) can probably be attributed entirely to the thoracoabdominal wounds. The same reasoning perhaps holds for the majority of

the 129 associated injuries of moderate severity, in which there were 33 deaths

(25.6 percent). In the 95 associated injuries classified as severe, there were

30 deaths (37.9 percent). There can be no doubt that in many instances in

this group the associated injuries played an important role, if not the major

role, in the fatality. Among these 95 severe associated wounds there were:

26 cord injuries, with 16 deaths.

7 brain injuries, with 1 death.
THORACOAB-DOMIXAL WOUNDS 141

15 fractures of the femur, with 4 deaths.

9 traumatic amputations, with ?> deaths.

8 other abdominal (not thoracoabdominal) wounds, with 4 deaths.

The influence of severe associated wounds is evident in a casualty cared

for by Maj. (later Lt. Col.) Eeeve H. Betts, MC. This was the only casualty

with a thoracoabdominal wound to die before operation in the 29 such injuries

handled by his team. This soldier had a right traumatic thoracotomy, a left

thoracoabdominal wound, a traumatic amputation of the right arm, and a severe wound of the right thigh. In spite of vigorous attempts at resuscitation,

including the administration of 500 cc. of plasma and 3,500 cc. of blood, his

blood pressure was never obtainable, and he died 5 hours after wounding.

It might be added that associated wounds, in addition to the part they

played in the case fatality rate of thoracoabdominal wounds, also played a

major role in their morbidity.'1

References

1. Medical Department, United States Army. Surgery in World War II. General

Surgery. Volume II. Washington: U.S. Government Printing Office, 1955.

2. Snyder, Howard E.: The Consultant in Surgery, 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, 1062, pp. 333-464.

4 The reader is referred to chapter XI (p. 441) for long-term followup studies on casualties with

thoracoabdominal wounds.

746-941-
Part II

COMPLICATIONS OF WOUNDS

OF THE CHEST
CHAPTER IV

Complications and Sequelae

Thomas H. Burford, M.D.

Except for two or three immediate complications, such as tension pneumothorax, hemorrhage, and acute gastric dilatation, almost any of the complications of wounds of the chest might occur at any time after wounding. It was

therefore necessary to be on the watch for them, and to try to forestall their

occurrence, at all times.

While the attempt to separate them chronologically is somewhat academic,

the complications of chest wounds may be divided, generally speaking, into

(1) early and (2) late or delayed complications as follows:

Early complications included tension pneumothorax, hemorrhage, acute

gastric dilatation, emphysema, pulmonary edema, atelectasis, hematoma of the

lung, bronchopleural fistula (which sometimes was persistent), wound disruption, clostridial myositis, and chylothorax.

Delayed complications included abscess of the lung, pneumonitis and pneumonia, chronic parietal sinuses, defects of the chest wall, adhesive pleuritis

(infolded lung), traumatic osteomyelitis, and abscess of the mediastinum.

The important sequelae of chest injuries in World War II were diaphragmatic hernia, hernia of the lung, and a group of residual symptoms, of which

pain and dyspnea were the most prominent.

TENSION PNEUMOTHORAX

General Considerations

Pathogenesis.—Tension or pressure pneumothorax might be of four

origins (figs. 42 and 43) :

1. It might result from a pulmonary laceration in which a tangential opening in the lung acted as a check valve, so that, during inspirations, gradually

increasing amounts of air were trapped in the pleural cavity. The flap of

lung prevented the escape of air into the bronchial tree on expiration. Most

tension, pneumothoraces were of this origin.

2. It might result from small perforating associated wounds of the subglottic larynx or the cervical trachea. In the latter type of wound, air dissected along the fascial planes to the mediastinum and might break into one

or both subcavities. Tension pneumothorax of this origin was infrequent.

145
146 THORACIC SURGERY

FIGTJISK 42.—Pathologic physiology of tension pneumothorax. A. Pneumothorax of moderate extent. As air

escapes into the pleural cavity, the affected lung collapses,

and there is moderate mediastinal shift to the unaffected

side. B. Tension Pneumothorax. The uninvolved lung, as

well as the involved lung, is now collapsed, as the result of

rnediastinal shift to the uninvolved side. Shock increases as

the result of collapse of the superior and inferior venae cavae,

and because of the decreased venous return to the heart

associated with the marked mediastinal shift.
COMPLICATIONS AND SEQUELAE 147

A

B

EICUKI; 4:!.—Tension Pneumothorax of various origins. A.

Tension pneumothorax resulting from laceration of cervical

Irachea and mediastinal pleura, showing: Laceration of cervical trachea (a), laceration of mertiastinal pleura (b). tension

Pneumothorax (c), collapsed lung (d), shift of heart (e), subcutaneous emphysema (f), and partial collapse of contralateral

lung (g). P>. Tension pneumothorax resulting from suckingwound of valvular typo, showing: Valvular sucking wound of

chest wall (a), tension pneumothorax (b), collapsed lung (c),

cardiac shift to intact side (d), and partial collapse of contralateral lung (e).
148 THORACIC SUEGEEY

,#

FIGURIO 43.—Continued. C Tension pneumothorax resulting

from pulmonary laceration following- packing of sucking wound,

showing: Sucking wound with airtight packing (a), laceration of lung, permitting egress of air into pleural cavity (b).

collapse of the lung (c), cardiac shift to intact side (d), and

partial collapse of contralateral lung (e).

3. It might result from the ingress of air through the thoracic wall in a

sucking wound.

i. It might follow the emergency closure of a sucking wound in forward

areas, without provision for release of trapped air or the continued escape of

air into the pleural cavity.

An occasional tension pneumothorax occurred during operation for

thoracoabdominal wounds (p. 103).

Incidence.—Tension pneumothorax as the result of trauma was encountered

only infrequently in forward hospitals, though it was somewhat more common

as a postoperative or posttherapeutie complication. Its infrequency is evident

in the statistics of the 2d Auxiliary Surgical Group. It was encountered by

this Group only 11 times in its 2,267 thoracic and thoracoabdominal injuries.

It is doubtful, furthermore, that all of these 11 cases were examples of true tension pneumothoraces, since the valvelike mechanism that produces it and that

permits easy ingress, but difficult egress, of air was not always found. In occasional cases in which air was found under more than normal pressure, or even

above atmospheric pressure, the explanation was usually either compression of

air by intrapleural bleeding or, most often, tbe irregular, splinting type of respiration that was the result of pain in the chest wall.
COMPLICATIONS AND SEQUELAE 149

The infrequency of pressure pneumothorax probably has several explanations :

1. The preponderance of shell-fragment wounds, which resulted in a preponderance of large defects of the chest wall. For physical reasons, air could

not be entrapped in the chest in such wounds.

2. The routine application of occlusive dressings tightly enough to end

the sucking or blowing effect of the open chest wound but not so tightly that a

tension pneumothorax was built up.

3. The almost routine use of a flapper-valve decompressive catheter in

collecting stations or battalion aid stations.

4. The excellent screening of inductees in World War II, as a result of

which preexistent restricting pleural adhesions, which were rather frequent in

World War I soldiers, were extremely uncommon.

The majority of tension pneumothoraces observed in World War II resulted

from continued leakage of air from the lacerated pulmonary parenchyma. If

such a laceration existed and was leaking air, closure of the external chest wound

converted the open pneumothorax into a progressive tension pneumothorax.

This type of tension pneumothorax was also uncommon, possibly becaiise bleeding from the pulmonary laceration usually stopped promptly and the hematoma

that surrounded the torn parenchyma produced a sufficient area of nonaeration

to limit the amount of air that, reached the pleural cavity until the laceration

was sealed over by natural processes.

Continued leakage of air occasionally had unusual explanations. A retained missile might offer a physical obstacle to natural closure of the air leak

in the lung (fig. 44), or there might, be a leak through a laceration in one of the

larger bronchi. Two unusual cases of tension pneumothorax were observed

by surgeons of the 2d Auxiliary Surgical Group :

In one case, the tension pneumothorax developed from a perforating wound

of the subglottic larynx : the air dissected the fascia! planes of the mediastinum

and perforated into the pleura. Tracheotomy was necessary to short circuit

the column of air.

In the other case, an instance of crushing injury, the patient sustained

wounds of the lower esophagus, mediastinum, diaphragm, and stomach, and the

air in the pleural cavity was swallowed air.

An occasional tension pneumothorax was of extreme degree (fig. 45).

That it could be survived was striking proof of the tremendous respiratory

reserve of the young, well-conditioned fighting men who made up the battle

casualties.

Clinical picture.—Extreme dyspnea was the most prominent symptom of

tension pneumothorax. The patient preferred to sit upright or semierect. His

worried, anxious expression indicated that he was fighting for breath.
150 THORACIC SURGERY

^^^""

I

B

FinntK 44.—Pressure (tension) pneumothorax. A. Posloroanterior roentgenogram showing pressure pneumolhorax of moderate degree with retained

foreign body. P. Same 24 hours later, showing prompt reexpansion of injured

lung. Leakage of air continued, however, and thoraeotomy 5 days after

wounding showed (hat I he presence of the missile offered a physical obstacle

to natural closure. It was lying in the periphery, only partly embedded in

the pulmonary parenchyma. The catheter functioned well, though it had been

introduced farther than was necessary. Operation was performed without difficulty on the totally equilibrated patient, and recovery was prompt.
COMPLICATIONS AND SEQUELAE 151

!?&*

FIGUEE 4.j.—Lateral roentgenogram showing extreme degree of pressure

Pneumothorax with mediastinal shift. This patient recovered without

complications after reduction of the tension pneumothorax.

Cyanosis, which might not be present originally, became increasingly prominent

as mediastinal shift caused interference with cardiac action. The veins of the

neck also became prominent, Physical examination revealed hyperresonance

of the involved hemithorax, with absence of breath sounds (the so-called silent

resonant chest) and a shift of the heart and mediastinum to the opposite side.

Management

The emergency management of tension pneumothorax has been discussed

under resuscitation (vol. I).

If emergency measures were not required (that is, if the compression of

the lung did not exceed 25 or 30 percent and if dyspnea were not a feature),

the practice was merely to observe the patient carefully for 10 to 14 days. In

most instances, pulmonary reexpansion had occurred by this time, and no

treatment was necessary.

In cases of any consequence, pneumothorax was best handled by the prompt

insertion of a water-seal intercostal catheter of sufficient size (80-36 F.) to

produce immediate decompression of the chest. As a rule, this procedure was

followed by prompt reexpansion of the lung (fig. 46), without which neither

resuscitation nor recovery could insure.
152 THORACIC SURGERY

FIGURE 46.—Management of tension pneumothorax. A.

Closed catheter drainage, with catheter high in pleura! cavity.

This is the decompression procedure of choice. B. Constant

decompression of chest with negative suction, which is required

when leakage of air is persistent. The addition of a second

bottle is important in this technique : A glass tube, open to the

air. passes through the third opening in the cork, and the amount

of suction varies with the distance this tube is under water.
COMPLICATIONS AND SEQUELAE 153

HEMORRHAGE

Incidence

There is surprisingly little discussion in the military literature of hemorrhage caused by wounds of the chest. The explanation is probably threefold:

1. Casualties with bleeding from one of the vessels in the pulmonary hilus

or from the other great vessels of the thorax or from the heart usually died on

the battlefield or in the battalion aid station. They seldom survived to reach

a field hospital.

2. Bleeding from other vessels of the chest was not usually a problem.

3. Another explanation of the infrequency of severe bleeding in chest

wounds was that the first effect of parenchyma! bleeding into the pleural cavity

was compression of the lung. In many instances, hemothorax had the

mechanical effect of ending the hemorrhage by compressing the blood vessels.

There were, of course, exceptions to the generalization that all casualties

with bleeding from the major thoracic vessels died promptly. In the

Mediterranean theater, survivals were recorded after lacerations of the azygos

and hemiazygos, and even after a laceration of the superior vena cava, but they

were most unusual.

Two casualties with vascular injuries of magnitude were observed by Maj.

(later Lt, Col.) Paul C. Samson, MC, in a field hospital. In the first case,

a laceration of the right innominate vein was controlled by packing, but death

followed a massive recurrence of the hemorrhage 24 hours later. The second

patient presented massive bleeding at the left apex, presumably from the subclavian vein. His condition was critical, but rapid reflection of the clavicle

permitted the blind placement of mass ligatures and control of the hemorrhage

before he became exsanguinated. Recovery ensued but was complicated by a

serious pleural infection.

Severe bleeding in chest wounds observed at field hospitals most often

arose from one of the systemic vessels, such as the intercostal, the pericardiophrenic, or the internal mammary vessels. The most serious hemorrhages occurred from the internal mammary and the intercostal vessels, from both of

which it was likely to be brisk. On the other hand, while complete division

of these or any other thoracic vessels might cause severe intrapleural hemorrhage, it was unusual to find active bleeding at operation, even if from 1,000 to

2,000 cc. of blood had previously been aspirated from the chest. The explanation was physiologic: The reduction in blood pressure caused by the blood loss

and the subsequent reduction in blood volume had allowed the vessels to retract

and become sealed off. The most frequent source of bleeding at operation was

an intercostal artery that had been incompletely divided and therefore was unable to retract.

The actual infrequency of serious bleeding in thoracic wounds is evident in

the analysis of 200 penetrating and perforating wounds of the chest, including
154 THORACIC SURGERY

55 tlioracoabclominal wounds, observed in forward hospitals by Maj. (later Lt.

Col.) Lawrence M. Shefts, MC, and Capt, (later Maj.) Ernest A. Doud, MC,

Active bleeding from the intercostal arteries was found at operation 10 times

and from the internal mammary arteries, from the mediastinal vessels, and

from the heart in 2 cases each. This is a combined frequency of 8 percent.

It had previously been the practice of these observers to expose the intercostal vessels routinely at operation, for fear of hemorrhage. They abandoned

the practice after finding in these 200 cases, 33 lacerations or transections of

these arteries in all of which bleeding had ceased by the time operation was

done. In this series, all of the bleeding vessels were found in one of two areas,

(1) the area extending from the origin of the vessel to the angle of the ribs or

(2) the area extending approximately 6 cm. from the lateral border of the

sternum.

In 4 of the 200 cases observed by Major Shefts and Captain Doud, bleeding

of considerable magnitude occurred from lacerations in the upper half of the

upper pulmonary lobes. It was readily controlled by suture. Hemorrhage of

similar degree was not observed from lacerations of the same extent in other

pulmonary lobes, probably because the injuries in the other lobes involved vessels of smaller size than the comparable lacerations in the upper lobes.

Diagnosis and Indications for Thoracotomy

Continued hemorrhage into the tracheobranchial tree was readily recognized by the reappearance of fresh blood after repeated attempts to clear the

airway. Otherwise, external evidences of bleeding were few; in chest wounds,

the most serious bleeding was usually internal.

It was not safe to make the diagnosis of intrathoracic bleeding solely on

the basis of the pulse rate, blood pressure, respiration, and general status. Some

patients with actively bleeding intercostal vessels remained in surprisingly good

condition.

The most reliable guides to the existence of continued serious hemorrhage

were:

1. Failure of the blood pressure to rise after apparently adequate

transfusion.

2. A fall in a blood pressure that had risen to relatively normal levels.

3. Keaccumulation of 1,200 to 2,000 cc. of blood in the pleural cavity

within 21 hours after the initial aspiration of similarly large amounts.

4. Persisting severe anemia, in spite of blood replacement, as determined

by serial hematocrit determinations.

5. Plotting of the probable course of the missile with reference to the

vascular supply.

It proved difficult to generalize on how much bleeding constituted lifeendangering thoracic hemorrhage. The fact that from 1,000 to 1,500 cc. of

blood could be aspirated from the pleural cavity within 12 to 18 hours after
COMPLICATIONS AND SEQUELAE 155

injury was not, in itself, an absolute index of lethal bleeding. Nearly all the

patients who had lost blood in these and even larger amounts responded

promptly to massive blood replacement, and subsequent aspirations produced

progressively smaller amounts of bloody fluid.

Decision for or against exploratory thoracotomy on the basis of the criteria

just listed proved entirely satisfactory during periods of relative quiet, when

casualties were admitted in small numbers and surgeons had time for deliberate

consideration and watchful delay. During rush periods, when they were confronted with large numbers of casualties, their judgment was often sorely tried.

Their decisions became more accurate in proportion to the number of casualties

they encountered.

The general policy was followed of exploring any injury in which there

was a reasonable doubt concerning the possibility of active intrathoracic hemorrhage. In the really urgent cases, in which procrastination would have been

disastrous, there was seldom any doubt of the need for surgery.

Management

The techniques employed at operation for intrapleural hemorrhage were

those ordinarily employed in vascular surgery. In hemorrhage from the internal mammary artery, it, was imperative that both ends of the damaged vessel

be ligated, since hemorrhage could occur from either end. If emergency access

to the great vessels proved necessary, it could be obtained at once by reflecting

the clavicle and cutting through the manubrium sterni obliquely with a Gigli's

saw. This technique, devised by Col. Johan Holtz, chief consultant in surgery

to the Norwegian Forces in the United Kingdom, was preferable to section of

the clavicle or to sternoclavicular disarticulation.

The prewar expectation that lobectomy would frequently be necessary in

parenchyma! lacerations, especially those extending into the hilus and involving

large vessels, was not fulfilled, nor was the expectation that total pneumonectomy might be necessary in some cases (p. 18).

The possibility of the postoperative recurrence of a preoperative intercostal hemorrhage had always to be kept in mind when the intercostal vessels

had not been exposed at operation. The experience of Major Shefts and Captain Doud (p. 153) showed that the policy of nonexposure was safe. There were

no deaths from any cause in the first 35 patients in whom, on the basis of their

previous experience, they did not expose the intercostal vessels at operation.

Case Histories

Case 1.—A casualty wounded by a high explosive shell fragment that perforated the

right upper chest had a sudden massive hemorrhage shortly after his admission to a field

hospital. Blood filled the entire trachea and the primary branches of the bronchus.

Bronchoscopy cleared the trachea only temporarily. Hemorrhage continued from the

orifice of the right upper lobe bronchus. The patient was taken to the operating room
156 THORACIC SURGERY

immediately. Hemorrhage could be controlled only by packing this orifice and holding the

packing in place by packing the entire right main stem bronchus. It was then possible to

perform a thoracotomy and suture the injuries in the bronchus and lung. The patient

made a good recovery and had a fully expanded lung 1 month later.

Comment.—As this case illustrates, massive hemorrhage was always a possibility in

chest injuries, infrequent though it might be. This patient's life was saved by his immediate transfer to the operating room and the bold and imaginative measures by which

bleeding was controlled.

Case 2.—This patient was admitted to a field hospital 5 hours after he had sustained

a penetrating wound of the left chest and penetrating wounds of the right upper arm and

left neck. The wound of entrance in the chest injury was in the left part of the neck.

Several attempts at aspiration of a large hemothorax were unsuccessful, and it was concluded that the blood had clotted. The wound of the neck was debrided, and the track

was explored in the area in which it ran superior to the first rib.

Aspiration was not attempted for the first 3 days after operation. On each of the

next r, days, from 400 to 500 ce. of blood was removed. On the 11th day, the yield was 000

cc. of thin, bloody fluid. During this time, the patient, received numerous transfusions.

On the 12th day after wounding, the patient suddenly went into severe shock. Neither

the blood pressure nor the radial pulse could be obtained. The respiration was slightly

labored, and the skin was cold and clammy. Breath sounds on the left side of the chest

were distant. The patient rallied after receiving 1,000 cc. of blood. Attempts at aspiration

of the left chest were not successful.

The following (13th) day, 400 cc. of blood-tinged fluid was aspirated. The pulse

ranged to 148. After the aspiration, under endotracheal anesthesia, a sickle-shaped incision was made, extending from the mid third of the clavicle to the fifth costosternal junction. The first rib was excised at the sternocartilaginous junction. As the pleural

cavity was entered, copious amounts of blood poured out. The second, third, and fourth

ribs were severed at the sternocartilaginous junction, and through the exposure thus

secured, it could be seen that the bleeding was in the region of the subclavian artery and

innominate vein. The bleeding point was compressed by the finger until it could be controlled by gross clamping and mass suture of the vessels at the apex of the chest. The

chest wall was closed with catgut sutures for the muscle and fascia and silk for the skin.

A catheter was inserted into the eighth intercostal space.

Although blood had been started in both ankles and the right arm as the operation was

begun, the blood pressure was imperceptible during most of the procedure. During the

operation and the immediate preoperative period, a total of 3.TOO cc. of blood was given.

An hour after operation, the blood pressure was 100/00 mm. Hg, and oxygen was discontinued. Four hours later, the blood pressure was 102/80 mm. Hg.

The postoperative course was without incident for the next 13 days. Then the hospital

blew down in a severe snowstorm, and this patient, along with 700 others, was evacuated

to another forward hospital, and 4 days later to a general hospital. When he was received

in the latter, the intercostal catheter was not draining, and he was dyspneie and distressed.

Several days later, a large drainage tube was inserted in the bed of the eighth rib, to drain

a well-established empyema. Recovery thereafter was uneventful.

Comment.—In this ease, the direction taken by the missile and the early clotting of

the hemothorax pointed to the possible laceration of a large blood vessel. In the absence

of shock and other evidence of gross bleeding, thoracotomy seemed to be contraindicated.

Subsequent events showed that it would have been the better procedure. The subclavian

artery and innominate vein had apparently been partially lacerated, and local infection

completed the severance 12 days after wounding. This patient's life was unquestionably

saved by the introduction of blood into three veins during the operation.
COMPLICATIONS AND SEQUELAE 157

ACUTE GASTRIC DILATATION

Acute gastric dilatation was a frequent occurrence in both thoracic and

thoracoabdominal wounds and was often sufficient to cause respiratory embarrassment. Its recognition was important before operation. Unless decompression was carried out, regurgitation would occur, and gastric contents might be

aspirated, with the usual serious consequence.

Eoutine decompression by the Mill er-Abbott or Wangensteen techniques

was carried out after operation in all thoracoabdominal wounds until all risk

of acute dilatation was past. The same method was used if this complication

developed, as it sometimes did, after surgery limited to the thorax.

EMPHYSEMA

Surgical emphysema was not frequent in World War II, probably because

of the low incidence of preexisting pleuropulmonary disease in U.S. soldiers.

It was of two types, superficial (subcutaneous) and mediastinal.

Subcutaneous Emphysema

The superficial variety of surgical emphysema resulted from penetration of

the lung by a missile or by indriven fragments of fractured ribs. In either type

of wounding, air escaped into the subcutaneous tissue (1) directly from the lung

if adhesions were present, or (2) indirectly, through the medium of an interposed pneumothorax. The trapped air then spread upward to involve the

tissues of the neck and face or downward to involve the abdominal wall.

Occasionally, the extremities were involved.

Diagnosis was readily established by the crackling sensation felt on palpation of the involved area. Koentgenograms confirmed the presence of air in the

tissues. Recognition was important because of the possible association of tension pneumothorax. The only condition which required differentiation was

clostridial myositis, which is also characterized by crepitation in the tissues.

Superficial emphysema seldom required any special treatment. Once the

opening in the pleura became sealed, which usually happened promptly, the air

in. the tissues was readily absorbed. If the pleural opening did not close and

the air in the tissues increased progressively, a needle was introduced into the

pleural cavity to permit the air to escape.

Mediastinal Emphysema

Mediastinal emphysema (fig. 47) was a much more serious condition than

subcutaneous emphysema, Air escaped into the mediastinum because of dam-
158 THORACIC SUBGEEY

\ .'t.

'C <:

FIGURE 47.—Schematic showing- of pathologic physiology of mediastinal emphysema. A. Leakage of air through penetrating

wound of trachea or bronchus, or rupture of these structures, finding its way (as shown by arrows) iirst into superior thoracic inlet

and then upward into neck and head and downward into trunk and

upper extremities. B. Tension pneumothorax, which may be

rapidly fatal, caused when air in mediastinal emphysema ruptures

the mediastinal pleura.
COMPLICATIONS AND SEQUELAE 159

i .'■■■' -

FIGURE 47.—Continued. C. Extensive

media stinal and subcutaneous emphysema.

This process, although it presents an

alarming picture, is compatible with life if

it is not accompanied by tension Pneumothorax.

f *

age to the extrapleural, intramediastinal segments of the tracheobronchial tree,

If it could escape into the pleural cavity, a tension pneumothorax developed.

If it had no route of escape, there was serious danger of compression of the

great vessels and even of the esophagus.

Diagnosis was easily made by palpation of the soft swelling in the suprasternal notch. It was confirmed by roentgenograms.

As a rule, decompressive intubation of the pleural cavity was sufficient for

relief of the condition (figs. 48 and 49). Tracheotomy was sometimes necessary.

Radical treatment was indicated only when the symptoms of compression were

severe enough to endanger life. In such cases, the swelling in the neck could

be incised, or, if this measure was not effective, cervical mediastinotomy could

be employed. So far as is known, this operation was not required in any patient

in the Mediterranean theater.
160 THORACIC SURGERY

WfiB

FIGT-RE 4S.—Management of mediastinal emphysema. A.

Decompression of air leak of moderate size by insertion of

Penrose drains through transverse incision in suprasternal

space. B. Tracheotomy in advanced mediastinal emphysema, to permit aspiration of secretions and facilitate administration of oxygen.
COMPLICATIONS AND SEQUELAE 161

FIGURE 4!).—Management of modiastinal emphysema. A. Open repair of

laceration of trachea, necessary when air leak is persistent: or is associated with

Pneumothorax not, controlled by closed suction drainage: Laceration of trachea

(a), esophagus (b). azygos vein (e), vagus nerve (d), and superior vena cava (e).

B. Insert showing detail of tracheal repair. Suture of laceration at right, angles

to long axis of trachea, to prevent obstruction is shown in (a). C. Reinforcement of repair wilh pedicled muscle or pleural graft.

PULMONARY EDEMA

Pulmonary edema was a possibility in all thoracic wounds and frequently

occurred with wounds in. other parts of the body. It, was most often associated

with, or caused by, one of the following- conditions :

1. Severe pulmonary contusions, in which it tended to appear early.

2. Dyspnea and anoxia, in. both of which, as Drinker and "Warren (1)

showed, pulmonary transudation is frequent.

:>. Too rapid administration of intravenous fluids, or the administration of

fluids in too large quantities.

4. Fat embolism, which most often was a complication of an associated

fracture.

5. Lower nephron nephrosis, a condition in with pulmonary edema seldom

appeared before the fifth day after wounding-.

The clinical manifestations of pulmonary edema chiefly took the form

of frothy pulmonary secretions in excessive amounts. If right heart failure
THORACIC SUKGERY

FIGURK 50.—Technique of intermittent positive pressure oxygen administration

in field and evacuation hospitals. A. Anesthetic machine with to-and-fro filter. B.

Anesthetic face mask, held over nose and mouth by rubber sling. C. Manual compression of bag .synchronous with each respiration (pressure 15-20 cm. ILO).

supervened, the symptoms and signs included: Hyperpnea, distention of the

veins of the neck, and falling pulse pressure and systolic pressure.

Since pulmonary edema was usually secondary to some other pathologic

process, which often was obscure itself, specific treatment was generally unsatisfactory and often failed entirely. The basis of therapy was an attempt

to increase oxygenation, and oxygen given through a mask, under positive

pressure (fig. 50), was sometimes distinctly beneficial. Repeated catheter suction was employed to remove the pulmonary secretions. If necessary, a small

catheter was left indwelling in the trachea, and oxygen was administered between aspirations. A few patients were benefited by atropine sulfate (gr.

1/100) by vein.

Right heart failure was treated by prompt venesection of from 500 to 750

cc. of blood or by the application of tourniquets (the so-called bloodless phlebotomy). It was difficult to distinguish from shock, but the differentiation had

to be made before either measure was instituted.
COMPLICATIONS AND SEQUELAE 163

FIGUKE 51.—Postoperative ateleetasis with complete collapse

of lung. Note trachea 1 and niediastinal shift.

ATELECTASIS

General Considerations

Massive pulmonary collapse as the result of trauma to the chest, as well as of

trauma to the abdomen, might involve all the lobes of one lung but more often

involved only one or two. The precise amount of trauma seemed relatively

insignificant. Collapse sometimes occurred from the pressure effects of bombs

or shells. In such cases, as well as in instances of direct trauma, contrecoup

collapse might occur, with only minor involvement of the homolateral side.

The frequent existence, before wounding, of bronchitis and other upper

respiratory infections favored the development of ateleetasis. Prolonged ether

anesthesia also encouraged its development.

Postoperative ateleetasis (fig. 51) was infrequent. In this variety, as well

as in the traumatic variety, the basic pathologic process was excessive fluid accumulations that completely obstructed a bronchus. The explanation for its

very low incidence was the routine and effective treatment of wet lung before

and after operation.
164 THORACIC SURGERY

Clinically, a patient with atelectasis presented a far greater degree of

dyspnea than might be expected from the collapse of a single lobe. Cyanosis,

though also more than might be expected, was not so prominent as dyspnea.

The trachea was deviated to the side of the collapse, and cardiac dislocation

toward the affected side was usual. A sudden rise of temperature, from normal

to 10:»° or 104° F., was typical. Physical examination of the chest revealed

the usual signs of a iionaerating lobe or lobes.

Management in Forward Hospitals

It was imperative that atelectasis be treated promptly and vigorously. Persistence of the collapse was likely to result in pulmonary consolidation. Mainehest surgeons, in fact, believed that the majority of postoperative pneumonias

were preceded by some degree of atelectatic collapse. In this belief, a number

of surgeons prescribed sulfonamide therapy as a prophylactic measure against

post atelectatic pneumonia.

The treatment of established atelectasis was directed to the same end as

the treatment of wet lung; that is, aiding the patient to expel obstructing fluid

from the tracheobronchial tree. He was positioned with the involved side up

and was made to cough at intervals of ."> to 10 minutes. If coughing was not

effective, a curved, semirigid rubber catheter of the Magill type was inserted

into the trachea, and sudden suction, of considerable intensity, was instituted.

Often, during intubation, the patient coughed strenuously enough to clear out

and aerate the involved lobe or lobes. Carbon dioxide inhalations were sometimes used to increase the depth of respiration, and back slapping and blow

bottles were also sometimes used.

If these measures were not promptly elective, bronchoscopy was employed,

under local anesthesia. Xo analgesic was applied to the vocal cords or trachea.

In a surprising number of cases, aspiration of only small amounts of mucus from

the orifices of the bronchi of the involved lobes corrected the atelectasis immediately. As experience increased, and especially as the efficacy of the method came

to be appreciated, it became more and more the practice to resort to bronchoscopy

without delay when atelectasis of any serious degree was encountered.

Typically, after spontaneous aeration or aeration following active treatment, rales appeared and persisted for several days, in spite of clinical and roentgenologic evidence of satisfactory aeration and the disappearance of dyspnea

and cyanosis.

Management in Base Hospitals

Atelectasis encountered in base hospitals was also infrequent. The lobar

type was occasionally encountered in the first, year of the experience in Xorth

Africa, and Italy but was seldom observed later. The atelectasis observed in

base hospitals was frequently complicated by infection and was practically

always the result of inadequate bronchial drainage. This was in contrast to
COMPLICATIONS AND SEQUELAE 165

the atelectasis seen in forward hospitals, in which the important problem was

wet lung secondary to trauma and anoxia.

In the base hospital, atelectasis, like tracheobronchitis and pneumonitis,

was likely to be present in casualties complaining of pain in the chest wall and

the abdomen and in casualties with spinal damage. Under these circumstances,

respiration was shallow and cough ineffective. When there was increased

secretion of mucus or of mucopurulent sputum in bronchitis, varying degrees

of tracheobronchial obstruction occurred, and atelectasis was always a possibility. Catheter suction or bronchoscopy was the correct treatment, supplemented by intercostal nerve block if pain was a feature.

In 338 wounds of the chest treated at the 21st General Hospital, Mediterranean theater, there were 2 deaths directly clue to lobular pneumonia, and the

same complication played a possible part in a third fatality. No instance of

lobar atelectasis was observed after operation, however, because of the vigorous

measures routinely instituted to prevent its development.

In the single case of total pulmonary atelectasis observed in this series, a

nonspecific type of bronchitis was found by bronchoscopy on the involved side.

No real improvement followed standard therapy. Pulmonary tuberculosis was

suspected, but it required numerous sputum examinations to establish the diagnosis. In retrospect, it was concluded that in this case, a subclinical pulmonary

tuberculosis was activated by the pyogenic infection that was responsible for

the pulmonary collapse. The patient had had a normal chest roentgenogram

2 months before he sustained the severe contusion of the chest that led to

atelectasis.1

HEMATOMA OF THE LUNG

General Considerations

Hematomas of the lung (figs. 52, 53, and 54), which were common, were

found in association with all types of chest injuries. The degree of pathologic

involvement ranged from simple contusions with small extravasations of blood

into the pulmonary interstitium and, to some extent, into the alveoli, to massive

interstitial hemorrhage. The latter variety of hematoma was associated with

infra-alveolar hemorrhage which involved whole lobes and even the whole lung.

In general, the clinical significance of a hematoma was in direct proportion

to the amount of pulmonary parenchyinal tissue involved. In the majority of

cases, the entity represented nothing more than a roentgenologic finding. In

the more severe cases, the process involved sufficient pulmonary tissue to give

rise to dyspnea and even to cyanosis.

1 So far as is known, active tuberculosis did not occur after any battle injury in the Mediterranean

theater, and there is no known instance in which reactivation of arrested disease could be attributed

to battle trauma. These circumstances are testimony to the effectiveness of the screening methods

used in the selection of combat personnel.

740-911v—05 13
166 THORACIC SURGERY

FIGURE 52.—1'osteroanterior roentgenogram showing

Iieniatoma and clearly defined missile track in left lung.

Note foreign body in left axilla.

From a diagnostic point of view, hematomas were occasionally confused

with intrapleural collections of fluid or with atelectasis. Thoracentesis and

bronehoseopy were frequently required to exclude these diagnostic possibilities.

An occasional hematoma was associated with a febrile response and hemoptysis,

which might lead the unwary to suspect pulmonary suppuration. The diagnostic confusion might lead, in turn, to the performance of incorrect drainage

procedures.

Management

Once the diagnosis of a hematoma was established, the accepted therapy

was entirely nonsurgical. No lesion encountered in all the broad spectrum of

thoracic trauma demonstrated more dramatically the remarkable recuperative

powers of the lung than did massive pulmonary hematomas. As a rule, serial

roentgenologic examinations showed slow but steady resolution of the process

and complete clearing of the lung.

Hematomas associated with retained foreign bodies of considerable size

of course represented a different therapeutic problem, as did those associated

with long missile tracks (fig. 52) and with peripheral lacerations. In such eases,

operative interference was frequently necessary for removal of the foreign body

or closure of the laceration. If a foreign body was present, it was wise to wait

for complete resolution of the pathologic process and for stabilization of the

patient before an attempt at removal was made.
COMPLICATIONS AND SEQUELAE 167

FIGURE 53.—Posteroanterior roentgenogram showing

typical infra pulmonary hematoma. Note rounded

shadow.

FIGUHE 54.—Posteroanterior roentgenogram .showing sharply

defined intrapleural hematoma.
168 THORACIC SURGERY

FIGURE •>">.—Hematoma of lung. A. I'osteroanterior

roentgenogram 0 days after wounding showing largo

hematoma of the left lung. B. Same, 4 weeks later,

with only small area of hematoma remaining.
COMPLICATIONS AND NEQCELAK 169

, /••

V

FIGURE r>5.—Continued. C. Same. 6 weeks after

wounding'. Note almost: complete disappearance of

hematoma.

Case History

The following case history is typical of the progress in most hematomas

of the lung:

Case 3.—This patient was wounded on 24 May 1944. A large shell fragment penetrated the left chest and caused a laceration of the lung and a hemopneumothorax on that

side. The wound was debrided. the sucking wound closed, and the shell fragment removed

from the chest wall. Repeated thoracenteses were performed.

Roentgenologic examination C days after wounding showed a large hematoma of the

left lung (fig. 55A). Clinically the patient's course was smooth and uneventful. Four

weeks after wounding, the hematoma was very much smaller (tig. 55B), and G weeks

later, roentgenologic examination showed almost no evidence of it (fig. 55C).

BRONCHOPLEURAL FISTULA

General Considerations

Bronchopleural fistulas of traumatic origin were of two types.

In the first group, the fistula occurred without serious parenchyma! damage and without pleura! infection or significant pulmonary infection. It represented a disruption of the visceral pleura and underlying peripheral lung,
170 THORACIC SURGERY

with the establishment of pleuroalveolar or pleurobronchiolar and bronchial

continuity, or with both.

These fistulas, which were usually small, might be caused in several ways:

1. By erosion or laceration of the lung from sharp, fixed rib fragments.

2. By the reopening of peripheral lacerations of the pulmonary

parenchyma.

3. By the avulsion of the line of repair of a pulmonary laceration that

had previously been sutured.

4. By necrosis around metallic foreign bodies or indriven costal spicules.

5. By denudation of lung tissue as the result of its being stripped from

an adherent area, either by collapse of the lung because of the accumulation

of exudates or transudates or by expansion of the lung after thoracentesis.

In the second group of bronchopleural fistulas, the fistula, was part of a

serious total situation, and the surgical measures necessary to correct it were

part of the major surgery required to care for whatever pleural or pulmonary

damage might be present. The procedure most often included drainage of an

empyema by rib resection, decortication of the lung (occasionally with segmental pulmonary resection), and, in very occasional instances, drainage of

a lung abscess.

Although bronchopleural fistulas were always a potential cause of tension

Pneumothorax, they were seldom associated with it. A few patients complained of a tight feeling in the chest, but most of them were unaware of what

had happened. In a small number of cases observed in the Mediterranean

theater, in which the fistulas developed during evacuation from forward to

base hospitals, the tension pneumothorax was of considerable proportions, and

the patients arrived dyspneic and in generally poor condition. Removal of the

air by needle resulted in only temporary relief, but permanent relief of symptoms and prompt healing followed the use of water-seal intercostal drainage.

Diagnosis was made by the discovery of a pneumothorax, either by physical examination or roentgenologic examination, or by both, in a patient whose

chest was previously free of pleural air and who had had no breakdown of

a chest wall wound to cause an open pneumothorax.

Management

Treatment of bronchopleural fistulas had three purposes: (1) To bringabout prompt removal of the air in the chest, (2) to obtain complete reexpansion of the lung, and (3) to close the fistula so that firm and permanent

healing would follow. Treatment was instituted as soon as the diagnosis was

made.

After manometric determinations of the intrapleural pressure, a small

intercostal catheter was inserted under local analgesia and via trocar into the

chest at the site of the pneumothorax. Since most bronchopleural fistulas gave

rise to apical air pockets, the most usual site of insertion was the second inter-
COMPLICATIONS AND SEQUELAE 171

space in the midclavicular line. The site, however, corresponded with the

location of the air pocket, which, because of adhesions, might be restricted to

some other portion of the chest. The catheter was connected to a long rubber

tube, the end of which was kept under water, to provide closed drainage. This

arrangement permitted air to escape from the pleural cavity only when the

pressure in it rose above atmospheric pressure. The lung was thus allowed to

expand slowly. At the end of 48 hours, and sometimes by the end of 24 hours,

the catheter could be withdrawn. If the fistula reopened, as occasionally happened, the catheter was reinserted.

The conservative method of treatment just described was always given a

fair trial, even though catheter drainage had to be instituted more than once.

It gave very satisfactory results. In 870 penetrating wounds of the chest

analyzed by Maj. Thomas H. Burford, MC, from the 2d Auxiliary Surgical

Group experience, there were 22 bronchopleural fistulas of the type just described. Twenty-one were closed permanently by the conservative method

outlined, though one patient experienced three recurrences of the fistula before

solid sealing was obtained. In the remaining case, operation was resorted to

after repeated attempts at catheter suction had proved unsuccessful. No patient in the group developed a pleural infection, which is highly significant,

since in several instances, the fistula persisted for 2 weeks or more. It was the

general experience that fistulas not associated with significant parenchymal

damage were not a source of pleural infection if the pleural cavity did not

contain blood.

If intrapleural infection did occur, operation was performed at once.

Otherwise, thoracotomy for repair of the fistula was not instituted until the

full possibilities of thoracentesis and intercostal water-seal drainage had been

exhausted.

In some cases, operation was necessary to smooth dangerously sharp rib

ends or remove in driven rib spicules or metallic foreign bodies. Only occasionally was it necessary to operate for the fistula alone. This was fortunate,

for the difficulties of finding a small fistula at an open operation were often

considerable.

The management of bronchopleural fistulas that were a part of other major

pathologic processes did not usually furnish problems referable to them alone.

Occasionally, however, pressure pneumothorax appeared suddenly in patients

with empyema, before dependent drainage had been instituted. Intercostal

catheter drainage was instituted at once, by the technique just described.

Case History

A typical instance of bronchopleural fistula treated by the method just

described follows.

Case 4.—This soldier, who was wounded in action on IT September 1944, sustained a

perforating wound of the right thorax, with lacerations of the right lung, right diaphragm,

and liver. A hemothorax developed promptly. lie was treated by thoracolaparotomy,
THORACIC SURGERY

Atfifßfri

Ear5

FIGURE 56.—Bronchopleural fistula. A. l'osteroanterior roentgenogram

showing delayed right bronchopleural fistula with Pneumothorax. B. Same,

showing complete reexpansion of lung after closure of fistula which occurred

48 hours after insertion of intercostal catheter.
COMPLICATIONS AND SEQUELAE 11 3

with suture of the diaphragm and subcostal drainage of the hepatic laceration. The

pulmonary laceration was not leaking and was therefore not sutured.

The immediate postoperative course was uneventful. Biliary drainage ceased, and the

drains were removed. The chest also cleared, but 2 weeks after wounding, the patient

began to complain of tightness in the right hemithorax, in which physical examination

revealed the presence of air. Roentgenologie examination (fig. 5GA) confirmed this finding,

ilanometric studies also furnished evidence of a small broncliopleural fistula of the right

lung.

A small catheter was inserted into the pneumothoraeie space, through the second intercostal space in the midclavicular line, and was attached to a water-seal bottle. Twentyfour hours later, the tube had ceased to bubble air. At the end of 4S hours, the water

column had ceased to oscillate, and the tube was removed. Examination at this time

revealed total disappearance of the pneumothorax and complete reexpansion of the right

pulmonary apex. These Undings were corroborated by roentgenograms (fig. 56B). The

fistula did not recur.

WOUND DISRUPTION

General Considerations

The causes of wound disruption in thoracic- injuries and the consequences

of the accident are best presented in an analysis of 10 cases observed at the 21st

General Hospital in the Continental Advance Section after the invasion of

southern France.

The 10 disruptions occurred in 74 sucking wounds, which occurred, in turn,

in 338 battle casualties admitted to the thoracic service of this hospital. All

but one of the- patients had been treated in U.S. Army field hospitals. This

man had received his initial treatment in a German hospital.

Analysis of these 10 cases of wound disruption revealed the following data :

1. In eight cases, the damage to the chest wall was severe, and there had

been considerable loss of soft tissue.

2. Bib fractures were present- in all cases, the number of fractures ranging

from one to five.

3. Pulmonary damage was severe in all cases.

4. In two cases, the wound of the chest wall had been contaminated by

intestinal contents from a thoracoabdominal wound.

f>. Six wounds were in the anterior chest wall, in which muscles are thin

and difficult, to draw together. Three were located laterally, and the remaining

injury was close to the spine.

(i. Dehridement had obviously been inadequate in the two small wounds in

the series and in another large wound, (he latter treated at the German hospital.

7. The wound had been left open in two cases. One of these patients had

been treated at the. German hospital.

8. Thoracentesis had been performed after operation in only three cases.

9. Eight patients had broncliopleural fistulas, bronchitis, and severe wet

coughs. In none of these cases had any measures been instituted to improve

bronchial drainage.

740 941v- -(!."> 14
174 THORACIC SURGERY

10. Empyema was present in every patient, and in only three instances had

there been an attempt to drain the pleural cavity. Infection in the pleural

cavity and lung, as well as in the chest wall, was thus an important factor in all

of these disruptions.

11. In six instances, respiratory embarrassment was the result of mobility

of the mediastinum.

12. All but one patient had had penicillin systemically, and at least three

had had it intrapleurally also.

Management

When these patients were received in the base hospital, disruption of the

chest wound had, in every instance, produced, or reproduced, a sucking wound.

Many patients were admitted in severe respiratory distress as a result of the

anoxia which had developed during evacuation. Closure of the wound was a

secondary consideration in every instance. All the patients needed other

treatment far more urgently.

The following treatment was instituted:

1. The wound was occluded with an airtight, petrolatum-impregnated

gauze dressing, kept in place by strips of adhesive tape or by an Ace type of

bandage. Because of its elasticity, this type of bandage permitted expansion

of the lung while at the same time it furnished necessary support to the

paradoxically moving chest wall.

2. Intercostal nerve block was carried out if respiration was painful or

paradoxical.

3. Oxygen was administered to all patients.

4. Tracheobronchial suction was used if the cough was ineffective.

5. Adequate pleural drainage, which was the keystone of treatment, was

instituted as soon as these emergency measures had been carried out.

In six cases, the pleura sealed over without other treatment. In three

cases, redebridement was necessary because the wounds contained necrotic

muscle tissue. Muscle flaps were developed and the wounds closed in layers

with interrupted silk sutui-es. The remaining patient, whose wound had been

secondarily closed at an evacuation hospital, had a second rupture, which was

satisfactorily closed by the same measures.

In other words, when the multiple etiologic factors of wound disruption in

these 10 cases were under control, wound closure was possible, either by surgical

closure or by spontaneous closure of the pleura after satisfactory drainage of

the intrapleural infection. The chest wall defect in the latter cases was allowed

to heal by granulation, after which the skin edges were drawn together by

adhesive tape. With proper initial management, it is doubtful that any of

these wound ruptures would have occurred.
COMPLICATIONS AND SEQUELAE 175

CLOSTRIDIAL MYOSITIS

Clostridial myositis was extremely infrequent in Avounds of the chest.

When it did occur, the etiologic factors and clinical manifestations were essentially the same as in clostridial infections in civil life. The principles of

management were also the same.

A point of great importance was that subcutaneous emphysema be clearly

distinguished from clostridial infections. The chief point of differentiation

was that in emphysema, except in the more extreme cases, air was confined to

subcutaneous tissues, while in clostridial infections, it was within the muscle

plane.

CHYLOTHORAX

There was no instance of chylothorax in any of the thoracic or thoracoabdominal wounds cared for by surgeons of the 2d Auxiliary Surgical Group.

The assumption is that most patients with these injuries died on the battlefield

from their severe wounds.

LUNG ABSCESS

Incidence

The incidence of lung abscess in World War II was extremely low. Preliminary figures compiled by the Medical Statistics Division, Office of The

Surgeon General, Army, based on sample tabulations of individual medical

records (table 10), show only 541 cases for the entire Avar, 382 in the continental

United States and 159 outside of the United States. There were 16 deaths, 10

in the continental United States. Of 255 cases of lung abscess (based on 20

percent sample tabulations of individual medical records) classified as secondary (table 11), 130 occurred outside the continental United States. The

figures include both battle and nonbattle cases, and not all of the abscesses

secondary to battle Avounds were related to Avounds of the chest.

The statistical evidence of the infrequency of lung abscess as a complication of battle wounds of the chest supports its infrequency in individual studies

and also supports the clinical impression of the World War II chest surgeons.

In one analysis of 870 battle wounds of the chest, by Major Burford and eventually included in the total figures of the 2d Auxiliary Surgical Group, there

Avere only 5 instances of lung abscess. Maj. (later Lt, Col.) John Burke, MC,

and Capt. (later Maj.) Theodore T. Jacobs, MC, in an analysis of 122 penetrating wounds of the chest at the 23d General Hospital in the European theater,

encountered only 2 lung abscesses. Other observers had similar experiences.

The explanation of the infrequency of this complication in battle-incurred

Avounds of the chest is twofold, (1) penicillin therapy and (2) the intensive

efforts immediately after -wounding to restore the normal respiratory physi-
170 THORACIC SURGERY

TABLE 10.—Number of admissions ]and deaths -for lung abscess in the U.S. Army, btj area of

admission and year, 1043-.'iS

[Preliminary data based on sample tabulations of individual medical reeords] 3

Area 1942-45 1942 1 1943 1

1944 1945

ADMISSIONS

3S2 81 132 89 SO

Overseas:

60

25

5

14

24

22

4

5

9 S 15

6

35

Mediterranean * 1 13 5

Middle East

1

2

1

1

o

5

2

4

6

2

o

1

13

5

1

10

Southwest Pacific

Central and South Pacific

5

10

159 10 43 41 65

Total Armv 541 91 175 130 145

DEATHS

Continental United States 10 1 7 1 1

Overseas:

Europe 4

1

1

1 1

1

1 1

Middle East : 1

G 1

o

1 1

Total Armv 16 2

! 10 2 9

1

It is estimated that-virtually none were ORO (carded for record only) eases. For the 2 years, 1943 and 1945, in which

the number of CRO cases was known, the 320 admissions included but 1 CRO ease.

- Underlying cause of death; year of death.

3 Complete files of records used for deaths, 1942 admissions, and oversea admissions in 1943. Samples of admissions

were: 20 percent for 1945, U.S. 1943, and Europe 1944; 80 percent for 1944, excluding Europe.

4

Includes North Africa.

5

Includes Alaska and Iceland.
COMPLICATIONS AND SEQUELAE IT:

TABLE 11.—Number of secondary cases ' of long abscess in the U.S. Army, by area and year,

19U--'i5

[Preliminary data based on 20 percent sample tabulations of individual medical records]

1844-45

Continental United States _

Overseas:

Europe

Mediterranean 2

Middle East

China-Burma-India

Southwest Pacific

Central and South Pacific_

North America 3

Latin America

Total overseas.

Total Army—.

Number

125

60

20

1944

Number

75

Number

45

130

15

15

-15

20 25

50 SO

125 130

i Battle and nonbattle cases.

- Includes North Africa.

s Includes Alaska and Iceland.

ology. Since lung abscesses were infrequent even before penicillin became available'in the spring of 1944, the second of these explanations must be considered

the more important.

The low incidence of lung abscess can also be interpreted as further evidence of the remarkable recuperative capacity of the lung, particularly when,

as just mentioned, its inherent capacity was supported by prompt measures to

assure a patent airway and total pulmonary reexpansion. Consistent with the

infrequency of localized intrapulmonary suppuration was the observation that

bacteria were seldom cultured from missile cavities when foreign bodies were

removed in uncomplicated cases (p. ->27).

There was no explanation, however, of why pulmonary abscesses developed

about an occasional foreign body and not about others. One explanation advanced was that while the heat of shell fragments might be sufficient to sterilize

most pathogenic bacteria, bits of clothing driven into the lung along with the

missile might carry infecting micro-organisms in with them. This is not an

acceptable theory, partly because this occurrence was so frequent and lung

abscesses so infrequent, and partly because the infecting micro-organisms

found in lung abscesses were usually resident respiratory flora. The number

of cases is too small to permit anything beyond the mere statement of facts, but

it might be mentioned that the abscess formed about a foreign body with recognizable bits of cloth attached to it in three of the five cases reported by Major

Burford. Other, isolated observations were to the same effect.
178 THORACIC SURGERY

Management

The type of lung abscess seen in battle-incurred injuries differed from the

type seen in civilian practice. In civilian practice, the abscess begins with a

diffuse area of pneumonitis, and, if progress is favorable, as it usually is, the

process proceeds to localization. In the traumatic type of abscess, the localized

phase was the first phase. This was a distinction of fundamental importance

from the standpoint of treatment: In the traumatic type of abscess, the earlier

the attack, the simpler the procedure, and the better the results.

In four of the five cases studied by Major Burford, the abscess was excised,

the excision including the foreign body in the three cases in which the missile

was retained. Drainage was instituted in the remaining case. All five patients

eventually recovered, though in two instances, the abscess recurred and required

secondary drainage. Drainage of an associated empyema Avas necessary in

both of these cases.

Penicillin therapy and the intelligent use of whole blood were important

parts of the routine of management, but good surgery was the basis of treatment.

Massive gangrene of the lung was not observed by surgeons of the 2d Auxiliary Surgical Group, but in two instances, extensive suppuration developed,

apparently on the basis of extensive vascular damage. The process in both

cases went on to multilobar areas of pneumomalacia with multiple bronchopleural fistulas and widespread pleuropulmonary sepsis. One patient recovered

after multiple drainage operations. The other died after total pneumonectomy.

MEDIASTINAL ABSCESS

Surgeons of the 2d Auxiliary Surgical Group encountered abscess formation of the anterior mediastinum in only one instance. The infection developed

about a retained foreign body, and the organism recovered was a pure strain

of hemolytic streptococcus. Complete and prompt recovery, without complications, occurred after thoracotomy, removal of the foreign body, evacuation of

the abscess, and intrapleural instillation of penicillin.

An occasional patient was observed in forward hospitals with localized

abscesses of the posterior mediastinum or diffuse posterior mediastinitis. These

infections were considered the only indication for posterior extrapleural mediastinotomy in war wounds of the thorax. None of this small group of patients

survived to reach base hospitals.

PNEUMONITIS AND PNEUMONIA

Infectious pulmonary complications, chiefly pneumonitis and the pneumonias, were considerably more infrequent in chest injuries than had been expected, in view of the World War I experience. The low incidence, which was
COMPLICATIONS AXD SEQUELAE 179

practically the same in thoracic and thoracoabdominal wounds, could be

explained in several ways:

1. The attention devoted to the correction of wet lung- both before and

after operation. Measures that drastically reduced the incidence of atelectasis,

as the correction of wet lung and maintenance of a patent airway reduced it,

also drastically reduced the incidence of pneumonitis and subsequent

pneumonia.

2. The postoperative routine which emphasized coughing, frequent turning in bed immediately after operation, and early ambulation.

3. Perhaps the unwitting prophylaxis instituted by the administration of

sulfoimmides and later of penicillin as part of the routine of management of

all wounds.

Pneumonitis almost always developed on the basis of atelectasis or of stagnation of excessive bronchial fluids. Pneumonia was more frequent in the

winter months, when it was often superimposed on a preexisting purulent

bronchitis. An occasional lobar pneumonia was a primary pathologic process.

Diagnosis of pneumonitis and pneumonia was by the usual symptoms and

signs (toxicity, increased fever, pulmonary consolidation) supplemented by

roentgenologic examination.

Sulfadiazine was the drug of choice. It was frequently observed that a

pneumonia that had developed under penicillin therapy responded promptly

to sulfonamide therapy. If stagnation of bronchial secretions was a persistent feature of the disease, and if the patient could not or would not cough

effectively, either catheter suction or bronchoscopy was employed, even when

pulmonary infection was clearly established. No undesirable consequences

followed this practice.

Atelectasis and pneumonia caused by inadequate bronchial drainage were

fairly common on neurosurgical and general surgical wards. The staffs of the

thoracic surgical wards saw many of these patients in consultation and assisted

in their care, particularly in the performance of catheter suction and

bronchoscopy.

TRAUMATIC OSTEOMYELITIS

Neither osteomyelitis nor osteochondritis was frequent after trauma in

World War II, in contrast to their relative frequency in World War I. Both

were managed by removal of the involved segments under systemic penicillin

protection. The wound was left widely open for 4 to 10 days. Then secondary suture or staged closure was carried out, depending upon the rapidity with

which the wound cleared up. To await sequestration of the bone was not in

harmony with modern surgical principles.

Osteomyelitis of the scapula was seen at least 10 times more frequently in

the earlv fighting in North Africa than later. The explanation was that in
180 THORACIC SURGERY

the early months of the war, debridenient about the scapula was not sufficiently

radical. Later, there was a better realization of the importance of adequate

initial wound surgery. Free incision with removal of sequestra usually resulted

in prompt cure.

CHRONIC SINUSES OF THE CHEST WALL

General Considerations

Chronic sinuses of the parietes were encountered in a small number of

patients in the base area and in a larger number in Zone of Interior hospitals.

The causes were chiefly as follows:

1. Injury to the costal cartilage, caused by the so-called gutter type of

wound, with destruction of the cartilage as a result. Sinuses of this origin

continued to drain until all diseased cartilage had sloughed off, or, better, had

been excised.

2. Eetained foreign bodies. Sinuses were particularly frequent when bits

of clothing or other foreign organic material had collected around retained

metallic fragments, but metallic fragments alone could be responsible for the

sinuses.

3. An unwise selection of suture material. In closing particularly large

defects of the chest wall, it was sometimes necessary to use pericostal or perichondral sutures to pull the ribs and cartilages together. Experience proved

that the use of heavy silk or wire or other nonabsorbable suture material was

unwise; healing was sometimes satisfactory, but many times these materials

acted as retained foreign bodies. As the war progressed, pericostal and perichondral sutures were not used if they could be avoided. If they could not be

avoided, absorbable suture material was used.

4. Un-united fractures or fractures that had healed with excessive scar

tissue and callus formation. These were infrequent causes of parietal sinuses

and were seldom an indication for surgery.

5. Osteomyelitis of the ribs or other bones (fig. 57).

Management

The basis of management of these sinuses of the chest wall Avas the removal

of the offending retained material, whatever it might be. The removal of

retained foreign bodies and unabsorbed suture material offered no difficulties.

If bone or cartilage was responsible for the sinus, the infected area was excised.

Xumorous exceptions were noted to the opinion that infection involving cartilages in the fused portion of the thoracic cage requires complete excision of

the involved fused cartilage for permanent cure. As experience accrued, it

was found that a less radical resection, involving only the infected segment,
COMPLICATIONS AM) SEQl'KLAK 181

FIGUKE 57.—Sinus of chest wall resulting from traumatic

osteomyelitis of clavicle. Note swelling of tissues just below

pointer.

was all that was necessary in most cases. If there was a recrudescence of the

infection, the more radical operation could be done as a secondary procedure.

At operation, the wound was opened widely and the offending material

removed. The extent of the debriclement depended upon the circumstances in

the individual case. Since all of these wounds were infected, the skin and subcutaneous tissues were left open, as at initial wound surgery. Secondary

closure of the incision was usually possible under penicillin protection from

5 to 7 davs later.

DEFECTS OF THE CHEST WALL

Wounds causing large defects of the chest wall were frequent, They reflected, in a dramatic fashion, the effectiveness of modern weapons. They were

also observed frequently because adequate debridement of an initially large

wound resulted in a sizable opening in the chest wall. This was particularly

true at Anzio, where many patients with large traumatic thoracotomies would
TIIOBACIC SUBGERI

B

FIGURE 58.—Defect of anterior chest wall. A. Large defect, with typical loss

of substance, sketched before debridement. B. Result 1 month after repair

of defect by swinging down small muscle flap from pectoralis major. This

picture was taken 7 days after delayed primary wound closure in a base

hospital. The patient recovered uneventfully. Note absence of lung hernia.
COMPLICATIONS AND SEQUELAE 183

not have survived except for immediate surgery in hospitals close to the

frontlines.

These large defects presented special problems of management. The necessary intrathoracic procedures were carried out with dispatch, particular attention being paid to removal of fragments of ribs and clothing, which were found

more often, and in larger amounts, than in any other type of chest wound.

Debridement had to be even more thorough than usual, because it was often

advisable to close the skin primarily, to enhance the security of repair.

Satisfactory restoration of the chest wall often required patience and

ingenuity. The procedures utilized to accomplish closure without dangerous

tension varied with the number and location of the defects. Pericostal sutures,

though generally undesirable, had to be used in some cases to approximate the

ribs and thus reduce the size of the defect. In flail segments of the ribs, it

was occasionally feasible to use wire to fix the ends. Muscle flaps were very

useful, particularly in the anterior chest (fig. 58), in which tissues for repair

were sparse. The paraspinalis group of muscles was used for flaps low in the

posterior chest, where there was a similar paucity of tissue. In an occasional

case, the subscapularis was used, as suggested by Maj. (later Lt, Col.) Eeeve

H. Betts, MC, and Capt. (later Maj.) William M. Lees, MC, with the arm

positioned to bring the scapula over the opening. If nothing else was possible,

closure was effected by reattachment of the hemidiaphragm.

ADHESIVE PLEURITIS

Pathologic Process

Deforming adhesive pleuritis, also known as infolded lung, was a fairly

common complication of chest injuries. Its mechanism was not clearly understood but could be postulated as follows:

1. The blood present in the pleural cavity after wounding resulted in

compression of the lung.

2. The lung was additionally compressed by an associated pneumothorax.

3. If the pleural blood clotted, it occupied a considerable portion of the

pleural space.

4. In the simplest type of infolded lung (fig. 59), as a result of the thoracic

wound, the associated hemothorax, and the resulting deflation of the lung, the

diaphragm was elevated and splinted. The costophrenic fringe of the lung was

dragged along the dome of the diaphragm and presumably became retracted.

Since blood was invariably present in some amount in all thoracic wounds,

symphysis occurred between the costophrenic fringe of the lung and the

diaphragmatic pleura at what might be termed the high watermark.

5. Eventually, as the result of absorption of air, or of aspiration of blood

or air, or of both processes, the lung began to reexpand, filling the pleural space

that remained bv rolling out over the area of the pleural symphysis and expand-
184 THOHACIC SUBGEBY

FIGUKE 59.—Diagrammatic representation of infolded lung- (adhesive pleuritis). A.

Rapid massive intrapleural hemorrhage. B. Lung infolding as it is compressed by massive

bleeding. C. Captive infolded lung (a), held by pleural membrane (b), resulting from

organizing hemothorax (c).

in«-those portions of its contour that could most conveniently occupy the available space. The tipper portions of the lung were free to expand and fill the

apex of the chest. The peripheral portion of the base could be filled only by

adapt ation of the lung to the available space.

The process just postulated furnished a satisfactory explanation for slight

degrees of pulmonai-y infolding. They were of no great clinical significance,

and they probably occurred much more often than they were recognized. On

the other hand, extensive degrees of infolding and distortion were serious.

They sometimes occurred as the result of adhesions between the visceral and

parietal pleural coats or between opposed portions of the visceral pleura (fig.

59). Bizarre distortions were occasionally observed, as the result of a symphysis between the lateral costophrenic fringe and the mediastinum, along its

diaphragmatic border.

Though the mechanism of infolded lung was not clearly understood, the

consequences were evident. Because the hemithorax was not completely filled

by the lung, areas within it that were not adequately filled by lung tissue were

likely to be filled by recurrent accumulations of pleural fluid. This fluid, after

the blood in the chest had been removed, was uniformly serous. It formed

only in small amounts, but it had a tendency to reaccumulate after it was removed by aspiration.

If the adhesive process involved large areas of lung, pulmonary expansion

was considerably slower than when an uncomplicated hemothorax was present,

and filling of the hemithorax was considerably delayed. These observations
COMPLICATION'S AND SEQUELAE 185

explained the contraeture of the chest Avail observed in such cases; it was merely

Nature's attempt to reduce the size of the hemithorax.

Some degree of infolding- was uniformly seen in association with massive

intrapleural clotting. Most observers thought that if roentgenologic examination showed obscuration shortly after wounding and showed clearing within a

period of weeks of expectant treatment and vigorous breathing exercises, the

patient had had an infolded lung and not an organizing hemothorax. An oro-anizino- hemothorax was like.lv to be irreversible without more active therapy.

Diagnosis

The only condition easily confused with deforming adhesive pleuritis was

organizing hemothorax. The differentiation was extremely important: An

organizing hemothorax of any extent constituted a definite indication for

thoracotomy and decortication: an infolded lung did not.

The differentiation was usually readily accomplished by roentgenologic

examination, but certain clinical features were also helpful. In organizing

hemothorax, but not, in infolded lung, the physical findings usually included

dullness on percussion over the affected area; decreased tactile fremitus; suppression of breath sounds; narrowing of the interspaces; and possibly retraction of the mediastinum toward the affected side, with elevation and relative

immobility of the corresponding hemidiaphragm. Blood was usually obtained

by thoracentesis.

Roentcenoerams taken in infolded lung showed a generalized obscuration

of the pleural space in the posteroanterior projection. In lateral films, there

was a triangular posterior obscuration generally regarded as typical of the

process. The opacity was produced by the infolding and malaeration of the

affected pulmonary area, as well as by the small, irregular, and usually intercommunicating collections of pleural fluid. It was the findings in the lateral

roent»-enograms which differentiated adhesive pleuritis from organizing hemothorax. In the former, the obscuration was patchy and diffuse because the

process was not localized. In the latter, the opacity was posterior and basal.

Management

If within 3 or 4 weeks after wounding, an infolded lung had expanded

sufficiently to fill the hemithorax, expectant treatment was continued. Even

though, the chest was somewhat contracted, it Mas thoughtthat return of function

to the chest wall by the practice of breathing exercises would eventually correct

the deformity. Conservative management was indicated whenever serial

roento-enograms showed that pulmonary reexpansion had been shared proportionately by all the lobes, so that the patient would not be left, for example,

with a fully expanded upper lobe and a seriously contracted lower lobe.

On the other hand, release of limiting adhesions by surgery was considered

justified if, within 3 or 4 weeks after wounding, the lung had not expanded
186 THOBACIC SÜBGEBY

sufficiently to fill most of the hemithorax or if serial roentgeiiograms showed

that the filling had been accomplished predominantly by one portion of the

lung at the expense of other portions. In most cases, though not in all, when

filling of the hemithorax was long delayed, it was much more likely that failure

of pulmonary expansion was the result not so much of infolding of the lung,

even if it was present to some degree, as of compression of the lung by the peel

or rind of an organizing hemothorax. In that type of case, decortication of

the lung was clearly indicated.

DIAPHRAGMATIC HERNIA

Up to 1944, the Medical Statistics Division, Office of The Surgeon General,

Army, coded diaphragmatic hernia with a residual group of hernia conditions.

The data for 1944 and 1945, when diaphragmatic hernia was coded separately,

show a total of 449 cases and 9 deaths (table 12). In 230 cases, diaphragmatic

hernia was the secondary diagnosis.

Data on deaths were obtained from a complete file of records. Admissions

in 1945 and for the European theater in 1944 were derived from a 20-percent

sample of records. Admissions in 1944 for areas other than the European

theater were derived from an 80-percent sample. Data oil secondary diagnoses

were derived from a 20-percent sample. A

Tot all of the hernias associated with

battle-incurred wounds were related to wounds of the chest.

Oversea Experience

The small samples from which the statistics just cited are derived do not

permit generalizations. They are in correspondence, however, with the impressions of surgeons both overseas and in the Zone of Interior that traumatic

diaphragmatic hernias were decidedly infrequent, Only 2, for instance, were

observed in 1,028 intrathoracic wounds analyzed by Major Burford from the 2d

Auxiliary Surgical Group experience.

In the first of these cases, the hernia was not suspected before thoracotomy,

which was undertaken for removal of a missile from the left lower pulmonary

lobe. In the second case (fig. 60), which was not a combat injury, the casualty

sustained a crushing injury to the upper abdomen when a jeep was blown off

the road, by the explosion of a mortar shell, and was overturned. Early thoracotomy revealed that the stomach and colon had herniated through a large

tear in the left leaf of the diaphragm. The tear extended to, but not through,

the left cms of the hiatus. Convalescence was uncomplicated, and postoperative

roentgenologic examination showed normal configuration of the diaphragm

and stomach. Both of these patients were returned to duty in the theater.

So far as is known, no instance of diaphragmatic herniation was observed

in the Mediterranean theater in a battle wound in which the diaphragm had

been sutured. The early experience had demonstrated the risk of suturing the
COMPLICATIONS AND SEQUELAE 187

TABLE 12.—Number of total cases (incidence), admissions, secondary diagnoses, and deaths

from diaphragmatic hernia 1 by area of admission and year, 1944-4-5

[Preliminary data based on sample tabulations of individual medical records]

Area Incidence -

Continental United State?

Overseas:

Europe

Mediterranean 6

Middle East

China-Bnrma-India

Southwest Pacific

Central and South PacificNorth America 7

Latin America

Total overseasTotal Army

Continental United States

Overseas:

Europe

Mediterranean ß

Middle East

China-Burma-India

Southwest Pacific

Central and South PacificNorth America "

Latin America

Total overseasTotal Armv-__

Admissions * \ Secondary

diagnoses 4

146

40

18

9

18

3

93

239

115

40

15

o

20

10

5

95

210

86

10

s

4

28

114

70

10

10

105

60

30

10

5

65

125

45

35

10

10

60

105

Deaths ä

i Battle and nonbattle cases.

2 Sum of admissions and secondary diagnoses.

3 Cases in which diaphragmatic hernia was the primary cause of admission to a medical treatment facility.

« Cases of diaphragmatic hernia secondary to, or concurrent with, some other admission diagnosis.

s Underlying cause of death, year of death, and theater of admission.

3

Includes North Africa.

' Includes Alaska and Iceland.
188 THORACIC SURGERY

4F

jBK

FIGURE CO.—Traumatic diaphragmatic hernia. A. Posteroanterior roentgenogram 4

hours after crushing injury of lower chest and upper abdomen. At operation, both stomach

and large bowel were found in chest. B. Same, 10 days after thoracotomy, reduction of

hernia, and repair of diaphragm.
COMPLICATIONS AND SKQUKLAK 189

«^'4*

FICJUKE 60.—Continued. C. Detail film after barium

meal demonstrating normal stomach pattern and intact

diaphragm. Patient made an uneventful recovery.

diaphragm with catgut whenever there was any risk of bile leakage. Sutures

of silk, cotton, or nylon held consistently. Bile, free of its normal confines,

always makes trouble, and the success of diaphragmatic suture was in large part

due to recognition of this fact and provision of adequate drainage for a sufficiently long period (p. 118).

Zone of Interior Experience

Diaphragmatic hernia of traumatic origin was seen only slightly more

frequently in the Zone of the Interior than overseas. The 28 patients observed

at the Kennedy General Hospital chest center, Memphis, Tenn., during the

•i-year period of its operation may be taken as typical, and the analysis of

these cases is the simplest method of presenting the main points in the clinical

picture and management of this condition.2

= This analysis was made by Maj. Felix A. Hughes, Jr.. MC : Maj. Karle B. Kay, MC ; Lt. Col.

Richard H. Meade, Jr., MC ; Maj. Theodore R. Hudson, MC : and Maj. (later Lt. Col.) Julian Johnson,

MC. All of these officers served at various times in the thoracic surgery center, Kennedy General

Hospital.
100 THORACIC SURGERY

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FIGUEE 61.—Diaphragmatic hernia. This patient, a prisoner of war, was

injured in France in 1944, and then worked in the United States for a year

without symptoms. A. Tosteroanterior roentgenogram made after onset of

symptoms induced by carrying heavy sacks. The greatly distended stomach,

partly filled with barium, occupies the left pleural cavity. B. Same, after

reduction of hernia and repair of diaphragm. Recovery was uneventful.
COMPLICATIONS AND SEQUELAE 191

Etiology and pathogenesis.—In 16 of the 28 cases, the wounds were caused

by shell fragments, or machine-gun, rifle, or pistol bullets. In the remaining 12

cases, the hernias, which were not combat-incurred, were variously caused or

precipitated by traffic accidents (9), a stab wound, a fall, and jumping from a

truck. In five of the combat-incurred hernias, the injured diaphragm had

been repaired overseas at the time of wounding.

In the 11 combat-incurred wounds in which the diaphragm had not been

repaired overseas, the defect was so small that no herniation occurred until sudden strain or prolonged strain caused it to enlarge. One soldier, for instance,

had sustained a penetrating wound 13 months before, for which thoracotomy

was not considered necessary. Suddenly, while carrying heavy sacks, he was

seized with severe upper abdominal pain. At operation, the entire stomach

was found in the chest (fig. 61). Another patient had sudden, acute symptoms

after he jumped from a truck. At operation, the colon was found herniated

through a defect only 1.5 cm. in diameter, and gangrene had already set in.

Three other patients with known hernias of several months' duration also developed acute intestinal obstruction while under observation in the hospital.

Emergency operation was successful in all three cases.

The first patient with a diaphragmatic hernia observed at the chest center

at Kennedy General Hospital furnished a useful lesson. He had sustained a

bullet wound of the right chest in May 1943. A few weeks later, he showed

no abnormalities of any consequence on roentgenologic examination (fig. 62A)

and had no symptoms of any kind. He continued well for a year. Then he

began to complain of pain in the right lower chest, and roentgenograms showed

a rounded mass overlying the diaphragm (fig. 62B). Exploratory thoracotomy

was performed, and the mass was found to be a herniated portion of the right

lobe of the liver. Undoubtedly, many cases of this kind have been observed in

veterans' hospitals and in private practice since the war. If there is no hemorrhage, gangrene, or perforation of the gastrointestinal tract, patients may

accustom themselves to living with a surprising degree of diaphragmatic

herniation.

In no instance was it possible to correlate the hernia, either in size or location (fig. 63), with the anatomic areas of weakness in which such hernias are

prone to occur. Obviously, however, increased abdominal pressure, produced

by strain, as a number of cases in this series show, may be the immediate cause

of herniations through previously created defects, even when the defect is small.

Pathologic process.—A definite sac was demonstrable in only two of the

hernias in the series. A membrane frequently covered a part of the herniated

structure, but it was not complete. The adhesions present in practically all cases

between the affected structures varied in extent and character. At times, it was

impossible to separate the herniated structures from the lung without some pulmonary damage. The size of the opening in the diaphragm varied from a

defect 1.5 cm. in diameter to one that involved the entire dome and extended into

the pericardium.
192 THORACIC SURGERY

6

FIGURE (i2.—Diaphragmatic-hernia. A. Posteroanterior

roeutgenogram 4 months afler penetrating wound of right

chest. There is no evidence of herniation in this li'.in.

and the patient was asymptomatic. B. Same, 1 year later,

showing herniation of right lohe of liver.
COMPLICATIONS AXD SEQUELAE 193

The dome of the left diaphragm was the site of the hernia in 12 of the 28

cases (fig. 63). Contusion defects were located more peripherally and penetrating defects more centrally.

At operation, practically all the organs in the peritoneal cavity were found

herniated through the diaphragm, either singly or in various combinations. At

one extreme were asymptomatic herniations of the omentum, discovered accidentally at operation for other conditions. At the other extreme were two

herniations, each consisting of the kidney, spleen, stomach, small bowel, colon,

and omentum. In one of these cases, the structures were densely adherent and

completely covered the lateral portion of the diaphragm. In the other, there

was an 8-inch tear in the pericardium.

In one case, there was a constricting ring defect around the herniated

stomach (fig. 64) ; if diagnosis had been delayed, ischemic changes, followed by

perforation, would undoubtedly have ensued. In one instance, in which previous repair had been done elsewhere, the diaphragm had been severed from its

attachments to the posterior chest wall, and a hydronephrotic, congenital bifid

kidney had herniated through the defect. It was necessary to mobilize and

remove the kidney before repair could be accomplished.

In one case, incarceration of the stomach resulted in progressive gastric

distention, and eventually the entire left pleural space was filled with the herniated organ, the lung on that side being completely atelectatic. After the

defect in the diaphragm had been enlarged, it was possible to express the air

from the stomach through the nasal tube inserted before operation. When this

had been accomplished, the adhesions could be separated and the hernia reduced.

Clinical picture and diagnosis.—Herniation of solid viscera was associated with vague pain in the lower chest but usually with no other symptoms.

Herniation of hollow viscera gave rise to more varied symptoms. In 11 cases,

all of combat origin, the initial symptoms were epigastric pain, especially after

meals and during recumbency; flatulence; indigestion; and dyspnea, which was

practically always present when there was considerable collapse of the lung.

Several patients stated that they could hear and feel gurgles in the chest.

If a hollow viscus suddenly herniated through the diaphragmatic defect,

the symptoms were more dramatic. In two instances, unconsciousness occurred,

not to be accounted for by associated injuries. The degree of pain and the

presence of nausea and vomiting depended upon the extent of the herniation and

the amount of obstruction it produced.

In some cases, as already mentioned, herniation of the omentum through

the diaphragm was discovered unexpectedly, at operation for other conditions.

In the four cases in which the liver was the herniating organ, only a presumptive preoperative diagnosis was possible. In one of these cases, the herniation,

which was recurrent, was found in the course of exploration of a draining sinus

of the chest wall. In two cases, the chest was aspirated, in the belief that the

fluid in the herniated stomach and intestines was pleural fluid. No evidence of

damage or infection was found at operation in either case.
194 TIIOKACIO SURGERY

3 ö

M
COMPLICATIONS AND SEQUELAE 195

1

FIGURE 64.—Diaphragmatic hernia. This hernia was found after a forced

march with a heavy field pack overseas; it may have originated in an automobile accident several years earlier. A. l'osteroanterior roentgenogram

showing hernia. B. Same, showing herniated, barium-filled stomach. Note

constricting ring.
190 THORACIC SntGEKY

Surgical repair.—All 28 hernias in this series were successfully repaired

through a transthoracic approach, usually under eiidotracheal anesthesia. The

excellent exposure so easily obtained by this approach made it preferable to

the abdominal approach. In a number of instances, the herniated structures

extended up to the dome of the thorax, and the adhesions present could have

been handled only with great difficulty through an abdominal incision.

Closure was eventually accomplished in every case in the series, though in

some, at first glance, it was doubtful that enough diaphragmatic tissue remained

to be useful. After careful dissection, however, enough tissue was developed

to permit satisfactory closure in every such case, though it was sometimes necessary to dissect the extension of the diaphragm into the transversalis muscle

before closure could be accomplished without tension. Two rows of silk sutures

were used, the second burying the first. When the diaphragm was detached

from the thoracic wall, secure closure was achieved by using mattress sutures

through the chest wall. The sutures were tied over tubes, and another row of

interrupted intrapleural sutures was placed.

In the first cases in this series, the phrenic nerve was not crushed unless

the line of the defect was such that contraction of the diaphragmatic fibers

would exert a pull on the suture line. This technique was later made routine

because, in a case in which it had been omitted, a hernia recurred 5 hours after

operation, presumably because of excessive movements of the diaphragm during

tracheal aspiration. Successful secondary repair was carried out several months

later. There was no evidence that paralysis of the diaphragm retarded healing,

and earlier experimental evidence by Meade (#) had shown that it did not

decrease the tensile strength of the diaphragm.

Drainage was employed only three times, once when a gangrenous colon

had to be resected and twice when empyema had preceded the hernia. Waterseal drainage was used in these three cases until the lung had fully reexpanded

and obliterated the pleural space. There were varying degrees of pulmonary

collapse in all cases in this series, but the lung reexpanded in all without difficulty, no matter how long the collapse had been present.

Postoperative management.—The usual routine of postoperative management was employed in these cases. Gastric suction was always instituted,

usually for 72 hours. If the patient could not keep the airway clear by his own

efforts, eiidotracheal aspiration was used.

Postoperative complications.—There were only three postoperative complications of any consequence. In one case, as already mentioned, there was

an immediate recurrence of the hernia. In one case, in which the lung was

damaged while it was being separated from the herniated liver, a temporary

pneumothorax developed. In one case, there was a postoperative recurrence

of the empyema which had complicated the original injury and which had to

be treated before repair of the hernia could be undertaken. In three other cases

transient pleural effusions appeared, but they disappeared promptly and did not

delav recoverv.
COMPLICATIONS AND SEQUELAE 197

HERNIA OF THE LUNG

General Considerations

Hernia of the lung was an extremely infrequent complication of combatincurred wounds, probably because of the inherent elasticity of pulmonary

tissue. This property causes the tissue to contract and retract from the chest

wall when intrapleural and intraplumonary pressures become equal in the

presence of the opening into the pleural cavity caused by a chest wound. The

concomitant pneumothorax and hemothorax that occur after wounding also

act to prevent pulmonary hernias. On the other hand, in view of the considerable number of large chest wall defects observed in forward hospitals, the

rarity of pulmonary herniations is remarkable.

According to Funk (3), who made a comprehensive review of the literature in 1918, only three hernias of the lung were reported in the Civil War,

and none were recorded in the Crimean War or in World War I. In the

South African War (1899-1900), Makins U), in an extensive experience,

observed only one case. Adams (5) found only 5 pulmonary hernias in 20,000

wounds of the chest in the Russo-Japanese War. Up to 1945, only 185 cases

had been recorded, most of which were combat-incurred.

Occasional instances of hernias involving single pulmonary lobes were

observed, but there was only one instance of true pulmonary hernia (fig. 65) in

the 2,267 thoracic and thoracoabdominal wounds in the 2d Auxiliary Surgical

Group experience. Of the seven cases recorded from the section of thoracic

surgery, Walter Reed General Hospital, Washington, D.C., by Capt. (later

Maj.) Elmer P. R, Maurer, MC, and Lt. Col. (later Col.) Brian Blades, MC,

six Mere combat-incurred, and the other was the result of trauma.

Traumatic hernias represent the largest group of pulmonary hernias. They

have been reported after crushing wounds, stab wounds, and perforating

wounds caused by rifle bullets and shell fragments. They occasionally appear

after surgical procedures. The congenital and spontaneous varieties are

decidedly infrequent.

In traumatic hernias, the first manifestation is the appearance, usually

from several weeks to several months after injury, of a tender swelling in the

chest wall, which increases in size on forced expiration and disappears on

inspiration. In acute traumatic hernias, the symptoms referable to the hernia

are obscured by the symptoms arising from the injury itself.

The diagnosis is usually made without difficulty because of the characteristic

behavior of the air-containing tissue. In four cases observed at Walter Reed

General Hospital, however, the classical signs and symptoms of pulmonary

hernia were present, but at operation no lung tissue was found in the defect

in the chest wall. In three of these cases, the liver had herniated into the defect.

The clostridial infections which occur in crushing injuries of the chest wall

may produce crepitant bulging in soft tissues, but the circumstances make it

unlikely that the infection will be confused with a true hernia of the lung.

74G-041V—65 15
198 THORACIC SURGERT

8jPässs

B

FIGURE 65.—True hernia of lung. A. Anterior view showing retraction of

chest wall when patient holds breath. B. Anterolateral view showing bulging

on forced expiration. This patient sustained a penetrating shell-fragment

wound through the anterior chest wall, with loss, by injury and subsequent

debridement, of the third and fourth costal cartilages and the anterior segments of the corresponding ribs. Three weeks after injury, protrusion and retraction of air-containing tissue were noted through the defect in the chest

wall. The phenomenon was not attended with symptoms. When the patient

was evacuated to the Zone of Interior, roentgenograms showed periosteal regeneration and it was thought that, with stabilization of the chest wall, the

pulmonary hernia would undergo spontaneous cure.

Management

Because of the infrequency of hernias of the lung, it is not possible to make

many definitive statements about their management. Emergency measures

were not necessary, and there was no indication for operation overseas. The

symptoms could be easily controlled by pressure dressings over the defect, and

spontaneous healing was always a possibility.
COMPLICATIONS AND SEQUELAE 199

Except for such complications as might be introduced by the wound, there

was nothing in the management of pulmonary hernias of traumatic origin

encountered in wartime that differed from the management of similar hernias

in civilian practice. Operation was always performed under endotracheal

anesthesia, to avoid risk when the pleura was opened widely, as well as to leave

the lung in the desired state of inflation after operation.

At Walter Eeed General Hospital, tantalum plates were employed tentatively, but the method had to be abandoned because of the impossibility of

maintaining immobility of the plate on the constantly moving thorax. In the

five true hernias in which operation was performed at this hospital, plastic

repair was accomplished with structures of the chest wall only (rib, periosteum,

and muscle.) The most important feature of the repair was coverage of the

defect in the chest wall with sturdy bone or with periosteum that would produce bone. After appropriately located ribs had been divided and released

from their periosteal envelopes, they could be shifted until the gap was bridged.

They were then anchored in the desired position by pericostal fixation, by

suture to the fascia or adjoining periosteum, or by fastening the mobilized rib

to an adjacent rib with absorbable sutures threaded through drill holes.

An essential point of repair was the creation of a local pneumothorax, so

to speak, by freeing of adhesions and of lung tissue about the margins of the

hernia orifice. The pneumothorax thus produced acted as a cushion between

the lung and the freshly repaired chest wall and reduced to a minimum the

chances that the lung would be forced into the chest wall if the patient coughed

or strained immediately after operation, when the repair was weakest.

Case History

Case 5.—This 25-year-old soldier sustained a penetrating shell-fragment wound of the

right chest on 15 January 1945. Treatment consisted of closure of the wound by suture,

intercostal water-seal drainage for 3 or 4 days, and three aspirations of the chest.

When he was admitted to Walter Reed General Hospital about 6 weeks later, his only

complaint was mild pain in the right chest, not associated with hemoptysis or cough. A

well-healed linear scar, 11 cm. long, was present in the right anterolateral chest. A second,

well-healed scar, 9 cm. in length, was present along the vertebral border of the right

scapula. Percussion and auscultation of the chest revealed no abnormalities. Roentgenologic examination revealed a metallic foreign body, 7 by 7 mm., and several smaller metallic foreign bodies, in the right lung. A defect in the right sixth rib laterally measured

8 centimeters. It was possible to insert three fingers into this defect for about 1 centimeter. When the patient coughed, as well as on forced expiration, with the glottis closed,

there was a definite bulging through the defect.

Operation was performed on 8 June 1945, under endotracheal ether anesthesia, by

the following technique (fig. 66) :

An incision was made over the defect in the right anterolateral chest wall at the

level of the sixth rib. The skin and muscles were divided. When the muscles were dissected free, the lung was exposed. It was found adherent to the chest wall. The adhesions were divided and the lung was separated from the chest wall over an area 10 cm.

in diameter.
THORACIC SURGERY

>A'1

B

a

„ OUP>/A

1RC"

FIGUKK 06.—Technique of repair of pulmonary hernia. A. Division of muscles of chest wall (a), disclosing margins of defect (b),

adherent lung, and plenral sac (c). B. Release of lung (a) and

pleural sac from margins of defect.
COMPLICATIONS AND SEQUELAE 201

FIGURE GC.—Continued. C. Development of intercostal

muscle bundles, to be used as first layer in closure of defect.

D. Approximation of intercostal muscle bundles with medium

silk sutures. Development of periosteal flaps from ribs above

and below margins of defect.
202 THORACIC SURGERY

EIGUKE 6G.—Continued. E. Suture of periosteal flaps over intercostal muscles to form second layer of closure and complete

repair.

The periosteum of the fifth and seventh ribs was developed into flaps, which were

sutured in place to bridge the defect. The first layer of closure consisted of intercostal

muscles brought together with interrupted sutures of medium silk. The ribs were then

approximated with retractors, and the two flaps of periosteum were joined with interrupted

sutures of medium silk. No effort was made to reinflate the lung, because, as just pointed

out, it was desirable to maintain a residual localized Pneumothorax for a time. The

muscles of the chest wall were brought together with interrupted sutures of fine silk, and

the skin was similarly closed, without drainage.

Convalescence was entirely uneventful. The wound healed per primam. The soldier

was sent on a convalescent furlough 4 weeks after operation, and when he was reexamined

on 14 August 1045, the area of the defect was firm, and there was no evidence of recurrence

of the hernia.

RESIDUAL SYMPTOMS

General Considerations

A large number of patients who had sustained chest injuries presented

a triad of residual symptoms, consisting of shortness of breath, soreness of the

chest, and paresthesias or pains in the affected side. These symptoms were

observed at various times after wounding, in both oversea and Zone of Interior

hospitals. At the Walter Reed General Hospital, they constituted the most

serious obstacle to returning men with chest injuries to full duty within a short

period of time.

Dyspnea was usually mild, but it appeared on very little physical exertion, and most patients complained of reduced exercise tolerance. It was often

necessarv for them to fall out of ranks.
COMPLICATIONS AND SEQUELAE 203

Pain was usually vague and usually parestlietic in nature. The patient

distinguished it from soreness, which most of them complained of at night,

when they tried to sleep on the affected side.

Except for variations in degree, the symptoms were consistent. They bore

no discernible relation to the type of injury sustained. They were as frequent

in simple penetrating wounds of the chest with no consequences beyond hemothorax as they were in more severe injuries. They occurred whether or not

thoracotomy had been performed. They also occurred whether the soldiers

were returned to combat duty or were given limited-duty assignments.

Special Studies

When this problem became of importance in thoracic surgery centers in

the Zone of Interior in chest casualties who otherwise could have been returned

to duty, it was found that very little was known about it. There were no subjective studies of dyspnea on exertion in such cases, and no objective studies

by determinations of the vital capacity to investigate possible permanent

damage.

At the Walter Eeed General Hospital, a study of the intercostal pain and

numbness which followed thoracic injury was undertaken by Maj. Donald L.

Kose, MC. Three methods were used:

1. The patient was asked to outline the painful area on his chest wall.

2. A complete neurologic examination was made.

3. Skin resistance tests were carried out by the Richter technique, to check

the impressions gained by other examinations.

With few exceptions, the patient's own zoning of pain points on his chest

wall corresponded with the results of the skin resistance tests. In the few

cases in which the results of the examinations did not coincide, it was thought

safe to discount the symptoms.

These studies established three practical points:

1. There was no satisfactory treatment for damaged intercostal nerves once

they had been injured. Intercostal nerve block provided temporary relief, but,

once the immediate effects had disappeared, the pain was sometimes more severe

than it had been originally.

2. Injury to a single intercostal nerve did not cause serious residuals.

3. If three consecutive nerves were crushed or cut, prolonged discomfort

followed, and it was serious from the standpoint of future vigorous activity.

Major Rose's study showed that residuals from the bruising of a single

nerve were of little consequence, whether it was damaged during rib resection

or in the course of an intercostal incision. Injury of at least two nerves was

necessary to produce symptoms. Pressure transmitted from the rib-spreading

retractor was apparently of little consequence.
204 THORACIC SURGERY

Management

This problem was of extreme importance in military medicine. In civilian

practice, it would have been considerably less serious. A civilian with discomfort after a chest injury could generally avoid activity which might aggravate it. The situation was quite different in military service, in which the

soldier who was ordered to drill, carry a pack, or perform some other activity

had no recourse but to obey orders as long as he was on active duty.

In military practice, furthermore, the medical officer was obliged to make

a decision as to the validity of the patient's complaint. He had to consider

seriously whether the pain was genuine and severe, or whether the soldier was

motivated by a desire to escape active duty or to be separated from service. If

the surgeon discounted the symptoms and sent the soldier off to duty when lie

was really unfit for it, he might do him a serious injustice.

Since the etiologic factors in postwounding discomfort were not clarified

during the war, treatment was unsatisfactory. The variable results in nerve

block have already been mentioned. Psychotherapy was useful in some cases.

As a result of the study conducted at "Walter Reed General Hospital, it

was concluded that the solution of the problem was preventive, to exercise extreme care in handling intercostal nerves at operation and to avoid, as far as

possible, any surgical technique that might traumatize them unnecessarily. The

corollary of this reasoning was that pericostal and perichondral sutures should

not be used. Encircling sutures of this kind had been used in a number of the

patients observed, with resultant temporary destruction of two or more nerves.

Surgeons at Walter Reed General Hospital believed that it was seldom

necessary to employ pericostal and perichondral sutures to accomplish a satisfactory closure of the chest wall. If the wound was posterior, particularly if

a segment of rib had been resected, it was not necessary to hold the ribs together

by sutures. Even when an intercostal incision was employed, there was usually

sufficient tissue to close the defect without fixing the exposed portion of the

thoracic cage with encircling ties.

The following technique was found satisfactory for the closure of practically all surgical wounds of the chest:

Interrupted sutures were placed in the intercostal muscles while the ribs

or cartilages were brought together with retractors. The placing of the instruments was important: The lower retractor must be placed not in the interspace adjacent to the wound but at least one interspace lower. The pressure

from this retractor would be transmitted directly against the nerve on the inferior edge of the rib if it were placed in the adjacent interspace. By placing

it one or two interspaces lower, injury to two or three consecutive intercostal

nerves, which this study had shown to be responsible for painful sequelae, could

be avoided.3

3

The reader is referred to chapter XI (p. 441) for long-term followup studies on casualties with

a number of the complications of thoracic wounds described in this chapter.
COMPLICATIONS AND SEQUELAE 205

References

1. Drinker, C. K., and Warren, M. F.: The Genesis and Resolution of Pulmonary

Trausudates and Exndates. J.A.M.A. 122: 269-273, 29 May 1943.

2. Meade, R. H., Jr.: The Tensile Strength of the Paralyzed Diaphragm. Preliminary

Report. J. Thoracic Surg. 2 :503-516, June 1933.

3. Funk, E. II.: Hernia of the Lung, With Report of Case of Spontaneous Hernia of

the Right Lung. Internat. Clin. series 28, 1:102-107, 1918.

4. Makins, George Henry: Surgical Experiences in South Africa, 1899-1900. London:

Smith, Elder, & Co., 1901.

5. Adams, E.: Hernia of the Lung, With Report of a Case of Spontaneous Hernia of

the Right Lung. Am. Med. G (n.s.) : 41-43, January 1911.

740-041'—03 IG
CHAPTER V

Wet Lung

Thomas H. Burford, M.D.

CONCEPT AND GENERAL CONSIDERATIONS

During the first year of fighting in the North African Theater of Operations, U.S. Army, it gradually became apparent that casualties with fluid in the

lungs, in contrast to those whose lungs were dry, presented many difficulties of

management. They required strenuous efforts at resuscitation if they were in

shock, and they did not respond well to them. They presented poor surgical

risks when emergency surgery was necessary. They were prone to develop

postoperative pulmonary complications, especially if they had coughed up

large amounts of blood before operation. Fatalities were proportionately more

frequent among them than among casualties with similar wounds whose lungs

did not contain fluid. When these patients came to autopsy in forward

hospitals, pulmonary edema was the most prominent finding.

Although most surgeons in the theater were aware of the phenomena just

described, the extreme seriousness of the problem was not immediately realized.

There was nothing in the civilian experience to call attention to pulmonary

edema as an immediate consequence of thoracic injuries.1 As a result, more

than a year was to pass after the onset of fighting in North Africa before the

concept of what came to be known as wet lung was developed and appropriate

methods of treatment were devised.

The term "wet lung" and the concept which underlay it were first presented

by Maj. Thomas H. Burford, MC, and Maj. Benjamin Burbank, MC, at a meeting of Fifth U.S. Army surgeons at the 38th Evacuation Hospital at Kiarclo

in February 1944. At the same time, they discussed its etiology and outlined the

principles of prevention and correction.

In their first presentation on this condition, Major Burford and Major

Burbank described wet lung as a more or less specific response of the lung

and chest wall to trauma. They postulated the operation of a soinatovisceral

reflex oriffinatino- in the chest wall and mediating alveolar and bronchiolar

1

In 19.37, Betts and Overholt (1) described a syndrome which sometimes occurred from 24 to 4S

hours after thoracic surgery, usually at night, and which consisted of slight cyanosis, noisy respirations, depression of the cough reflex, and a shocklike state. No matter how hard the patient tried,

he could not raise the secretions whose retention was producing anoxia and anoxemia. The only way

to break the cycle was to remove the retained secretions, for which bronchoscopic aspiration was

necessary. In a number of respects, this syndrome seems to resemble the wet lung encountered in

combat-incurred injuries.

207
THORACIC SURGERY

responses. They particularly emphasized the part played by the painful chest

wall in the pathogenesis of wet lung. It was the chief explanation of the

patient's inability to raise the secretions formed in excess as the result of trauma.

The immobilization of the chest wall made effectual coughing impossible, and

the result was the saturation of the tracheobronchial tree with secretions which,

under normal circumstances, would have been coughed up.

Major Burford and Major Burbank further suggested that a definite

one-two relation probably existed between the wet lung of trauma and the

massive pulmonary collapse which was so common in World War I. Their

theory was that the wet phase, which was not recognized, precipitated the second

phase, in which massive collapse occurred (p. 210).

The concept of wet lung, as presented by Major Burford and Major Burbank, was precise and specific. Later, Maj. Lyman A. Brewer III, MC, and

other chest surgeons in the Mediterranean Theater of Operations, U.S. Army,

expanded the original concept into a looser, broader concept of traumatic wet

lung. In this later concept, the term "wet lung" was used for all forms of

retained tracheobronchial fluid resulting directly or indirectly from trauma.

Becognition of the importance of wet lung in no wise detracted from the

importance of the primary lesion or of associated injuries. On the contrary,

it permitted a more rational approach to the entire problem of combat-incurred

chest injuries. The important considerations stressed by Major Burford and

Major Burbank were as follows:

1. The chest reacts to trauma- in a way peculiar to itself, whether the injury

is a slight contusion of the chest wall or a severe penetrating or perforating

injury.

2. The reaction caused by trauma profoundly influences the whole pathologic process, the therapy applied, and the prognosis.

PATHOGENESIS AND PATHOPHYSIOLOGY

The pathogenesis of wet lung can be understood only if the normal physiology of the respiratory tract is borne in mind. In addition to its function

as an airway, the tracheobronchial tree has a definite secretory function, combined with the capacity to rid itself of its own secretions and of aspirated material or other fluid substances which do not normally belong within its lumen.

Evacuation of the tracheobronchial tree is accomplished (1) involuntarily, by

action of the cilia and movement of the bronchial musculature, and (2)

voluntarily, by coughing.

In spite of the extensive experience of World War II, little is yet understood concerning the effect of trauma to the chest on the function of the

bronchial cilia and on other factors influencing the passage of secretions

through the tracheobronchial tree. The presumption seemed warranted that

after trauma, these functions became depressed or were perhaps entirely interrupted. Clinically, it was clear that the normal consrh mechanism was
WET LUNG 209

seriously impaired in the presence of moderate and severe trauma, and sometimes of slight trauma.

The lung, which is a specialized organ, reacts to trauma in just as specialized a manner as does the brain or any other specialized organ. In combat

casualties with chest injuries, the pulmonary reaction took two forms:

1. The production of an excess of secretions or, in the broader concept of

Major Brewer and his associates, of transudates and extravasated blood also.

2. The development of conditions which prevented the normal and adequate elimination of these fluids.

At present, there is insufficient evidence to permit formulation of a precise

explanation for this dual process. Experimentally, de Takats and his associates (2) demonstrated that any appreciable trauma to the chest wall was

followed almost immediately, in 60 percent of the animals, by widespread

bronchial spasm and increased bronchial secretions. Bronchial spasm of the

same degree could also be produced by stimuli applied within the abdomen,

such as traction on the cystic duct or the mesentery.

It would be tempting to apply these experimental results to combat casualties and to postulate the existence of reflex bronchial and bronchiolar spasm

originating after trauma as the result of a painful chest wall or pleura, but

there are two reasons why the transfer would not be justified:

1. The whole case for bronchospasm rests on evidence that is still far from

acceptable.

2. The hypothesis of bronchial spasm would explain only part of the

phenomena observed in traumatic wet lung.

Even though it was not possible to explain the initial effect of thoracic

trauma on the function of the tracheobronchial tree, the course of events afterward was quite clear:

1. The presence in the tracheobronchial tree of mucoid secretions in far

more than normal amounts, as well as of transudates, blood, and aspirated material caused a mechanical obstruction and prevented adequate oxygenation of

the alveoli.

2. With the suppression of the normal cough reflex, th& tracheobronchial

tree became increasingly less capable of eliminating secretions, and more fluid

accumulated in it.

3. As these conditions continued, less oxygen became available to the

pulmonary capillaries. It could be assumed from the work of Drinker and

Warren (3) that anoxia increased capillary permeability and permitted more

plasma to be lost into the tissues. Increased amounts of fluid extravasated

from the pulmonary capillaries into the alveoli further decreased the oxygen

available for the bloodstream.

4. The plugging of branch bronchi with secretions prevented the exchange

of gases in the lobules supplied by these bronchial divisions, and lobular atelectasis resulted.
210 THORACIC SURGERY.

5. Plugging of a branch bronchus to a lobe or of a stem bronchus to a lung

increased the anoxic anoxia that was the result of partial obstruction, for two

reasons: (1) The alveolar bed available for the absorption of oxygen was far

smaller than normal, and (2) sooner or later, a mediastinal shift resulted.

When blood was present in the tracheobronchial tree as the result of

trauma, it could, in itself, cause bronchial obstruction. It also had another

effect, that the irritation of the bronchial mucosa that it caused was responsible,

in turn, for an increase of tracheobronchial secretions.

When wet lung appeared soon after wounding, its most potent effect was

the promotion of anoxia. When it persisted or was allowed to progress without

treatment to the point just described, it paved the way for subsequent pulmonary

complications. A patient who was not too severely wounded and in whom

other conditions were favorable might recover from his initial shock without

complete removal of the fluid that was producing obstruction of the tracheobronchial tree. In such an instance, however, the causative factors were unchanged, and the stage was set for the development of tracheobronchitis,

atelectasis, pneumonitis, and pneumonia. Wet lung sometimes seemed to be

the chief factor upon which the outcome of an injury hinged. Failure to take

active measures to combat it could lead to chronic pulmonary invalidism, and,

before this complication was clearly understood, more than one patient with an

uncontrolled wet lung died from this cause alone.

It was of the greatest importance that anoxia be relieved promptly. If

it was not, serious changes occurred in other organs, particularly in the central

nervous system, which is highly sensitive to an oxygen deficit. Severe cerebral

anoxia, even if it persisted for only a short time, could result in serious cortical

impairment. The psychotic manifestations and coma observed in some patients

with chest injuries could reasonably be attributed to this cause.

There was clear clinical evidence of the relation of the pathophysiologic

disturbances produced by wet lung to the patient's general status. In numerous instances, shock which had not responded to standard replacement therapy

and other resuscitative measures, or which had become deeper as they were in

progress, cleared up quickly, and even dramatically, when appropriate- measures for the relief of wet lung were instituted.

As clinical experience accumulated, the theory seemed reasonable that a

definite relation might exist between the wet lung of trauma as it was recognized in World War II and the massive pulmonary collapse described by

Pasteur (4) in 1914 and described later, under the name of acute massive

atelectasis, by Churchill (5). It was an attractive hypothesis to conceive of wet

lung as the antecedent stage, and in a sense the precipitating cause, of silent

massive pulmonary collapse.

Such an assumption would explain the extreme rarity of massive pulmonary collapse iii the Mediterranean theater, where surgeons became increasinglv alert to the recognition of wet lung and increasingly vigorous in its
WET LUNG 211

treatment. Minor degrees of atelechisis were frequently observed in cases of

wet lung which were inadequately treated.

ETIOLOGIC FACTORS

The events just described were most often observed after chest injuries.

Wet lung, however, Mas a possibility in other injuries, including thoracoabdominal injuries, abdominal injuries, and head injuries, particularly those that

were associated with coma and unconsciousness.

Usually, though by no means always, the degree of wetness depended upon

the type and severity of the primary lesion, the size and velocity of the missile,

and whether or not the missile had struck a portion of the bony cage or only

the soft tissues. The size of the intrapulmonary vessels that were damaged

had a bearing on the amount of blood extravasated. Wet lung was present to

some degree in practically all cases of thoracic trauma, though it might be

transitory or so slight as to be almost unrecognizable clinically even when it

was carefully searched for. Sometimes, too, the primary thoracic lesion was

of such severity that it masked the underlying physiopathologic substratum.

In many cases, on the other hand, wet lung was present to a far more severe

degree than might have been expected from the relative mildness of the initial

wounds.

A number of other factors played a part in the causation of wet lung:

Pain

Pain was an almost invariable component of chest trauma. Its exact influence in the production of wet lung was never fully clarified, but there was

no doubt that it played an important part in both its inception and its progress.

It had at least three harmful effects:

1. It induced a shallow type of respiration, for protective reasons.

2. The natural reaction to pain was voluntary splinting of the affected

area.

3. The affected hemithorax therefore moved less than the unaffected side,

with a resultant decrease in the movement of air back and forth in the bronchi.

A decrease in the tidal respiration was probably of more importance than was

at first recognized, as it lessened the amount of secretion that might be disposed of by evaporation.

Suppression of the Cough Reflex

The normal voluntary cough mechanism consists of four steps:

1. The air is drawn voluntarily into the lungs by raising the ribs and

lowering the diaphragm.

2. The breath is held momentarily by closing the glottis.
212 THORACIC SURGERY

3. The abdominal muscles are tensed, the intercostal spaces are narrowed,

and the diaphragm is relaxed to provide explosive force.

4. The glottis is then suddenly opened, and the bechic blast required to

raise the sputum is thus released.

A number of conditions present in chest trauma prevented the succession

of steps just listed, all of which are necessary for effective coughing. Pain

arising in either the chest wall or the pleura prevented both expansion and

forceful contraction of the thorax. Rib fractures were frequently associated

with severe pain when either coughing or deep breathing was attempted. If

there were multiple fractures of the ribs or of the sternum, with a resulting

flail chest, the paradoxical movement of the chest wall made effective coughing

impossible. On inspiration, it moved outward. Attempts at coughing simply

aggravated these paradoxical movements.

Wounds that caused abdominal pain, whether they were located in the

abdomen or in the chest, prevented the tensing of the abdominal muscles necessary for an effective cough. The pistonlike action of the diaphragm, which is

a part of the act of coughing, was impossible in a diaphragmatic injury. Ileus,

acute dilatation of the stomach, and the presence of free fluid in the peritoneal

cavity also had a more or less inhibitory action on the cough mechanism.

Sedation and Anesthesia

Oversedation from the too-liberal use of morphine was a fairly frequent

contributing cause of wet lung. As their experience increased, shock officers

in field and evacuation hospitals learned to be constantly on their guard against

giving morphine to freshly wounded casualties. Often the patients did not

need it at all. They were simply apprehensive as the result of anoxia and

disturbed and uncomfortable from the ambulance ride. When morphine was

really needed, it was given intravenously, not subcutaneously, in a/4-gr. or at

most y'o-gs. doses.

Early in the war, as pointed out elsewhere (vol. I), and much less often

later in the war, casualties with fractured ribs, flail chests, and other painful

thoracic and abdominal wounds often arrived in the shock wards of field and

evacuation hospitals with overclosages of morphine compounding their original

difficulties. For a variety of reasons they had received too much medication.

Respiratory distress was sometimes as inherently frightening to the inexperienced medical officer as to the casualty, and efforts made by these officers to

relieve the patient were sometimes as frantic and ineffectual as the patient's

own efforts to get his breath.

Whatever the background, oversedation invariably led to an increase in

the accumulation of secretions in the tracheobronchial tree and a decrease in

the cough reflex. As a result, shock was increased, and preparation of the

casualty for emergency surgery or for further evacuation became more difficult.
WET LUNG 213

Prolonged administration of an inhalation anesthetic to a patient in poor

condition, whose reaction was delayed after operation, often led to the retention of bronchial secretions and to later pulmonary complications. This was

particularly true if the airway had not been kept clear by catheter suction

during the operation and if bronchoscopy had not been performed at the

conclusion of the procedure when there was any doubt at all about the efficacy

of suction.

Preexistent Respiratory Infection

It was not unusual for secretions to be present in the bronchial tree before

injury. Soldiers who had undergone exposure during combat, particularly

during the cold, wet months of winter, frequently had upper respiratory infections or frank bronchitis, associated with mucopurulent secretions. In the

Mediterranean theater, preexistent respiratory infections were often aggravated by the circumstances of evacuation. During the mountain fighting in

the winter of 1943^4, casualties had to be brought down the mountain by litter

carry. Often as many as 8 to 12 relays were required between the battalion

aid station and the collecting station. As a result, exposures of 12 hours or

more after wounding were not unusual.

Overhydration

]STo matter how urgently replacement therapy might be needed, it had to be

instituted judiciously in patients whose cardiorespiratory physiology was disturbed after wounding (vol. I). The administration of too much plasma in

battalion aid and clearing stations, or even of too much blood in field and

evacuation hospitals, might place such an extra load on the circulatory system

that pulmonary edema might develop and contribute to the etiology of wet lung

arising directly from the wound.

CLINICAL PICTURE

Wet lung usually appeared shortly after wounding, sometimes within a

few hours. Less often, it did not develop for as long as 5 or 6 days after injury.

The presence of abnormal amounts of fluid in the tracheobronchial tree in

thoracic injuries was manifested by certain cardinal symptoms and signs, the

early recognition of which prevented the development of graver complications.

Cough and dyspnea were the chief symptoms, and rales were the predominant

physical finding.

Symptoms.—The cough associated with wet lung was usually described

as a wet cough because of the rattling or gurgling element always present in it.

It might be hacking, harassing, continuous, or paroxysmal. Small amounts of

sputum were often raised by constant coughing, but the cough remained moist;

because there was little expulsive force behind it, it was never fully productive.
2W THORACIC SüRGEBI

Inexperienced medical officers might receive the impression that, because some

sputum -was raised, tracheobronchial drainage was good, but the persistence

of wheezes and rattles in the chest proved that it was still poor. As a matter

of fact, only the most superficial secretions were raised, just as small amounts

of fluid are splashed out from the top of a full cup that is continuously

replenished.

The dyspnea characteristic of wet lung could be explained in a number of

ways. It might be the result of painful, jerky, shallow respirations, each inspiratory effort being limited by the pain that the preceding effort had caused.

When trauma had been considerable, the explanation might be hemothorax or

mediastinal shift. When damage had been minimal, the most reasonable explanation was partial bronchial obstruction with resulting anoxia. Some

patients seemed to be having typical asthma, Apprehension was an occasional

cause of dyspnea.

When dyspnea was extreme, orthopnea, restlessness, excitement, and disorientation were present as the result of cerebral anoxia.

Signs.—The patient's appearance varied according to the severity of his

injury and whether or not he was in shock. Fever and evidences of toxicity

were constantly present in late cases.

Inspirations were frequently grunting because they were painful. Motion

was usually restricted over the involved area of the chest, Breath sounds were

reduced in intensity, but if hemothorax, pulmonary hematoma, or some similar

complication were not associated with the injury, the percussion note and the

tactile fremitus were unlikely to be materially altered.

The most characteristic physical finding in wet lung was the presence of

rales, bronchial in character. They were sometimes heard on both sides of the

chest; their bilateral presence was a valuable diagnostic sign. More often,

they were more intense on the injured side. They ranged from high-pitched

wheezes, which some surgeons considered indicative of associated bronchospasm, to medium or coarse bubbling rales or rhonchi. Rales that were wheezing and high-pitched sometimes had a dry quality. Sometimes fine rales that

were predominantly moist or bubbling were so numerous as to suggest the type

heard in simple, nontraumatic pulmonary edema or in bronchial asthma.

These rales were frequently bilateral. Bubbling, sonorous rales were sometimes heard in combination with a classical trachea! rattle; in such cases the

sputum was predominantly liquid.

Bales were often so loud that the stethoscope was not needed to identify

them. They could be heard at the bedside, or even at some distance from the

patient, just as in typical bronchial ashma. While all varieties and gradations

of rales might be present in any single chest, diffuse moist rales were especially

characteristic of the primary phase of traumatic wet lung.

Bales were sometimes not demonstrable unless the examination was made

immediately after the patient had coughed. They might not be heard at all if

sticky mucus was attached to the tracheal or bronchial wall or if a branch
WET LUNG 215

bronchus was completely blocked. In such cases, fine crackling sounds could

usually be heard if the stethoscope was placed over the patient's mouth.

As already indicated, a coexistent hemothorax, pneumothorax, or some

other finding might so alter or mask the typical clinical symptoms and signs of

wet lung that its existence would not be suspected unless the medical officer bore

the possibility in mind.

DIAGNOSIS

Clinical observations.—In early stages of traumatic wet lung, the evidence

of moisture obtained by auscultation was the most important diagnostic sign.

The presence of rales anywhere in the chest, even over portions not involved in

the trauma, was a valuable clue, indicating as it did that wet lung was either

present or in process of development.

In advanced cases, the diagnosis, as already stated, could sometimes be

made without the use of the stethoscope because dyspnea was so obvious and

rales were audible even at a distance from the bed. The physical findings in

late cases were those ordinarily observed in atelectasis and pneumonia. Distant bronchial breathing was often heard over small areas of the chest and

might represent either patchy lobular atelectasis or a pneumonic process. The

diao-nosis of wet lung was established if the intensity or location of bronchial

breathing changed with forced coughing.

The character of the secretions raised was also of diagnostic significance.

Hemoptysis usually denoted pulmonary injury; the blood was fresh-looking

when hemorrhage was recent and was clotted and mixed with mucus when it

was not. If the secretions were the result of reflex stimuli from trauma to the

chest or irritation from aspirated material, or were part of a very early infection, they were likely to be mucoid. As infection developed in the bronchial

tree, they became increasingly purulent. The presence of purulent sputum

could sometimes be explained on the basis of a preexisting respiratory infection

and sometimes by the development of a new infection in the stagnated bronchial

secretions. Thin, yellow, pink or colorless fluid, often frothy because of the

admixture of air, indicated the pulmonary transudation and exudation (edema)

typical of more advanced wet lung. Then, serosanguineous fluid suggested

hemothorax with bronchopleural fistula. Similarly, thin, seropurulent fluid

suggested early empyema with bronchopleural fistula. Most often, the sputum

represented a combination of the types described rather than a single, clear-cut

type.

Roentgenologic examination.—While roentgenologic examination was

highly desirable in all instances of chest trauma, it was always deferred until

the patient was brought out of shock and steps had been taken to dry out the

tracheobronchial tree.

The roentgenograms, which were taken, whenever possible, in at least two

planes, were frequently difficult to interpret and were not always useful. In

the initial stages of wet lung, roentgenologic changes were minimal, even when
216 THORACIC SURGERY

there was clinical and auscultatory evidence of a considerable degree of obstruction and moisture. Patchy lobular atelectasis in the early stages might be indistinguishable from the shadows cast by a pulmonary hematoma (p. 165) or

the pathologic process present in pulmonary contusion (p. 4). When intrapulmonary bleeding had occurred, the shadows were likely to be round or oval.

When a hematoma was present, there might be evidence of small, loculated

air pockets. Later, when lobular or total pulmonary atelectasis had occurred,

the collapse of the affected parts of the lung produced the classical signs of

mediastinal shift and narrowing of the intercostal spaces.

On the whole, while roentgenologic examination was sometimes useful and

was never omitted because of the chest injury, the diagnosis of wet lung in the

early stages was a clinical matter.

Differential diagnosis.—As a practical consideration, the question of differential diagnosis seldom arose in connection with traumatic wet lung. Theoretically, the condition had to be distinguished from bronchial asthma, pulmonary edema of cardiac origin, and pulmonary edema associated with

peripheral vascular failure.

The differentiation was not difficult, The history of trauma and the

absence of any history of previous asthmatic attacks promptly ruled out bronchial asthma. Since the young soldier was almost never a cardiac subject, the

necessity of differentiating traumatic wet lung from pulmonary edema of

cardiac origin almost never arose. Occasionally, however, patients with thoracic

injuries had had such vigorous intravenous fluid therapy that the blood volume

had become too much for an already embarrassed respiratory mechanism and

right heart failure had supervened. In such cases, the manifestations of wet

lung were interwoven with, and intensified by, those of right heart failure.

Pulmonary edema associated with peripheral vascular failure either from

shock due to severe trauma or from an overwhelming toxemia was sometimes

difficult to differentiate from wet lung, particularly when shock was associated

with the latter. The nature of the exciting lesion, the pallor, low blood pressure, tachycardia, and weak, thready pulse had to be evaluated, as well as the

response to attempts to clear the tracheobronchial tree. In wet lunsr, the response was usually rapid. If the pulmonary edema was assoeiated\vith peripheral vascular failure, it would not respond to the therapy indicated for

wet lung because its etiology was different,

PROPHYLAXIS

As was their experience accumulated, medical officers came to realize that it ., „„

the part of wisdom to regard as a potential candidate for wet lung every

casualty with a chest wound, a thoracoabclominal wound, a severe abdominal

injury, or a head injury. On their admission to forward hospitals, all patients

in these categories, particularly those who complained of thoracic pain or who

presented dyspnea, wheezing, hemoptysis, and a cough, were carefully examined
WET LUNG 217

for evidences of fluid in the pulmonary tree. The following routine was carried

out:

1. Unless the patient was in shock or unconscious, he was placed in

Fowler's position, so that the abdominal contents would gravitate into the

pelvis. The diaphragm could thus act more effectively, with corresponding

improvement in respiration and in the efficacy of the cough. The position

was changed frequently if the patient could not turn himself. This measure

was not always stressed as it should have been.

2. If the patient was dyspneic or cyanotic, oxygen was administered by

nasal catheter or by the Boothby-Lovelace-Bulbulian mask.

3. If his breathing was at all wet, the patient was encouraged to cough

(fig. 67A), the chest being supported manually whenever personnel could be

spared for this purpose. The physical support of a painful chest was helpful,

and the psychic effect was excellent; the patient was impressed with the importance of coughing because someone took the time and trouble to help him to do

so. If he was sufficiently alert to comprehend, as already mentioned, the importance and rationale of coughing were explained to him, which made him much

more willing thereafter to cough, in spite of any associated discomfort.

4. If the patient was conscious, complained of pain, and had evidently had

no previous sedation, a small close of morphine sulfate, preferably not more than

gr. Vs, was given by vein, so that it would act promptly and its effect on the painful chest could be more accurately evaluated.

5. The usual measures employed in all chest wounds were carried out. If

the dressing covering a sucking wound was not already airtight, it was rearranged. The indicated resuscitative measures were instituted, with great care

not to overload the circulation with fluids. The gastric tube was inserted if

there was evidence of ileus or gastric distention (fig. 67B). If a hemothorax

or tension pneumothorax was present, aspiration was employed to increase the

vital capacity.

If wet lung had not yet become established but was merely impending or

incipient, these measures were usually effective and the patient rapidly became

a fit candidate for surgery in a forward hospital or could be safely evacuated to

a fixed hospital.

MANAGEMENT

Principles

As already pointed out, the various factors responsible for wet lung constituted a vicious circle. They included accumulation of secretions in the smaller

bronchi; limitation of normal respiratory motion because of pain; the suppression of the cough reflex, as well as of the desire to cough, because of pain; and

the resultant effect of the wet lung on the oxvgenation of the blood.
218 THORACIC SURGERY

FIGURE 67.—Management of patient with wet lung. A. Clearance of chest by coughing,

with patient supporting his own ehest, B. Insertion of Levin tube for control of gastric

dilatation. C. Application of elastic binder for stabilization of flail chest or external fixation of fractures. D. Intercostal nerve block (for details of technique, see fig. 68). E.

Aspiration of bronchi by catheter passed transnasally. F. Bronchoscopy, which is resorted

to if catheter aspiration is not successful. G. Administration of intermittent positive

pressure oxygen therapy by manual compression of ventilatory bag of field hospital portable anesthetic machine.
WET LUNG 219

Breaking- this vicious circle by attacking its various components was the

basis of the active therapy of established wet lung. In its active management,

as well as in its prophylaxis, the principal aims of therapy were:

1. The maintenance of an open airway, so that inspired oxygen could

reach the alveolar capillaries.

2. The prompt correction of conditions that were contributing to dyspnea,

anoxia, and shock.

To achieve these aims, it v.-as necessary to control the production of fluid

in the lungs and to promote adequate bronchial drainage, as well as to institute

such other measures as were necessary to correct the disturbed cardiorespiratory physiology.

Relief of Pain

Relief of pain and physiologic remobilization of the chest wall after

thoracic injury were the sine qua non of a successful therapeutic effort in wet

lung. In prewar civilian practice, the desired results had been achieved by

adhesive strapping and the administration of morphine. These measures had

never been physiologically sound. In combat-incurred injuries, both were ineffective, and even in stove-in chest, they were not necessary.

In severe flail chest with extreme paradoxical respiration, strapping of

the chest or the use of a firm binder was occasionally necessary to prevent ballooning out of the chest wall (fig. 67C). The method was never officially forbidden, but with these very occasional exceptions, its use was avoided.

The administration of morphine was equally undesirable. It made the

patient less aware of his discomfort, it is true, but it did not make the cough

mechanism painless, and it diminished the cough reflex. Furthermore, by

dulling the sensorium, it made the patient less aware of his own responsibility

for overcoming his respiratory difficulties.

Intercostal Nerve Block

The most effective method of relieving chest pain and making it possible

for a casualty with a chest wound to evacuate the tracheobronchial tree by

coughing was intercostal nerve block at the site of injury (fig. 6TD), or, alternatively, paravertebral sympathetic nerve block. One reason that it was necessary to employ both the intercostal and the paravertebral techniques of

nerve block was that certain wounds were so situated that simple intercostal

block was not always feasible.

Whether intercostal nerve block did more than abolish pain and effect

an interruption of the reflex arc was a matter of speculation. It was, however,

a logical procedure. According to Lewis (6), afferent pain, impulses from the

thoracic abdominal wall are transmitted by way of the sympathetic nerves,

whose fibers accompany the intercostal nerves as far as the intervertebral foramina, whence they depart as rami communicantes to form part of the paravertebral sympathetic chain. There seemed little difference, therefore, between
THORACIC SURGERY

interrupting the pain pathway by blocking the intercostal nerves or blocking

the paravertebral chain through which pain impulses pass.

The nerves could be anesthetized at any point posterior to the lesion. At

least three nerves were always injected, to provide a generous margin of anesthesia around the traumatized area. As many as 10 intercostal nerves or paravertebral ganglia could be blocked with safety, but when more than 4 or 5

nerves were to be injected, it was the policy to give a small preliminary close

of some barbiturate, to lessen the risk of a procaine hydrochloride reaction.

Local infiltration, which produced its effects by blocking the sensory end

organs, was effective in simple, uncomplicated rib fractures with contusion of

the chest wall, but it was contraindicated in casualties with open wounds, because all such wounds were potentially if not actually contaminated. Furthermore, the involved area in casualties with open wounds was frequently too

extensive for local infiltration to be practical. This was sometimes, however,

a valuable supplement to an extensive blocking procedure after which a small

localized area of pain occasionally persisted, though an otherwise effective

block had been obtained.

If the site of injury were so located posteriorly that even paravertebral

block would require injection through contaminated tissue, paravertebral block

incorporating at least two nerve segments above the superior margin of the

injury was useful, for it blocked an appreciable number of the pain impulses

which travel cephalad in the paravertebral sympathetic chain.

Technique of nerve block.—The needles used for intercostal nerve block

were ordinary intravenous needles, iy2 inches long. A 1-percent solution of

procaine hydrochloride was usually used, though, an occasional surgeon preferred a 2-percent solution. An intradermal wheal was raised over the chosen

rib at its angle over the inferior border of the rib between the costal angle and

the wound or fracture site (fig. 08). Then the needle, without the syringe attached, was introduced through the wheat until the point had impinged lightly

upon the inferior margin of the rib. From this point, with the bevel directed

inferiorly, the needle was moved until the tip just cleared the inferior edge of

the same rib. After the needle had been advanced about 0.5 cm., aspiration was

carried out in two planes, to exclude the possibility that it might have entered a

blood vessel. When this point had been settled, from 4 to 6 cc. of 1-percent

procaine hydrochloride solution was introduced into the tissues. The total

number of thoracic segments injected was determined by the number of ribs

fractured or, if the lesion was a simple contusion, by the area involved.

Needles 3 or Zy2 inches long were preferred for paravertebral nerve block.

A small piece of loose rubber on the shaft indicated the depth to which the

needle was to be inserted.

Paravertebral injection of the thoracic sympathetic ganglia was best performed with the patient in the lateral recumbent or the prone position. The

sites for injection were marked on the skin, opposite the spinous processes and

about 4 cm. lateral to the midline on the affected side. These points lie directly
WET LUNG 221

//

I

^v. \

V

\

\

j.\\

• IS*

%»_, V

IK'-

\

to .;

B C

FIGUISB 6S.—Intercostal nerve block in management of painful wounds of chest wall.

A. Schematic showing of effects of painful chest wall on retention of secretions and on

effectiveness of cough. B. Infiltration of skin and muscles with procaine hydrochloride.

Long needle is gently manipulated until the tip comes into contact with the rib. C. Injection of procaine hydrochloride (3-5 cc. of 1-percent solution) beneath rib four fingers

from spinous process. Care is taken not to inject solution into intercostal vessels.
•>•>'! THORACIC SURGERY

over the transverse processes. The best results were achieved when one or two

ganglia cephalacl to the area of involvement were also incorporated in the block.

The needle, without the syringe, was introduced perpendicularly through

the skin until contact was made with the dorsal surface of the transverse process ; it was seldom necessary to introduce it more than 4 centimeters. The rubber marking was readjusted on the shaft from 3 to 4 cm. from the skin surface

before the needle was withdrawn slightly. Then, with its bevel directed medially, the needle was redirected anteromedially and passed just inferior or just

superior to the transverse process. It was slid along the body of the vertebra

to the depth indicated by the marker. At this location, the tip of the needle lay

in the immediate vicinity of the sympathetic chain.

If, during its insertion, blood or spinal fluid appeared, the needle was withdrawn and was reinserted in a slightly different direction. If blood or spinal

fluid did not appear, the syringe was attached to the needle, and aspiration was

carried out in two planes, to be sure that the needle did not lie in a blood vessel,

in a prolongation of the subarachnoid space, or in the pleural cavity.

If aspiration was negative, 6 cc. of 1-percent procaine hydrochloride solution was injected into the tissues. If the needle had been introduced correctly,

relief from pain was almost immediate, only just enough time being required

for infiltration of the solution through the tissues surrounding the sympathetic

chain.

As soon as either intercostal or paravertebral nerve block had been accomplished, an attendant forced the patient to cough.

If open thoracotomy was necessary in a patient who had not previously

been submitted to nerve block, advantage was taken of the opportunity to block

the nerves under direct vision by injecting procaine hydrochloride solution.

Crushing the nerves with a fine hemostat was a much less desirable procedure.

Results of nerve block.—Blocking out of the pain stimuli by injection of

the intercostal nerves or by paravertebral block produced prompt and often

dramatic results. Pain and discomfort almost invariably disappeared. The

patient was willing to cough because it was no longer painful to do so, and

evacuation of the fluids in the tracheobronehial tree was effected.

It was impossible to overlook the possible influence of nerve block on constriction of the bronchial tree and secretion of mucus. Clinical evidence supported the hypothesis of its role. Frequently, casualties were seen with

respiratory distress that could not be accounted for by the severity of the

thoracic injury, pain in the chest wall, shock, the presence of blood or other

fluid in the bronchial tree, aspiration of gastric contents, infection, or exposure

to noxious gases. Coughing was apparently free and forceful, but wheezing

persisted, and sputum was not raised. Once the intercostal nerves were blocked,

however, the picture changed. Wheezing disappeared promptly, and sputum

was raised freely. The assumption in such cases was that reflex bronchial

spasm probably played some role in tire previous symptoms and signs.
WET LUNG 223

Relief of pain and discomfort after intercostal nerve block lasted for varying periods of time but almost never for less than 24 hours. The block could

be repeated as necessary, but frequently a single injection gave permanent

relief. Why relief of pain extended beyond the period of the pharmacologic

action of the drug is difficult to explain. Possibly relaxation of muscle spasm

and improvement of the blood supply to the traumatized area played some part

in the results.

The beneficial effect of paravertebral block usually lasted from 2 to 4 hours.

One injection frequently gave permanent relief, and more than three were

almost never necessary.

An effective nerve block, in addition to rendering anesthetic the area

innervated by the somatic nerves blocked, sometimes also provided immediate

relief of pain in a referred area, occasionally on the side opposite the trauma.

When the nerves were blocked at thoracotomy, the stimuli arising from

the chest wall and parietal pleura were diminished, and the patient was usually

free from pain during the most important part of the postoperative period.

Nerve block at operation also eliminated the necessity for later intercostal

nerve block.

Catheter Aspiration

If, after a reasonable period of time, a patient with traumatic wet lung did

not improve under the measures just outlined, combined with the usual regimen of resuscitation, mechanical measures had to be employed. The circumstances of the individual case determined whether catheter aspiration (fig. 67E)

should be tried or bronchoscopy (fig. 67F) resorted to at once. The length of

the trial period, which might be as short as 5 or 6 hours or as long as 20 to 24

hours, depended upon the patient's original injury, his clinical status, the roentgenologic findings, and his progress under treatment. Some patients were too

exhausted to cough effectively without aid, and some were uncooperative for

other reasons.

Whether catheterization or bronchoscopy was used, the aims were the

same:

1. To remove excess fluid in the lower airway.

2. To loosen deeper secretions by local manipulation.

3. To promote more efficient cough.

A long delay was not justified if the situation was complicated by a communication between the tracheobronchial tree and a pleural cavity containing

fluid.

Catheter aspiration of the tracheobronchial tree had so many advantages

that it was employed in all cases in which bronchoscopy was not clearly

indicated (p. 227) :

1. It was preferable to bronchoscopy in patients who were desperately

ill but conscious. Experience showed that in such cases the manipulations

required in bronchoscopy might be extremely dangerous.
224 THORACIC SURGERY

2. Catheter aspiration was particularly valuable in acute emergencies

which permitted no delay.

3. The equipment was almost always readily available from standard hospital supplies.

4. The technique was so simple that it could be readily mastered, in contrastto the elaborate training necessary in bronchoscopy.

5. Catheter suction could be repeated as often as necessary.

Technique.—The technique generally employed for catheterization (fig.

69) was a modification of the method described by Haight (7) in 1938. Suction

was usually provided by ordinary ear, nose, and throat suction machines, which

delivered from 15 to 20 pounds of negative pressure. Connecting tubing and

a Eobinson ureteral catheter or a similar catheter, size No. 16 or No. 18, with

one or two openings, constituted all the equipment necessary. If electricity

was not available, as it sometimes was not in combat areas, an attachment to

the windshield wiper or gas intake manifold of a motor vehicle served as an

emergency source of power. The portable hand suction machine devised by

Major Brewer was often used in forward installations in which electrical suction

machines were not always at hand.

Anesthesia was not required unless the gag reflex was hyperirritable. Then

2 percent Poniocaine hydrochloride (tetracaine hydrochloride) or 5 percent

cocaine was sprayed onto the pharynx and painted onto the hypopharynx with

a curved swab or applicator. When local analgesia was necessary, a small dose

of some barbiturate was given before it was applied, and fluids were withheld

untilthe gag reflex had returned.

The patient was placed in the semi-Fowler position, with the neck flexed.

If he was unconscious, the neck was fixed by supporting the raised head on a

pillow or a folded blanket. If he was conscious, the tongue was pulled rather

sharply forward, to anchor the larynx. Occasionally an epiglottis that was

unusually flaccid so covered the larynx that catheterization was impossible without a laryngoscope to provide direct vision.

The catheter was introduced through the nostril and advanced until the

larynx was reached. If the patient was unconscious, the index finger of the

FIGURES CO.—Technique of traeheobronchial catheter aspiration.

A. Robinson type of rubber catheter after sterilization by beat on

bent catheter guide, to provide for slight curve of tip. The catheter

is sterilized in 70 percent alcohol or some similar sterilizing solution

when it is used, to assure maintenance of curve.
WET LUNG 225

B

FIGUEE 09.—Continued. B. Forward fixation of larynx

with left hand, by holding tongue forward with gauze-covered

fingers. AYith the right hand, the catheter is rapidly advanced through the nares and past the glottis as the patient

inspires deeply. If he is comatose, a mouth gag is used,

and the epiglottis is picked up with the left forefinger. The

catheter is then guided through the larynx. C. Advancement of catheter into trachea by intermittent suction over

Y-tuhe. Once it is in trachea, it is moved back and forth to

stimulate coughing.
THORACIC SURGERY

z. C./>V/V^S

FIGURE 69.—Continued. D. Introduction of catheter into

right main stem bronchus. When the patient's head is turned

sharply to the left, the right stem bronchus is more directly

in line with the trachea. The catheter is then advanced and

intermittent suction employed. E. Introduction of catheter

into left stem bronchus, by reversing the procedure described

in D. The head is turned markedly to the right in this stage

of the procedure.
WET LUNG 227

left hand engaged the tip of the epiglottis, so that the catheter could be passed

through the larynx -without difficulty.

When the catheter had entered the larynx, it was withdrawn for about 1

centimeter. If the patient was conscious, he was asked to take a rapid, deep

breath. During the inspiration, the catheter was quickly advanced into the

trachea. In an occasional case, it was easier to introduce it during the expiratory phase of a cough. The successful entrance of the catheter into the trachea

was signified by involuntary coughing, passage of air through the trachea, or

sudden hoarseness. The irritation caused by the catheter was likely to stimulate

all but moribund patients to cough, but hoarseness was the most certain indication that the catheter was in the trachea. Occasionally, when the tube had been

accidentally introduced into the esophagus, a free flow of air about it simulated

respiration. If the accident was not recognized and oxygen therapy was used,

gastric dilatation of serious proportions might occur.

Suction was not applied until the catheter had been advanced into the

trachea for several centimeters. When the manipulations were discontinued,

the patient was urged to cough. This he usually did forcibly—in fact, he found

it impossible not to—because of the stimulation of the tracheal mucosa by the

catheter. Often more sputum was coughed up around the tube than was

aspirated through it. Suction, coughing, and manipulation of the catheter were

alternated until all portions of the tracheobronchial tree were apparently free

of fluid. Continuous periods of suction never exceeded 5 seconds, and they were

briefer if the patient seemed exhausted by them or if he became cyanotic.

It was simple to introduce the catheter into the right stem bronchus; the

patient's head was merely turned well to the left. To enter the left stem

bronchus was somewhat more difficult (vol. I). The head had to be turned

far to the right and the chin elevated. The tube was advanced as far as possible into each stem bronchus. After aspiration, the patient was rolled on his

side, with the more involved lung uppermost, to permit drainage of the small

bronchi by gravity.

After catheter aspiration, most patients coughed with greater efficiency

because of the improved ventilation of the pulmonary tree. Because of the

absence of appreciable trauma to the larynx or bronchi, the procedure could be

repeated as often as every 2 to 3 hours if this was necessary. In the occasional

case, bronchial secretions and pulmonary transudates formed with such rapidity that aspiration was necessary at 30-minute intervals. In such cases, the

catheter was left in the trachea, sometimes from 8 to 12 hours. Wien this was

necessary, 100 percent oxygen was administered continuously through the

catheter between aspirations, at the rate of 1 to 2 liters per minute.

Bronchoscopy

Bronchoscopy played a valuable role in the management of war wounds

of the chest. At no time was its use routine. It was property considered a

highly technical procedure, requiring skill and experience for its safe use and
228 THORACIC SURGERY

to be used only on definite indications. It was made more- widely available as

the war progressed, however, because thoracic surgeons already trained in

its use taught the technique to selected general surgeons and qualified

anesthesiologists.

The decision to employ bronchoscopy rather than catheter aspiration was

made on the indications of the individual case. It was sometimes preceded by

a trial of catheter aspiration but in other instances was resorted to immediately.

Its chief advantage over catheter suction was that it was more thorough. Because both stem bronchi were visualized, aspiration could be carried out with

more assurance that all secretions and obstructing mucous plugs had been removed. When it was indicated, bronchoscopy also permitted the direct application of procaine hydrochloride, cocaine, or epinephrine solutions to the

swollen bronchial mucosa. The resulting shrinkage of the mucosa further

increased the lumen of the airway.

Indications.—No hard-and-fast rules were formulated, but in general,

bronchoscopy was regarded as the procedure of choice in wet lung under the

following circumstances:

1. When tracheobronchial aspiration by catheter had been ineffective because of failure of the lung or segments of the lung to reexpand with positive

pressure, and moisture persisted in the chest.

2. When mucous plugs or blood clots were thought to be present in the

branch bronchi.

3. When obstruction of the trachea or bronchi had been present for a considerable time. Under these circumstances, sudden loosening of large amounts

of secretion from the obstructed bronchus might flood a normal bronchus, with

grave consequences.

4. When the cough was weak and ineffectual and there was danger of

flooding the contralateral bronchus by sudden release of large amounts of

secretion.

5. When a patient was admitted to the hospital completely exhausted, with

the tracheobronchial lumen brimming with secretions that he did not have the

strength to cough up. In this type of patient, bronchoscopy was mandatory.

In fact, the more critical his condition, the more urgent was the indication.

6. When lobar or total pulmonary atelectasis had occurred, because of the

dangerous reduction in the vital capacity.

7. When bronchial obstruction recurred in spite of repeated tracheobronchial catheter aspirations. The cause of the obstruction was usually

incomplete removal of obstructing material by catheter suction.

8. When vomitus had been aspirated, or was thought to have been

aspirated, into the lungs. This was an imperative indication, because of the

highly deleterious effect of gastric secretions on bronchial and pulmonary

tissue.

9. When emergency thoracotomy was necessary. Bronchoscopy immediately before operation, in addition to emptying the tracheobronchial tree and
WET LUNG 229

improving the cardiorespiratory status, made the administration of the anesthetic simpler and safer.

Techniques.—The standard technique of bronchoscopy was employed.

The procedure was usually carried out in the operating room but could be performed by a skilled bronchoscopist without moving the patient from the

stretcher orbed.

General anesthesia was contraindicated if there was an unusual amount of

fluid in the tracheobronchial tree. Topical analgesia was employed in most

cases, but in numerous semicomatose or apparently moribund patients, no

anesthesia was used. Oxygen (100 percent) was administered continuously

to all patients who showed any evidence of anoxia.

The operation was performed as rapidly as possible, so that a severely

wounded patient, in shock, would not be exposed to the fatiguing effects of

prolonged coughing.

Some surgeons, after the trachea and main bronchi were cleared, palpated

the chest carefully, in an endeavor to find secretions still in situ in spite of

apparently successful aspiration. When such areas were found, the tip of the

aspirator was applied directly to the orifice of the affected lobe, to excite coughing and raise the remaining secretions.

Oxygen Administration

Oxygen inhalations by means of the nasal catheter or the Boothby-Lovelace-Bulbulian mask were used promptly whenever cyanosis accompanied wet

lung or dyspnea was severe. Some patients were disturbed at first by the face

mask, but with sufficient, encouragement, they all became reconciled to its use.

If moisture persisted in the lungs after intercostal nerve block and catheter

aspiration or bronchoscopy, the oxygen was delivered under positive pressure

(figs. 67G and 70). This was a technique described by Barach and his associates

(8) shortly before the war, to relieve the pulmonary edema associated with

pneumonia, gas poisoning, and cardiac disease. When the technique was first

applied to combat-incurred wounds in the winter of 1948-44, considerable difficulty was encountered. A simple and effective solution of the problem was the

use of a to-and-fro anesthetic system, with a soda-lime canister and rebreathing

bag. Positive pressure was maintained manually on the bag, care being taken

to avoid pressures higher than from 2 to 0 cm. FLO. Pressures as high as 10

cm. H20 or more were dangerous; they could cause a considerable rise in

venous pressure; a fall in systolic, diastolic, and mean blood pressures: and a

decreased blood flow.

Fluid that was constantly forming in the alveoli and bronchioles could not

be completely removed by suction, but suction, with nerve block and the other

measures described, removed enough fluid for oxygen under positive pressure to

keep the bronchioles patent. The use of oxygen under pressure also opposed

the hydrostatic pressure of the blood in the capillaries and increased the vital

capacity. If the lungs were not too severely damaged and if shock, tension

746-941'—05 17
THORACIC SURGERY

FIGL'EE 70.—Administration of oxygen under intermittent positive

pressure in management of wet lung, Cassino, Italy, 19-13. A. Administration with portable circle filter anesthetic machine: Face

mask; tubes in circle filter; respiration bag, which was manually

compressed to supply positive pressure oxygen to face mask; portable anesthetic machine with circle filter and soda-lime canister;

water manometer to determine amount of positive pressure; and

large oxygen tank.

pneumothorax, and other adverse factors could be controlled, this method was

practically always successful in drying up wet lung caused by tracheobronchial

transudatioii and exudation. It was of particular value when an excessive and

injudicious use of blood and plasma was a contributory factor in the edema

and when ventricular failure was impending-.

Oxygen was sometimes administered under positive, pressure in the early

stao-es of traumatic wet lung. Its prophylactic value was thought to be consid-
WET LUNG 2:51

f$s£g9KE3H

Uly

B

FIGL'KK 70.—Continued. P>. Administration with portable to-nndfro soda-lime canister anesthetic machine: Face mask; soda-lime

canister; respiration bag, which was manually compressed to supply

positive pressure oxygen to face mask; portable anesthetic machine with valves and bubbler for ether (only water was used

in oxygen therapy) ; and oxygen tank.

erable, but the indications for its employment on this indication did not become

fully established during the war.

Other Measures

Atropine administration.—If moisture continued to be present in the

lungs and vigorous measures to empty the tracheobronchial tree proved ineffective, atropine was sometimes given intravenously, in i/100- gr. closes. I f reflexspasm of the bronchus were initiated by thoracic injury, as the experimental

work of cle Takats and his associates (2) had suggested, one might expect

atropine to abolish vagal reflexes and reduce tracheobronchial secretions. De

Takats himself, however, found that this method prevented bronehospasm in

less than half of his experimental animals, even when amounts up to gr. %

were employed. Atropine was not widely used during the war, and the clinical

experience with it was too conflicting to permit any definitive statements concerning its value except that when wet lung was fully developed, this drug was

not effective.
9'W THORACIC SURGERY

Carbon dioxide inhalations.—Carbon dioxide inhalation was another

controversial measure occasionally employed in wet lung. This gas is a true

expectorant, and hyperventilation with it had the mechanical effect of loosening

viscid secretions and propelling them upward along the tracheobronchial lumen.

If hypoxia was present, most observers regarded the method as equivalent to

whipping a tired horse.

The preferred method was to use 100 percent carbon dioxide and to administer it by means of a catheter and small funnel as the patient took two or three

deep breaths. Forced coughing during and following the brief period of

hyperpnea thus produced was of the greatest importance and was not always

sufficiently stressed. Unless the patient coughed, the method lost much of its

effectiveness. If carbon dioxide was not available, rebreathing into a paper

bag was often employed as a substitute, usually very effectively.

RESULTS OF THERAPY

Once proper measures had been instituted to relieve pain in the chest wall,

clear the airway, and permit effective coughing, the entire picture of a patient

with wet lung usually changed promptly. Results were often dramatic. A

cyanotic, comatose patient, with wet, rattling respirations, often became alert

and oriented, with good color and almost normal respirations, within a matter

of minutes.

Once the wet lung was controlled, it was possible to evaluate the primary

injury. Ilemothorax, shattered ribs, and the shell fragment in the lung looked

less ominous and often seemed less urgent. The lung had been restored to normal, or almost normal, capacity to cope with the injury or with the surgery

required to correct the injury. Evaluation of the total patient was possible,

in short, under circumstances which permitted a deliberate rather than a frantic

approach to the problem.

An undoubted result of the recognition and vigorous management of wet

lime was apparent in the Mediterranean theater in a number of respects,

including (1) the low case fatality rate and low morbidity of chest injuries,

(2) the infrequency of lung abscess after injury, and (3) the almost complete

absence of massive atelectasis.

CASE HISTORIES

The following case histories illustrate a number of the points in the

foregoing discussion of traumatic wet lung:

Case 1.—A 23-year-old sergeant was received in an evacuation hospital 3 hours after he

had sustained penetrating wounds of the chest and buttocks from a high explosive shell

fragment. The pulse was 110, the respiration 30 and noisy, and the blood pressure

110/80 mm. Hg. The patient was extremely dyspneic and complained of severe pain in the

chest and abdomen.

Evidence of a large amount of fluid in the left chest almost obliterated all other physical findings. Loud musical wheezes were heard over the right chest anteriorly and posteriorly. Roentgenologic examination confirmed the presence of fluid in the left chest. The
WET LUNG ^°

left eighth rib was fractured, and a small foreign body was seen above the left diaphragm

behind the heart.

Morphine (gr. %) and atropine (gr. Vino) were given by vein. The pain was somewhat relieved, but not enough to permit effective coughing. Complete relief followed

blocking of the fifth through the tenth left intercostal nerves. The patient immediately

coughed up a large amount of mucus mixed with fresh and old blood, after which he was

able to breathe deeply and without discomfort. The lungs were dry on auscultation.

Debridemont of the chest wall was then carried out without difficulty under Pontothal

sodium (thiopental sodium) anesthesia.

The patient continued to raise bloody sputum for a week, but there was no reaeeumulation of fluid in the tracheobronchial tree and no recurrence of chest pain. After a total

of 2,730 cc. of bloody fluid had been removed from the left chest by repeated thoracenteses,

the left lung was almost completely reexpanded, and the remainder of the patient's

convalescence was uneventful.

Comment.—In this case, retention of blood in the bronchial tree as the result of intrapulmonary hemorrhage was chiefly responsible for the wet lung, though an excess of mucus

was also a factor. Severe chest pain, which prevented effective coughing, was not relieved

by a large dose of morphine but was promptly relieved by blocking the appropriate intercostal nerves. Immediately thereafter, the patient, by his own efforts, raised the blood and

mucus that had accumulated in the tracheobronchial tree, and recovery was without further

complications.

Case 2.—A 21-year-old sergeant was received in a field hospital in severe shock 3 hours

after he had sustained a sucking wound of the left chest and penetrating wounds of the

right chest, thigh, forearm, hand, and cheek. The pulse was 140, and the blood pressure

could not be obtained. Breath sounds were diminished on the right side of the chest, and

signs of fluid were elicited on the left side.

The patient had had no medication since he was injured and was in severe pain. He

was therefore given morphine gr. % by vein after an occlusive dressing had been placed

over the sucking wound, Bain was completely relieved after a second injection of morphine,

in the same amount and also by vein, but only small quantities of bloody sputum were

raised. After the administration of two units of plasma and 500 cc. of blood, the pulse fell

to 132 and the blood pressure was 101/80.

Two hours later, the patient's condition suddenly became critical. He was comatose

and cyanotic. The pulse was weak and thready. Kales were audible in the trachea.

Catheter suction was instituted at once, and large amounts of frothy yellow sputum wore

aspirated. The response to this measure was dramatic. The patient immediately regained

consciousness, and his color and pulse improved. The catheter was kept in place for S hours,

and suction was repeated every 20 to 30 minutes. Between aspirations, 100 percent oxygen

was administered through the catheter.

At the end of 8 hours, during which time the patient's condition steadily improved,

roentgenograms of the chest showed fluid in the left chest and foreign bodies in both lung

fields. Since the tracheobronchial tree was now apparently dry, the catheter, which meantime had slipped into the right main bronchus, was removed. After a transfusion of 500 cc.

of blood and a unit of plasma, 100 cc. of air and 200 cc. of bloody fluid were aspirated from

the left chest.

Seventeen hours after admission, when the blood pressure had reached 108/71 mm. Hg.

bronchoscopy produced a considerable amount of bloody fluid from both main bronchi.

Careful inspection showed that the prolonged intubation had apparently caused no trauma

to the larynx or the trachea.

Immediately after bronchoscopy, operation was done under intratracheal ether-oxygenanesthesia. It included debridement of the sucking wound of the chest wall; ligation of the

internal mammary vessels, which were lacerated though not actively bleeding; suture of

the laceration of the upper lobe of the left lung; removal of several small metallic foreign
m rilOIUCNJ 8UBGÜKY

bodies from the pericardium and another from the right chest wall; and intercostal drainage. A foreign body in the lower lobe of the left lung and another in the right lung were

left in situ. While the chest operation was in progress, another surgical team debrided the

other wounds. At the conclusion of the operation, bronchoscopy was repeated, and a

moderate amount of bloody mucus was aspirated from both stem bronchi. The patient

received a unit of plasma and 500 cc. of blood during the operation.

The immediate postoperative status was satisfactory. The following day, the patient

became disoriented, presumably as the result of cerebral anoxia, though he had been receiving oxygen continuously, by nasal catheter, since operation. The temperature was 00.4° i\,

the pulse 1Ö0, and (he respiration 48. Coughing produced thin yellow fluid, but the pulmonary tree appeared to be filling up with moisture.

Tracheobroneliial aspiration by catheter somewhat improved the patient's critical condition. Tracheal rhonchi and coarse bronchial rales disappeared, but medium and fine rales

could still be heard diffusely over all lobes of both lungs. Fluid was apparently beingformed more rapidly in the peripheral portions of the pulmonary tree than it could be

removed by natural processes. Since the clinical picture resembled that seen in pulmonary

edema accompanying heart disease and gas poisoning, positive pressure oxygen was begun.

"Within 15 minutes, a notable improvement occurred. The pulse fell to 120. The respirations fell to 32 and became considerably less labored. Only a few fine rales could be heard

at the bases of both lungs. At this point, positive pressure oxygen was discontinued, and

administration by the Boothby-Lovelaee-Bulbulian mask was resumed.

During the next 24 hours, the patient had two additional attacks of pulmonary edema,

each one resembling the acute attack just described. In each one, the effect of oxygen

administration under mild positive pressure was as striking as in the first attack. Recovery

thereafter was uneventful.

Comment.—This case is a striking example of the therapeutic problems presented by

traumatic wet lung in a patient with multiple chest and other wounds. Immediate

tracheobroneliial catheter aspiration, intratracheal oxygen administration, and cautious

fluid replacement over an 8-hour period made this soldier a suitable candidate for surgical

closure of a sucking chest wound and the intrathoracic surgery required. Bronchoscopy

just liefere operation aided in the maintenance of a patent airway during operation, and

its repetition at the conclusion of the procedure simplified the first 24 hours of the postoperative course. Three attacks of apparently true pulmonary edema over the next 48

hours were controlled by the administration of oxygen under mild positive pressure. Why

edema developed in this case after operation is not clear, but anoxia caused by severe

trauma to both lungs was probably an important factor, as was tracheal obstruction from

mucus and blood.

There seems little doubt that this patient survived because of the therapy instituted

for the control of the wet lung that followed his combat-incurred injuries, one of which

was a sucking wound of the chest.

Case 3.—A 27-year-old lieutenant sustained a sucking wound of the chest that was

treated immediately by an occlusive dressing and 24 hours later by suture; the skin was

left open. For the next '< days, small amounts of pure blood were expectorated.

When the patient was admitted to a thoracic surgery center ."> days after wounding, he

was comfortable while at rest but moderately dyspneic on exertion. The cough was wet

but was productive of only small amounts of blood-tinged mucoid sputum. A few coarse

rales were heard parasternally on the right. Koentgenograms taken the following day

showed a right-sided hydropneumothorax without cardiac shift. Aspiration of the chest

on the second and third days after admission produced 3G0 cc. and 300 cc, respectively, of

old blood and air from the right pleural cavity. On each occasion, highly negative

intrapleural pressure prevented further aspiration.

The patient's wet cough continued in spite of these thoracenteses, frequent changes of

position, and the administration of carbon dioxide. On the third day after admission.
WET LUNG 2sr

roentgenograms of the chest showed a minimal residual hemopneumothorax, an expanded

upper lobe, and atelectasis of the middle and lower lobes on the right side. Bronchoseopic

aspiration, instituted immediately, produced large amounts of blood clots and mucus, amid

which partly formed bronchial and bronchiolar casts were discernible. Roentgenologic

examination 18 hours later showed almost complete reaeration of the atelectatic lobes.

The cough became loose and remained productive for 4 days after bronchoscopy, then

ceased altogether. On the 12th day after wounding, roentgenograms showed the right lung

to be completely expanded and almost normal in appearance.

Comment.—In this case, although roentgenologic evidence of atelectasis was obscured

in the first roentgenograms by the overlying hemothorax, certain points in the history and

physical findings pointed to the diagnosis. They included continued wet cough with inadequate expectoration, extensive pneumothorax without cardiac shift, and the development of pronounced evidence of negative pressure after aspiration of relatively small

amounts of fluid from the pleura 1 cavity. The aspiration of old blood clots and mucus by

bronchoscopy resulted in the prompt reestablishment of a patent airway and prompt

reexpansion of the lung.

Earlier attention to the wet lung in this case would have permitted the use of simpler

methods of management and might have prevented the development of the complicating

atelectasis.

Case 4.—When this patient was seen 2 hours after he had fallen off a motorcycle, he

was complaining of severe pain in the left chest and dyspnea. Pie had a paroxysmal,

ineffectual wet cough. There was extreme tenderness over the left fifth and sixth ribs, and

a flail segment in this area was undergoing paradoxical oscillations. Numerous wheezes

and rhonchi were present bilaterally. Roentgenologic examination revealed anterior and

posterior fractures of the left fifth and sixth ribs.

Intercostal block of the third through the ninth ribs, which resulted in only partial

relief of pain, was supplemented by paravertebral block of the sympathetic ganglia of

the same segment. Pain was promptly relieved, and paradoxical oscillations of the flail

segment ceased. There was still some moisture in the lung, but the remaining wheezes

and rhonchi disappeared, and respirations became entirely normal, within 5 minutes after

the intravenous administration of Mso gr. of atropine sulfate.

On the third day after wounding, a moderate recurrence of pain and wetness was

immediately controlled by repetition of the paravertebral block.

Comment.—This case well illustrates the effectiveness of nerve block in the management of flail chest of limited extent, as well as the (occasional) effectiveness of atropine

as an adjuvant measure in the control of wet lung.

Case 5. This patient was seen in a shock tent on 4 February 1044, 43% hours after

wounding. He had sustained a penetrating wound of the left anterior chest and was

complaining of hemoptysis; dyspnea; a painful wet cough; and pain in the left shoulder,

left chest, and hepatic area. He was in critical condition, extremely dyspneic and

cyanotic, and showers of moist rales were heard throughout both lungs. Examination

also revealed tenderness and rigidity in the left upper quadrant of the abdomen. Roentgenologic examination revealed a retained missile in the region of the left diaphragm and

an extensive pathologic process in the left lung and left pleura! cavity.

An hour after the patient had been received in the shock tent, intercostal block of

the left fourth and fifth intercostal nerves was carried out, and 200 cc. of air and blood

were aspirated from the left pleural cavity. There was immediate improvement in the

pain, dyspnea, and cyanosis originally present. The left upper quadrant of the abdomen

was no longer rigid. There was also an improvement in the wet lung. Two hours later,

the patient again complained of pain, and there was a recurrence of the pulmonary difficulties. A paravertebral sympathetic block (O4-0) was immediately performed, and a

large amount of blood and mucopuruient sputum was aspirated through a tracheal
öoß THORACIC SURGERY

catheter. Pain was promptly relieved, and pulmonary moisture was greatly reduced.

Shortly afterward, the wound was dehrided.

Recovery was smooth except for slight pain and moderate dyspnea the day after

operation. Both symptoms were promptly relieved by intercostal block of the fifth

through the ninth intercostal nerves. A week after his admission, the patient was so much

improved that he could be evacuated.

Comment.—When this patient was first seen, his condition was so critical that it did

not seem that he could possibly survive. Nerve block effected considerable improvement,

but when his pulmonary difficulties recurred, he seemed so exhausted that mechanical

aspiration of the traeheobronehial tree was resorted to at once. In this case, the correction of wet lung was clearly lifesaving.

Case 6.—A 21-year-old soldier, injured in an automobile accident, complained of

hemoptysis, persislent pain on coughing, and pain on deep breathing. When he was admitted to a thoracic surgery service 48 hours after the accident, he was dyspneic and

complained of discomfort and pain in the left lower chest. There was no external evidence

of injury. The percussion note was resonant bilaterally, but there were diffuse wheezes

and rhonchi throughout both lungs. Tain was so severe that coughing was impossible,

in spite of urging. Pressure over the seventh, eighth, and ninth ribs in the left anterior

axillary line elicited exquisite tenderness, but roentgenograms of the chest revealed no

abnormalities.

In spite of failure to demonstrate any rib fractures, an intercostal block of the area

of tenderness completely relieved the pain. Shortly afterward, the patient coughed up

several tablespoonsful of thick, white, tenacious mucus. Two hours later, physical examination revealed entirely normal findings in both lungs. Recovery was uneventful

thereafter.

Comment.—In this case, nerve block permitted effectual coughing by relieving the

pain that had prevented it previously. There was only mucus in the traeheobronehial

tree, and it may be that this is an instance of an abnormally large secretion of mucus

because of reflex stimulation via the intercostal nerves. If this reasoning is correct, one

effect of the nerve block may have been to reduce the secretion of mucus."

References

1. Betts, R. H., and Overholt, R. H.: The Prevention and Treatment of Postoperative

Pulmonary Complications by Bronchoscopie Aspiration. S. Clin. North America 17 :SS5-

803, June 1937.

2. De Takats. G., Reck, W. C and Fenn, G. K. : Pulmonary Embolism. An Experimental and Clinical Study. Surgery (> :339-3G7, September 1930.

3. Drinker, C. K., and Warren, M. P.: The Genesis and Resolution of Pulmonary

Transudates and Exudates. J.A.M.A. 122 .-200-273. 20 May 1043.

4. Pasteur. W.: Massive Collapse of the Lung (Syn. Active Lobar Collapse). Brit. .T.

Surg. 1:5S7-C01. April 1014.

5. Churchill. E. D. : Pulmonary Atelectasis. With Especial Reference to Massive Collapse of the Lung. Arch. Surg. 11:480-51S. October 1925.

(i. Lewis, Thomas : Pain. New York : The Macmillan Co., 1042.

7. Haighf. C. : Intratracheal Suction in the Management of Postoperative Pulmonary

Complications. Ann. Surg. 107 :21S-22S, February 1038.

S. Barach. A. L.. Martin, .1., and Eckman, M.: Positive Pressure Respiration and Its

Application to the Treatment of Acute Pulmonary Edema. Ann. Int. Med. 12:754-705,

December 1038.

2 The reader is referred to chapter XI (p. 441) for lona-tcrm followup studies on casualties whose

chest wounds were complicated by the wet hm# syndrome.
CHAPTER VI

Hemothorax and Hemothoracic Empyema

Thomas H. Burford, M.D.

GENERAL CONSIDERATIONS

At the beginning of World War II, there was little or no realization of

the fact that hemothorax was the most frequent, and probably the most important, complication of wounds of the chest. A brief experience with these

wounds, however, compelled the recognition of both its frequency and its importance. The principles and techniques by which hemothorax was managed

influenced the entire scheme of the treatment of chest wounds from forward

hospitals through chest centers.

In view of these facts, it is surprising to find that hemothorax had attracted very little attention before World War II. Surgeons who dealt with

it at all were divided into two schools. One group maintained that absorption

of the sanguineous intrapleural material would invariably take place, and with

reasonable promptness. The other group advocated the prompt evacuation

of the pleural cavity, on the premise that blood, by its mere presence, was

harmful. Even those who did not accept the theory that all hemothoraces were

absorbed by natural processes believed that this occurred in 90 to 95 percent

of all thoracic wounds.

When the literature of the prewar period is examined, one cannot fail to

be impressed with the small number of observers who concerned themselves

with the fate of the 5 or 10 percent of patients whose hemothoraces were not

absorbed. This lack of concern was evident in the military manual on thoracic

surgery issued in 1943 under the auspices of the American Association for

Thoracic Surgery and the National Eesearch Council (1). Blood in the chest,

according to this manual, tends to remain fluid, probably because it is clefibrinated by the motions of the lungs and the heart, A section was devoted to the

management of infected hemothorax, but no recommendations were made for

dealing with the exceedingly important complication of clotted hemothorax.

The omission was typical. It was also unfortunate, The casualties whose hemothoraces clotted or did not absorb for other reasons constituted the group who

developed empyemas that tended toward chronicity and who presented encased

lungs or contracted hemithoraces, with resulting impairment of respiratory

function.

Until articles on unabsorbed hemothorax began to be published from the

Mediterranean Theater of Operations, U.S. Army, in World War II, not many

observers even mentioned the possible clotting of blood in the pleural cavity.

740-941'—05 IS 237
238 TIIOKACIO SUKGKKY

It is also startling-, in retrospect, to find in the prewar literature almost no

effort to distinguish postpneumonic and metapneumonic empyema from posttraumatic empyema, although the latter variety, if not correctly managed, gives

rise to a far higher incidence of chronicity. Both varieties were discussed as if

they were of the same origin and had the same characteristics. Studies on

hemothorax as an antecedent to empyema were remarkable for their paucity.

The recognition of hemothorax as perhaps the most important complication of wounds of the chest was a development of World War II. Had the

prewar laissez-faire approach to it been carried over into military surgery,

it would have resulted in an intolerably hioh. rate of pleural sepsis in World

War II.

Nomenclature.—Before proceeding with the discussion of hemothorax

and its sequelae, it is necessary to define the meaning and implications of the

terms used for this condition in World War II:

The term "simple hemothorax" implied the presence of blood in the pleural

cavity, without complicating features. This term was used whether the blood

was the result of injury to the chest wall alone or was the result of a penetrating or a perforating wound.

The term "infected hemothorax" implied the presence of bacteria in the

pleural fluid, plus the clinical manifestations of their presence.

The term "chronic hemothorax" or "chronic traumatic hemothorax" was

used to indicate any collection of blood in the pleural cavity that could not be

reduced by thoracentesis. The term implied that fresh blood had ceased to

enter the pleural space, that hemostasis had been achieved, and that the collection of blood was therefore residual. A chronic hemothorax was usually an

organizing hemothorax. It was the clotting of the blood plus its inevitable

sequela, organization, that made aspiration no longer possible. A neglected

accumulation of intrapleural blood that could be satisfactorily aspirated was

not considered chronic because it could be evacuated at will by proper treatment.

There was general agreement that the term "chronic hemothorax" was both

inadequate and misleading. It did not indicate, or even suggest, the really

important element in. the pathologic process. This element was the presence

of fibrin, whether it was derived from blood spilled into the pleura, or from

exudate formed by the pleura, or had been deposited in some other manner.

Some such term as "fibrothorax" would have been more expressive and more

correct, but the term "chronic traumatic hemothorax" began to be used, and

semantic changes were not practical in wartime.

INCIDENCE OF HEMOTHORAX AND ITS COMPLICATIONS

Hemothorax.—Statements concerning the incidence of hemothorax in

combat-incurred wounds of the chest are necessarily imprecise. Probably

every casualty with a perforating or a penetrating thoracic wound had a hemo-
HEIIOTHORAX AND HEMOTHORACIO EMPYEMA 239

thorax of some degree. In a certain proportion of injuries, perhaps 15 or 20

percent, the collection of blood was so small as to cause no clinical manifestations, and it was rapidly absorbed by natural processes.

A'arious studies from the hospitals in the Mediterranean theater, including

the chest centers, show the incidence of hemothorax to range from 80 to 84

percent. Well, over half of the casualties received in field hospitals after

wounding already had enough blood in the pleural cavity to make its removal

an urgent part of the effort to restore the cardiorespiratory equilibrium. More

significant than the high initial incidence is the fact that about three-quarters

of the casualties received in base hospitals arrived with sufficient intrapleural

blood to require treatment,

In the great majority of hemothoraces, once the policy of early and complete thoracentesis had been established, recovery was prompt and uncomplicated in the absence of complications from other components of the thoracic

injury. In 752 hemothoraces treated at the 300th General Hospital chest

center in the Mediterranean theater, between 1 April and 20 December 1944,

by Maj. Thomas H. Burford, MC, and Maj. (later Lt. Col.) Edward F. Parker,

MC, there were no complications in 603 of 678 cases in which the blood could

be removed by aspiration. The average time required for complete clearing

of the chest was from 10 to 14 days, and the average number of thoraeenteses

required was from 3 to 4.

Clotting and organization.—The hemothoraces that gave rise to difficulties were those in which clotting occurred. Exactly how often this happened, it is not possible to say. During the Italian campaign, some forward

hospitals reported incidences of clotting ranging to 25 and 30 percent. These

levels are exceptionally high. In one or two later studies, the incidence was

9 or 10 percent, which is rather low. Clotting probably occurred in about

15 percent of all hemothoraces, even when thoracentesis was undertaken early

and was repeated as necessary.

The incidence of clotting naturally varied with circumstances. It was

more frequent in severe wounds. It was also more frequent the longer thoracentesis was delayed. A casualty who was brought promptly to a hospital

near the frontline and whose chest was evacuated as part of the regimen of

resuscitation seldom developed an organizing hemothorax.

In nearly all instances of extensive clotting, some degree of organization

of the clot followed. Infection, with its clinical manifestations, could and did

occur in many unclotted hemothoraces, but it was much more likely to occur

in large clotted collections. Two other consequences of clotting were also

serious:

1. If an organizing hemothorax was of any size, simple removal of the

clots at thoracotomy or attempted evacuation of the pleural cavity by waterseal intercostal drainage practically always proved inadequate, and the resulting pulmonary reexpansion was entirely unsatisfactory.
240 THORACIC SURGERY

2. If expectant treatment was employed in organizing hemotliorax, the

period required for resolution was always prolonged. In one group of 13

patients observed late in the war, the total time for clearing ranged from 41

to 125 days and averaged 78 days. Clotting of a hemothorax was therefore

an important cause of prolonged morbidity.

Infection and hemothoracic empyema.—Most infected hemothoraces

were preceded by clotting, and most posttraumatic empyemas were preceded

by infected hemothoraces. There was seldom any doubt of the sequence of

events. In a small number of cases, even uninfected organizing hemothoraces

produced extreme degrees of respiratory crippling, though the worst of these

cases did not compare in severity with the crippling observed in patients in

whom infection of a hemotliorax had been permitted to become chronic. During World War I, chronic empyema was the most frequent complication of

chest wounds {2). Almost a quarter of the thoracic casualties died, and from

25 to 30 percent developed empyema. If these same proportions had prevailed

during World War II, the results of chest wounds would have been disastrous.

In the early months of fighting in North Africa, before the management of

hemothorax had been standardized, the incidence of empyema was high, running to 25 or 30 percent in some hospitals. Even in the chest center at the 53d

Station Hospital, Bizerte, which was equipped and staffed for the specialized

care of chest injuries, it was 22.6 percent. By the end of the war, the general

incidence in the theater did not exceed 10 or 11 percent, and more than one

hospital had achieved an incidence as low as 7 percent. In the European

Theater of Operations, U.S. Army, which had the early experience of the Mediterranean theater to guide it, chronic hemothoracic empyema was also

infrequent.

An incidence of even 7 percent is much higher than the incidence of empyema after chest wounds in civilian practice. The explanation of the difference is simple: In civilian life, the agents of wounding are usually ice picks and

bullets, which have a limited and localized destructive capacity. In combatincurred injuries, on the other hand, while bullets were frequently as innocuous

from this standpoint as they are in civilian life, most wounds were large wounds,

and tissue destruction was extensive. Moreover, in combat-incurred wounds,

the missiles often carried with them into the chest fragments of fractured ribs,

bits of clothing, and other debris. Eetained metallic foreign bodies, unless they

were very large, played no significant role in most intrapleural infections

(p. 327)."

In World War II, the factors most frequently responsible for posttraumatic

empyema were delayed and inadequate evacuation of the pleural cavity, inadequate debridement, inadequate drainage of the pleural cavity, and excessively

prolonged treatment by aspiration and instillation of penicillin when it was

obvious that radical therapy was required. The necessary interruption of professional supervision of casualties in the chain of evacuation was probably

responsible for a small number of cases early in the war. How serious a part
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 241

inadequate early treatment plays in the development of empyema is evident in

figures reported by d'Abreu (3) : When the British evacuated 88 soldiers of all

nationalities who had been engaged in guerrilla warfare in Yugoslavia and who

had had no early surgical treatment for their chest wounds, they found that

48 of them had empyema.

The reduction in the incidence of posttraumatic empyema as the war progressed was the result of several factors, the most important of which was the

increasing emphasis put upon early, complete evacuation of the pleural cavity,

which was followed by prompt reexpansion of the lung. The advent of penicillin, with its beneficial effect on residual infection, also played a part. Penicillin

represented an improvement over the sulfonamides, but it was not the major

factor in. the improvement. The most important single factor in the lowered

incidence of posttraumatic empyema was the improvement in the surgery of

chest wounds that came to pass with the increased experience of general and

thoracic surgeons and of anesthesiologists.

Figures for empyema supplied by the Medical Statistics Division, Office

of The Surgeon General, appear in tables 13 and 14. In connection with table

13, attention is called to the fact that data available only for 1944 and 1945

TABLE 13.—Admissions for empyema of the chest in the U.S. Army, by area and year, 19I)2-Jt5

[Preliminary data based on sample tabulations of individual medical records]

[Rate expressed as number of admissions per annum per 1,000 average strength]

1942-45 1942 1943 1944 194.5

Area

Number

Kate NumberRate NumberRate NumberRate Number

Rate

Continental United

States 406 0. 03 121 0. 05 175 0. 03 75 0. 02 35 0. 01

Overseas:

Europe . . 100

14

4

1

15

25

20

4

0. 02

. 01

. 03

. 00

. 01

. 02

. 04

. 01

2 0. 02 13

5

4

0. 05

. 01

. 08

20

9

0. 01

. 01

65 0. 03

Middle East

China-Burma1

7

7

4

. 01

. 01

. 02

. 03

Southwest Pacific

Central and South

Pacific

North America 2_

1

2

5

2

. 01

. 01

. 05

. 02

2

11

11

2

. 01

. 04

. 06

. 02

5

5

. 00

. 01

Total overseas 3_- 201 0. 02 12 0. 02 48 0. 03 51 0. 01 90 0. 02

Total Army G07 0. 02 133 0. 04 223 0. 03 126 0. 02 125 0. 02

1

Includes North Africa.

2

Includes A.laska and Iceland.

3

Includes admissions on transports.
242 TIIÜIUCIO SÜBGEKY

show that the incidence of empyema during- this period was nearly six times

higher than the number of admissions due to the condition.1

For 1944 (table 13), preliminary tabulations of individual medical records

showed 126 admissions and 805 secondary cases of empyema. The figure for

the secondary cases was derived from a 20-percent sample, consisting of 161

punchcard records. One-third of the cases of empyema occurred among admissions in the Zone of Interior and two-thirds among admissions overseas. In

the latter group, more than 70 percent of the cases were of battle origin. Threefourths of the remaining cases originated in disease and the other quarter in

nonbattle injuries. Nearly 90 percent of the empyemas secondary to battle inTABLE 14.—Distribution of a 20 -percent sample1

of secondary cases of empyema of the chest

in the U.S. Army, 19.J4? by area of admission, type of admission of primary condition,

and evacuee status

[Preliminary data based on tabulations of individual medical records]

Continental

United

States

Overseas

Type of admission

Europe

Mediterranean

Middle

East

ChinaBurmaIndia

Southwest

Pacific

Central

and

South

Pacific

North

America

EVACUATED

Battle injury and wound:

Thoracic 3(5

5

8

s

s

1

1 4 1

Thoraeoabdominal

Other regions

Total 49 IT ; i 4 1

Nonbattle injury:

Thoracic 1

1

1

Thoraeoabdominal

Other regions

Total 3

Disease:

Pneumonia 1

1

5

Bronchiectasis 1

Other diseases i 1 1 1

Total 7 i 1 1 1 1

Grand total 59 IS 2 5 2 1

Sec footnotes at end of table.

1

It should be pointed out again that the term "admissions" refers to patients admitted to medical

treatment facilities for the specified condition as the primary cause of admission, while the term

"incidence" includes not only these patients but also patients in whom the specified condition was

reported as secondary to other admission diagnoses.
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 243

TABLE 14.—Distribution of a BO percent sample 1of secondary cases of empyema of the chest

in the U.S. Army, 19/+4,2by area of admission, type of admission of primary condition,

and evacuee status—Continued

[Preliminary data based on tabulations of individual medical records]

Continental

United

Slates

Overseas

Type of admission

Europe

Mediterranean

Middle

East

ClnnaBurmaIndia

Southwest

Pacific

Central

and

South

Pacific

North

America

NOT EVACUATED

Battle injury and wound:

1 1

1

Total 1 1 1

Nonbattle injury;

4 1

1 1 1 1

Total 5 1 1 2

Disease:

26

2

21

3 4 2

Bronchiectasis

Other diseases 2

Total 49 3 6 2

Grand total 54 5 7 2 1 3

i Two sample cases—one admission each in the European theater and in the Southwest Pacific Area—have been

omitted from the table since they could not be located in the card file.

21944 refers to year in which primary cause of admission occurred. The empyema may have occurred in that year

or subsequent to 1944.

jury followed injuries of the chest or tlioracoabdominal region. There were

115 separations from service for empyema during the 1942-45 period.

PATHOGENESIS OF ORGANIZING HEMOTHORAX

Natural History of Simple Hemothorax

Origin of blood.—Though it was not always possible to determine the

exact origin of the blood in the pleural cavity, by far the most frequent source

was wounds of the lung. Hemorrhage from the lung, however, tends to spontaneous arrest within a short time. Lacerations of intercostal vessels were the
244 THORACIC SCRGERY

"& ^^ 1^

FioviiK 71.—Hemothorax with recurrent pulmonary hemorrhage. A. Rosteroanterior roentgenogram showing extensive right hemothorax. with retained foreign

l>ocly. 7 days after wounding. R. Same. 7 days later, after secondary hemorrhage

from lung.

second most frequent source; in many instances, bleeding from these injuries

was combined with bleeding- from wounds of the lung. In a much smaller number of injuries, the source of the bleeding was the internal mammary vessels;

the vessels of the heart, the pericardium, or both; and the larger vessels, such as

the innominate and subclavian arteries and the azygos vein. As has already

been pointed out. casualties with injuries of the great vessels of the chest seldom

survived to reach a held hospital.

Secondary hemorrhage into the pleural cavity Mas extremely uncommon.

It was recorded only 3 times in 752 cases of hemothorax studied by Major Burford and Major Parker. In only one of the three cases did the hemorrhage

recur from the lung (fig. 71), 2 weeks after wounding. In the second case, the

recurrence was from a laceration of the intercostal artery. In the third case,

an unsuspected traumatic aneurysm of the right subclavian artery ruptured, and

the patient died almost at once (p. 45). The roentgenologic examination (fig.

72) did not arouse the suspicion that a lesion of such potential gravity could

coexist with the characteristic picture of clotted hemothorax.

Effects of blood on pleural structures.—In spite of the problem hemothorax has presented, at least in combat wounds, there have been remarkably

few studies of the intrapleural changes associated with it. The fiuoroscopic

studies made by Edwards and Davies (//,) in 1940 represent one of the first

serious efforts to ascertain the nature of the pleural response to blood in the

pleural cavity. Before the war, opinions differed concerning its irritative effects. The World War II experience was not conclusive, and final judgment,

must be reserved.
HEiK »THORAX AND HK1K»THORACIC EMPYEMA 215

>

»fe;.

-\

I

FIGIT.E 71.—Continued. C. Same, 2 days later, showing residual clotted hemothorax after two thoraeenteses. 1). Same, after thoraeotomy for removal of

foreign body and decortieation of right lung. At operation, it was found that the

secondary hemorrhage had occurred from a laceration of the lung at site of entry

of missile.

Little evidence was produced in World War II to substantiate the theory

that unaltered liquid blood acted as an inflammatory agent. This generalization held, however, only while the blood remained unaltered. There seemed

no doubt that it underwent rather profound physiochemical changes as soon

as it left its normal endothelial-lined habitat and that these changes were progressive in both kind and degree. The first fluid aspirated after wounding

was pure blood or distinctly bloody, but its character changed as aspirations

were continued. It became serosanguineous, and then, before the chest was

entirely emptied, it became merely serous.

A fibrin layer was uniformly found on the pleural surface in all hemothoraces. It was always more pronounced in clotted than in unclotted cases.

Since clotted blood not only binds fibrin but also represents a greater physiochemical departure from normal than a liquid hemothorax, in which fibrin is

free, the inference was that the fibrin layer represented an inflammatory response rather than a passive deposition of fibrin or a salting-out phenomenon.

As would be expected, the response was proportional to the degree of alteration

of the blood; that is, whether it was (1) clotted or (2) clotted and contaminated.

In the hemothoraces controlled by thoraeenteses, laboratory studies showed

that the pleural fluid was low in protein and relatively free of red blood cells.

Even in uncomplicated hemothoraces, as just pointed out, a certain amount of

fibrin was deposited over the pleural surfaces, but the thin, shaggy coat was

not demonstrable on roentgenologic examination, and the fibrin content of the

intrapleural fluid was so small that total aspiration was entirely feasible (fig.

73).
246 THORACIC SURGERY

FIOIJEE 72.—Posteroanterior roentgenogram

showing clotted right liemothorax. There is

nothing in the film to suggest the traumatic aneurysm of the first portion of right subclavian artery, rupture of which was immediately fatal.

Theories of Origin of Organizing Hemothorax

The pathogenesis of organizing liemothorax was no clearer at the end of

the war than at the beginning. There •were no facilities in a combat zone for

experimental studies on why clotting occurred in some traumatic hemothoraces

and did not occur in others. Clinical and pathologic observations in a large

number of chest injuries do, however, permit a certain amount of legitimate

speculation.

Certain causes could be eliminated at once. An analysis of the missiles that

caused the wounds associated with clotted liemothorax revealed no common denominator to explain what occurred. The degree of pneumothorax present

apparently played no part, as might have been expected; the presence or absence

of air does not influence the clotting of blood. The relative severity of the

wounds of the lungs and soft tissues played no decisive role; hemothorax was

more frequent in severe injuries because severe injuries were more frequent.

Organizing hemothorax occurred in some cases in which the injury was limited

to the external chest wall and also occurred in some contusions and blast

injuries.

"With these obvious factors eliminated, it was necessary to turn to the

mechanism of clotting for a possible explanation of clotted or organizing

hemothorax. There were three theories:

1. The first hypothesis was that bacteria might be present in the pleural

cavity and, in the presence of blood, might incite an exudative response, which
HEMOTHORAX AND HEMOTIIORACIO EMPYEMA 247

**:

FIOUHK 73.—Massive liquid hemothorax without infection. A. Posteroanterior roentgenogram made shortly after wounding and showing hemothorax.

B. Same, 10 days later, after six thoracenteses, by which a total of 3,150 cc.

of blood and other fluid was removed.

would favor the formation of fibrin deposits, rather than a transexudative

response. If bacteria were seeded generously over the pleura! surfaces, a

frankly suppurative response would be expected, and a true suppurative pleuritis would develop. If, however, they were implanted in such small numbers

as not to incite a widespread pleural response, their presence might still be sufficient to alter the response from transexudative to exudative, and the clinical

picture would be dominated by the presence of fibrin deposits rather than

by suppuration.

The sharp and often prolonged febrile responses seen in organizing hemothorax furnished clinical evidence of the exudative character of the pleural

response to blood. In uninfected hemothoraces, a moderate febrile response

often occurred, but it was practically always of short duration, usually no longer

than from 10 to 14 clays. In infected cases, the clinical manifestations

continued, and if suppuration were impending, they became more pronounced.

Bacterial seeding probably explained some instances of organizing hemothorax, but it could not be accepted as a universal explanation. It was

undoubtedly a factor in some hemothoraces which went on to empyema. The

fact that nonhemolytic Staj)hylococciis aurens was the most frequent causative organism in empyema and that this organism does not produce fibrolysin

lent some support to this theory. Clotted blood containing pathogenic bacteria, served as an excellent culture medium, just as devitalized muscle served

as a culture medium in all wounds. This was particularly true of anaerobes,

which develop rapidly under low oxygen tension. Clot formation about bacteria in hemothorax also had the effect of preventing penicillin or the sulfonamides from reaching these entrenched organisms. They were not influenced

by either local or systemic therapy.
248 THORACIC SURGERY

2. The second hypothesis was that clotting in hemothorax might be the

result of the simultaneous presence of blood and coagulative ferments in the

pleural cavity. This theory was not considered acceptable. For one thing,

the actual amount of blood present seemed of no importance; the preponderance of white clot present in some cases pointed to an excess of plasma. There

was also no uniformity in the time at which clotting occurred. Clotted blood

was sometimes found in the pleural cavity when thoracotomy was performed

from 4 to 6 hours after wounding. Sometimes, the clot was so firm a few clays

after wounding that it defied needle aspiration. In other instances, the blood

might remain liquid for many days, and all of it, could be removed by

thoracentesis.

There was no acceptable explanation for these variables. It might be that

the churning movements of the diaphragm, heart, lungs, and chest wall had a

defibrinating effect. Sellors (5) remarked that any surgeon who opened a

recent hemothorax must have been impressed "by the tumultuous way in which

the blood is flung about the pleural cavity." Fibrin and blood clots were often

seen in the costophrenic sinus and the lower portion of the pleural cavity within

a short time after wounding. Another consideration was that both the lungs

and the muscles are ready sources of thromboplastin.

Even granting all of these facts, acceptance of the theory that the presence of whole blood and coagulative ferments was responsible for organizing

hemothorax would leave many cases unexplained.

3. The most reasonable hypothesis was that, as the result of trauma, normal pleural fluid was so modified that it became exudative rather than serous.

As lias already been pointed out, a response by the pleura could be expected

whenever blood was spilled into the pleural cavity as the result of wounding,

even if the process went no further. Moreover, wounds of the lungs and pleura

cannot be fundamentally different from wounds of other tissues. If this reasoning is sound, the so-called edema of wounding might be expected to occur in

these tissues just as in other damaged tissues. The presence of edema, which

reached its peak within 2 to 4 days after wounding, could reasonably be

assumed to affect the character of the pleural effusion caused by trauma, in all

probability making it richer in fibrin. There would then be present in the

pleural cavity an excess of coagulative ferments from the wounded chest wall

or lung or both, combined with an excessive fibrin from the pleural effusion.

In other words, there would be added to the whole blood spilled into the pleural

cavity, which might itself clot by natural physiologic processes, increments

from the pleural response to wounding that would enhance the natural process

of clotting.

It is easy to explain why earlj- thoracotomy and evacuation of whatever

intrapleural fluid was then present did not necessarily protect the patient

against the development of a subsequent clotted intrapleural mass. Wounds

of the thorax frequently resulted in the widespread changes known as wet
HE1I0TII0RAX AND IIEMOTHORAOIC ElIPYKMA 249

lung (p. 207). Wet lungs were heavy and soggy, and they expanded only

sluggishly and never completely in the absence of vigorous corrective measures. For a few days after wounding, therefore, dead space2

in the pleural

cavity permitted the accumulation of pleural exudate that eventually became a

part of, or constituted, the clotted intrapleural mass. If all the blood in the

pleural cavity had been evacuated at thoracotomy or otherwise, the pleural

exudate that continued to accumulate under these circumstances was chiefly

white. If all the blood had not been removed, the clot would be layered or

marbled.

The hypothesis seems reasonable that a change in the character of the

normal pleural fluid furnishes an explanation for the clinical vagaries observed

in clotted hemothorax. It also seems to explain the sequential relation of this

process to the original trauma.

PATHOLOGIC CHANGES IN CHRONIC TRAUMATIC

HEMOTHORAX

The limited pathologic studies possible in a combat zone seldom warrant

generalizations on any subject. A large enough number of hemothoraces were

observed, however, to elucidate the pathologic changes in chronic traumatic

hemothorax and to establish the rationale for its management.

Gross Pathology

All hemothoraces, as already pointed out, involved typical and definite

changes within the pleural cavity, slight at first but more pronounced as the

process went on to clotting and organization.

The process of hemo-organization began with the laying clown of a thin,

loosely adherent film of fibrin and blood cells over both pleural surfaces. Within 2 or 3 days of its formation, angioblastic and fibroblastic proliferation

began to occur.3 As early as from 7 to 14 clays after wounding (figs. 74 and

75), fibroblasts could be seen growing out from the older (pleural) side toward

the younger portion. The transition to adult fibrous tissue was progressive

and rapid (fig. 76). Capillaries grew in from the pleura, and within 8 to 10

weeks, complete cellular symphysis had occurred in most cases. Decortication,

which would have been simple earlier, had now often become impossible (figs.

77 and 78).

^ Dead space may be defined as any air or fluid or matter without the confines of a normal anatomic

habitat and without a blood supply.

3 These observations -were made on specimens secured at operation for bronchoplcural fistulas,

removal of foreign bodies, and similar conditions. Small clotted hemothoraces were often found at

these procedures, and, when interest in this complication of thoracic wounds had developed, sections

were regularly taken for study.
250 THORACIC SURGERY

*^?<*>^

FIGUEE 74.—Fhotomicrograph showing organizing hemothorax with replacement of acute fibrinopurulent deposit by

young vascular connective tissue at end of first week after

wounding. The pleural aspect of the layer of exudate removed from the visceral pleura is toward left and periphery

toward right.

The essential feature of chronic traumatic hemothorax was the formation

of this fibroblastic and fibrinofibrous membrane or peel over the visceral and

parietal pleurae. Once it had formed, the hemothorax was converted into an

enclosed hematoma of the pleural space (fig. 79).

It should be emphasized that, in the beginning, the pleura itself took no

part in the pathologic process. Until fusion between it and the rind occurred,

it remained remarkably normal in appearance. The pleural thickening which

was sometimes described on roentgenograms was never observed at operation.

The practice of describing peripheral obscuration as thickened pleura was

incorrect and misleading. In the early phases of an organizing hemothorax,

examination of sections of the encasing sac never revealed elastic tissue, although elastic fibers were always found in sections from the hm«' or the soft
HEMOTHORAX AND HEMOTHORACIC EML'YEMA 251

*f

/ 1

•'• •.-,': .•-"' A

' „-' si> -

, »'• *' '* •" ';• «• -

'?>': J't&'" '-A .

' ' z ' "»' S -"""V" -v - ** « *

' '..'' * " -': " 'V*s'$'--''i "> ^iS^ffi^

.•.»•<;« ;.-. '-

•' , -i -V.* •" *•*

tf:''. •

•'. •/';« ;«s^

'«<rV&**"

LFIGUEE 75.—Photomicrograph showing fibroblastic membrane from clotted

hemothorax 11 clays after wounding. Note that, even at this early stage, the

hemothorax has a definite capsulelike character. Capillaries have already begun

to appear in older (pleural) side at bottom of specimen. Hematoxylin and

eosin stain. (X GO)

tissue of the thoracic wall just beneath the pleural mesothelium. If, however,

the process went on without interruption, the membrane eventually underwent

complete fibrous and vascular union with the pleura, which then lost its identity

as a delimiting membrane.

The facts just stated were of great, importance in the selection of the time

for decortication (p. 286). The ease with which a cleavage plane could be established between the two layers (the rind and the pleura) at operation was a

direct function of the age of the limiting membrane (fig. 78). Experience

showed that after 4 weeks from the date of injury the chances of performing

satisfactory decortication dropped rapidly with each succeeding week.

The development of infection, even if it went on to suppuration, did not

accelerate the process of organization of the hemothorax to any appreciable

degree. There was also no evidence that the union between the peel and the

underlying pleura was any firmer when infection was present.

The most prominent feature of the intrapleural mass was that it was

always relatively or absolutely solid, because of the fibrin component. It was

usually thickest in the basal thoracic gutter posteriorly. The distribution of
m THORACIC SURGERY

&^*.»i •-—'«-»Js^r*— #- > ,^"t»" ~ - - • -? *■■■ . -• ..--»■■

, v-i» . . -i . • . . • ,->. .. '«;. • •?.- --',.•

T jr • • -^' " ..

FioiJKE 7(j.—Photoiiiici'dgniiih showing section of peel of

clotted Ueniotliorax 4 weeks after wounding, ileinbrane lias

assumed a definitely fibrous character. Capillaries are

visible at their point of entrance from visceral pleura (lower

left of section). Heniatoxylin and eosin stain. (X 100)

the fibrin thus followed the natural principles of jrravity as they would operate

in any recumbent subject with an accumulation of fluid in the pleura.

In the typical organizing hemothorax, the mass was made up of three

layers (fig. 79) :

1. The outer layer was a tough organized membrane (rind, peel), the

thickness of which was related to the length of time that had elapsed since

wounding. At the end of 4 or 5 weeks, the rind was usually from 2 to 4 mm.

thick. Later, it might be from 5 to 8 mm. thick, or even thicker. If the mass

was composed of solid fibrin, the rind was always very thick.

This rind completely surrounded the original hemothorax and was intimately attached to the visceral and parietal surfaces of the pleura, though

usually, in spite of the intimacy of the adhesions, it could be separated without

difficulty from the visceral pleura, at least in early stages of the process. The
HEMOTHORAX AXT) IIEMOTHORACIC EMPYEMA 253

1#

%$M**l

£>.">

H-rs'-

:

v'fVf*.v

fc " *

4

^^%4tÄ^«*^r^ '-'■■« ' ,'\V' • >*

it'.-*-' «t'^?^t;**»=*:7.:'«>>:»'', •' "-.'--.• '

«. '

r

-~ ^iL ^^S"*; ;,i' '' , • ;' . '

V'V -;-?*"-**,-•" •'/" ' •' ' - ' •

EIGTTKE 77.—Photomicrograph allowing section from clotting

hemothorax. Note fusion between dense layer of collagenous

connective tissue and subjacent pleura and lung (lung is to

left).

rind was resistant, did not tear readily, and had the gross appearance of fibrous

tissue.

The rind usually passed directly from the visceral to the parietal pleura

at all points at which these surfaces met, but attenuated projections frequently

extended beyond these limits, along opposed pleural surfaces or into the interlobar fissures. The costophrenic gutter was almost consistently obliterated

by the elevated diaphragm and was sealed off by the reflection of the peel.

Beyond these points of symphysis, it was often surprising to find only a thin

layer of filmy pleural adhesions. At a greater distance, entirely free pleural

space might be encountered.

2. The middle layer of the chronic traumatic hemothorax was a soft, unorganized mass, with the consistency of fibrin. It differed from patient to patient

in gross appearance, chiefly because of differences in color. Sometimes, it was

almost, white. Sometimes, it was the color of mahogany. Sometimes, it was
254 THORACIC SURGERY

FIGURE 78.—Photomicrograph of section through membrane, pleura, and

lung (lung is at lower margin) in posttraumatic empyema 12 weeks after

wounding. Note cellular intimacy. No line of demarcation can be seen,

and surgically no line of cleavage could be established. This patient's

chance for decortication was forfeited by delay in resorting to it. Van

Giesoirs stain. (X 100)

definitely bloody. A certain amount of marbling was not uncommon, but it

was more frequent to find the middle layer the same color throughout, Differences in color seemed to depend upon the relative proportions of blood and

plasma in the mass or upon the amount of pleural effusion or pleural exudate

that had originally accumulated and that had been modified by whatever

degenerative changes might have occurred with the passage of time.

•3. The third layer (center) of the intrapleural. mass was typically tabulated (fig. 79). It might consist of a single large space or of a network of

spaces. Sometimes, it was a mushy core from whose interstices fluid could be

squeezed. The fluid looked like what it was, supernatant fluid from a mass of

retracting fibrin. It varied in color from yellow to red, brown, or mahogany.

The formation of the central, fluid-filled space or spaces was clearly the

result of retraction of the original clot. In fact, the whole pathologic process

in organizing hemothorax did not seem to differ in any important way from the

well-known process of organization in infra vascular thrombi.

The foregoing description bears out what has already been said (p. 238),

that the term "oro-anizina- hemothorax" or "chronic traumatic hemothorax"
HEMOTHORAX AND HEMOTIIORACIC EMPYEMA 255

Pan eta

Visceral leura

Collapsed lun~

Clot

Fibroplastic

peel or en--

velop investing pleurae

Serum poc

riui

Fibrinous par

tition

Purulent portion

EIOXJKE 79.—Cross-sectional diagram showing pathologic process in clotting, organizing hemotliorax. Membranous peel (rind), essentially a fibrinofibrous envelope, is

shown investing visceral and parietal pleurae. In center is loculated purulent material.

Loculation explains why in many infected hemothoraces infection could not be diagnosed

by thoracentesis, because aspirating needle did not reach center of process, which was

recognized only at operation.

carried no implication of the origin or gross appearance of the intrapleural

mass. The nomenclature suggests that the mass might be the result of the

presence of clotted blood alone, as in some instances it was. The gamut was

run, however, from such cases through (1) those in which a considerable portion

of blood was still present but in which there were also present increments of

white clot (that is, plasma, fibrinous pleural effusion, or fibrinous exudate) to

(2) those in which the entire mass seemed to consist of white clot, The variations seemed due not so much to the amount of whole blood originally spilled

into the pleura as to the pleural response to its presence,

Histopathology

Histologie examination of sections from an organizing hemotliorax confirmed the gross observations (figs. 74-78 and 80-85). As already pointed out,

as early as 7 to 10 days after wounding, there was microscopic evidence of

fibroblastic and angioblastic proliferation from the pleural surfaces to the clot.

The peel or rind thus formed increased progressively in thickness as the fibroblastic invasion continued.
256 THORACIC SURGERY

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FIOUKE 80.—Photomicrograph showing layer of fibrin 3

mm. thick removed from visceral pleura in uninfected clotted

hemothorax 11 days after wounding. Note beginning organization in portion immediately adjacent to pleura (on left).

"Within ?> or 4 weeks after wounding;, adult fibrous tissue was demonstrable

in the outer layer of the organizing- hemothorax. The fibers and nuclei were

arranged roughly parallel to the surface. The long axes of the capillaries were

at right angles to the surface, and the capillaries were continuous through the

pleura.

Within 4 to 7 weeks after wounding, small arterioles, with smooth muscle

fibers in their walls, could be demonstrated at or near the outer surface of the

peel. Active fibroplasia continued along the inner (younger) surface, with

resulting increases in the thickness of the rind. In some instances, layers of

fat cells developed in the peel along the outer surface. It was speculated, but

never proved, that tins phenomenon might possibly represent a regressive process, heralding eventual degeneration and absorption of the peel. For reasons

not clear, the membrane was always thicker, more vascular, and more adherent

on the parietal than on the visceral pleura.
HEMOTIIORAX AND HEMOTHORACIC EJIPYEMA 257

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FIGURK 82.—Photomicrograph showing calcium deposition in collagenous connective tissue layer of exudate on visceral pleura in organizing

liemothorax.

Microscopically, the rind in hemothoraeie empyema could not be differentiated from the rind in organizing liemothorax without infection. The only

evidence of inflammation seen under the microscope was observed on the inner

surface of the rind, along which fibrin or blood clot was in process of organization. It was limited to infiltration by varying numbers of polymorphonuelear

leukocytes (fig. 85).

The second (middle) layer appeared on microscopic examination to be

merely a mass of fibrin with scattered, formed blood elements trapped in its

meshes.

Pulmonary Effects of Organizing Hemothorax

"When the process of organization was complete, a dense fibrous membrane

encased some portions of the lung, or the whole lung, thus limiting its mobility

and preventing its complete expansion. A contraction of the hemithorax was

sometimes present also. Even in the early stages of an organizing hemothorax,

it was easy to see that the tough, resistant, inelastic rind that invested the visceral pleura effectively prevented pulmonary reexpansion. If the process were

not terminated by surgical measures, fibrosis increased, and the rind and the

pleura became intimately adherent. As time passed, tough scar tissue extended

through the pleura into the interstitial pulmonary tissue. The decree of eel-
HEMOTHORAX AND HEMOTHORACIC EMPXEJIA 259

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FIGURE S3.—Photomicrograph showing- biopsied section of

lung and pleura after removal of overlying exudate. Xote

that pleura retains most of its normal characteristics.

lular intimacy made it difficult, and sometimes impossible, to develop a clea-\ ase^

plane at operation, particular^ if the pleura had been denuded or the lungwounded. In such cases, the results of surgery were not likely to be good:

The lung, even when liberated by the procedure of decortication, could not

expand because the fibrotic process had extended to it, When complete pulmonary reexpansion was impossible, the stage was set for the development of

infection.

When the intrapleural mass was removed, it was frequently evident that

the lung had not only been compressed by the intrapleural accumulation but

had also been greatly displaced and had sometimes been infolded also (p. 183).

Resolution

Massive organizing hemothorax not treated by surgery could terminate in

two ways: (1) by the formation of a fibrothorax or pleural calcification (fig.

82) or (2) by the development of a suppurative process. Spontaneous resolution of small and even moderate amounts of accumulated clotted blood or small

amounts of fibrin was conceivable. If resorption of larger amounts occurred,

which was not usual, recognizable sequelae were almost inevitable,

The rapidity and extent of clearance in any given hemothorax were impossible to predict. In some cases in which the initial observations gave

promise of complete and prompt resolution, the process might suddenly become

static usually about the fourth week. Perhaps the chief reason for the dis-
2(iÜ THORACIC SURGERY

FioriiE ,S4.—Photomicrograph showing replacement of

fibrinous exudate, pleura, and adjacent lung (lung is at

extreme left) by collagenous connective tissue in organizing

liemotliorax.

cussion concerning the optimum timing of deeortieation (p. 286), which continued throughout, the Avar, was the lack of agreement concerning the possibilities

of resolution in an organizing liemotliorax. The exact size and type of an

intrapleural mass in which spontaneous resolution, might be expected were

never agreed upon, nor was the length of time in which expectant treatment

should be practiced. Generally speaking, cavities involving less than 50 percent of the pleural space or less than 500 cc. in volume usually cleared spontaneously over a 6-week period, but this was a generalization to which there

were multiple exceptions. No doubt, the most important consideration was

the thickness of the intrapleural mass. It was repeatedly observed that roentgenologic clearing was confined to the inner portions of the clot. The thickest

areas, notably the portion in the posterior thoracic gutter, were still clearly

demonstrable on roentgenograms after almost complete clearing of other areas

had occurred.
HEMOTHORAX AND HEMOTIIORACIC EMPYEMA 261

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EIGUKE 85.—Photomicrograph showing infected organizing hemothorax with

bacteria (Staphylococcus hemolyticus on culture) deep in unorganized portion

of fibrin and growing in masses in its meshes. Note conspicuous absence of

leukocytes.

BACTERIOLOGY OF ORGANIZING HEMOTHORAX

Hemotlioraces represent the largest hematomas with which the body must

deal. They are usually far too largo to vascularize rapidly, which probably

accounts for their tendency to infection, particularly when they are of the clotted type. This tendency was one of the many reasons why it was important

that thoracentesis be performed promptly and repeated as necessary.

All types of bacteria were isolated from hemotlioraces, including a surprisingly large proportion of anaerobic streptococci and staphylococci. Bacterioiogic findings in 24 cases of hemothoracic empyema are shown in the

following tabulation:

Number

Bacteria of eases

Proteolytic and saceharolytie clostridia. 2

Microcoecus tetragenus 2

Hemolytic Staphylococcus aiircits 1

Hemolytic Staphylococcus aurcus, proteolytic Clostridiiim 1

;74 0-94 V—G~> 10
THORACIC SURGERY

Number

Bacteria of cases

Hemolylie Sttipli glococcus aiircus, hemolytic Streptococcus. Pscudomonas acruginosa- 1

Hemolytic Stuphylococcus attreus, Eschcrichia co'li, Acrobactcr uerogciics, nonliemolytic Streptococcus 1

Streptococcus viridans 1

Hemolytic Streptococcus- 1

Anaerobic Streptococcus 1

Nonhemolytic Streptococcus, Pscudomonas acruginosa 1

Streptococcus viridans, proteolytic and saccharolytic clostriclia, Bacillus protcus 1

Proteolytic Clostridium 1

Eschcrichia eoli 1

Eschcrichiu, type unidentified 1

Clostridium, unclassified - 1

Cultures sterile G

Pscudomonas acruginosa 1

Clostridial infections, which were not numerous, were nearly always caused

by non-gas-forming bacteria. Remarkable combinations of bacteria were found

in both the liquid and the unclotted hemothoraces. In the order of frequency,

the offending organisms were streptococci, clostriclia, staphylococci, Esclierichia. and Pesudomonas. Regardless of the bacteriology, the clinical course

was essentially the same, except that when Esclierichia was present, the illness

was usually more serious.

In some cases, bacteriologic confirmation was lacking in spite of clear-cut

signs that infection had occurred. There were two explanations:

1. Bacteria might not be present in demonstrable numbers in the fluid

portions of the mass.

2. The needle might, by chance, have been introduced into loculations (fig.

79) in which the fluid was still uninfected. If this was the explanation and

infection had actually occurred, repeated efforts to find organisms would eventually be successful as the infection spread to the entire mass or as more

rewarding sites were selected for aspiration.

In some patients, for whom no explanation was forthcoming, signs of

sepsis were clear cut and organisms were found in fluid aspirated from the

chest, but there was virtually no leukocytic response (fig. 85). In this group

of cases, the fluid was thin and practically without sediment, even when

organisms were present in large numbers.

In some cases, suppuration, as evidenced by purulent material on aspiration, did not manifest itself for I to (> weeks. In a considerable number of

these cases, it had been thought that resolution was occurring. The factor (or

factors) which determined which cases would go on to prompt suppuration

and in which suppuration would be delayed or would not be evident at all was

never clearly demonstrated. Whatever the factor (factors) might be, the

explanation was probably the balance or imbalance between (1) the rapidity

and extent of the clotting that trapped the infecting bacteria in the fibrous mass
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 263

and kept them from contact with the pleura and (2) the ability of the pleura to

control or eliminate the bacteria that were originally in contact with it. If the

organisms in an infected hemothorax were virulent and if seeding was heavy

and early, a suppurative pleuritis was likely to occur promptly. Both the

liquid and the clotted contents of the intrapleural space would be involved in

the pathologic process. If, however, for one reason or another, the contaminating bacteria did not gain the ascendancy and instead became entrapped

within the clotted intrapleural mass, then the mechanism of a delayed or latent

infection was set up.

PHYSIOPATHOLOGY OF HEMOTHORAX

The bony thorax imposes definite limitations on the size of the thoracic

cavity. This means that any space-occupying medium can seriously disrupt

the normal function of the heart and the lungs. From this point of view,

pneumothorax and liemothorax produced almost identical physiopathologic

results. By impeding cardiac return and pulmonary expansion, they tended

not only to reduce the volume of circulating blood but also to decrease the degree of oxygen saturation. The response was an increased cardiac and respiratory rate, both of which were almost invariably observed in any severe thoracic

injury. The pain caused by damage to the thoracic cage and the voluntary

restriction of motion to minimize the discomfort further added to the physiologic disturbances because the respiration was rapid and shallow and the pulse

was fast. For these various reasons, it was necessary to empty the chest of

blood and air as rapidly as possible.

CLINICAL PICTURE AND DIAGNOSIS

Simple hemothorax.—The diagnosis of simple liemothorax almost never

offered any difficulty. The history of wounding was clear cut. liemothorax

was known to be the most frequent complication of thoracic wounds. Finally,

the pleural contents were readily aspirable. At first, the fluid was blood or

bloody. Later, if resolution began to occur, the blood disappeared and the fluid

became serous, as well as scantier, on successive aspirations.

Roentgenologic examination revealed intrapleural obscuration consistent

with the presence of fluid (fig. 86). The lung margin was characteristically

distinct and scalloped. This finding was particularly suggestive if the lateral

view revealed the process localized to the posterior half of the involved

hemithorax.

Organizing hemothorax.—The diagnosis of organizing liemothorax was

not always so simple. In the early stages, when clotting had occurred but

fluid could still be obtained, it was sometimes impossible to distinguish the

condition from a simple hemothorax. Later, it might be necessary to insert
2ß4 THORACIC SURGERY

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FIGURE SC.—Spontaneous resolution of clotted hemothorax. A. Posteroanterior

roentgenogram showing clotted hemothorax on right. B. Same, showing spontaneous

resolution after G weeks.

FIGUEE S7.—Posteroanterior roentgenogram showingright clotted hemothorax. Note that border of partially collapsed lung is still fairly distinct. In liquid

hemothoraces, borders of collection of blood were usually seen only as diffuse haze.
HEMOTHORAX AM) HEMOTHORACIC EMPIE1IA 265

FiGtiiiE 8S.—Lateral roentgenogram showing clotted

liemothorax over right lower and middle lobes. The

sharp superior border seen in this view and not seen

in posteroanterior roentgenograms came to be recognized as typical of clotted liemothorax.

the needle into many different areas of the chest to obtain any fluid. The

aspirated material consisted of only small amounts of serum, which contained

fragments of clot and fibrin threads. Efforts at drainage by insertion of an

intercostal water-seal catheter were practically always unsuccessful.

If organization had gone on to fibrosis, the clinical picture was distinctive.

A patient with fibrothorax was likely to show an overall contracture of the

affected hemithorax: narrowing of the intercostal spaces; elevation and more

or less immobility of the leaf of the diaphragm on the affected side; often

considerable limitation of movement of the chest wall; and, not infrequently,

an associated atrophy of the extracostal musculature, no doubt as the result

of disuse.

Roentgenologic examination in organizing liemothorax (figs. 87 and 88)

revealed a dense opacity corresponding to the area of the original hemothorax.

Resorption and consequent improvement in the roentgenologic appearance

(figs. 89 and 90) was observed in a few cases that had reached this stage, but,

as a rule, narrowing of the interspaces, as well as contracture and relative

immobility of the chest wall, was likely to remain unaltered.

Hemothoracic empyema.—The clinical picture of hemothoracic empyema

was that of typical empyema modified by the special considerations introduced
)Ü THORACIC SURGERY

m^i

i

FicrKB Si).—Clotted homodiorax with spontaneous clearing. A. Posteroanterior

roentgenogram showing clotted hemothorax 2 weeks after wounding. B. Same, 1

month later. Chest has almost completely cleared by natural processes. Neither

thoracentesis nor surgery was used.

by the chest wound. Fever "was usually high, and the patient was likely to

become more toxic than he had been. There might be an associated pneumonitis

with, productive cough.

The sudden spillage of purulent pleural fluids in large amounts into the

bronchial tree made the diagnosis of empyema with bronchopleural fistula

simple. If there was leakage of only a small amount, the diagnosis was more

difficult. The finding of a fluid level, otherwise unexplained, on the roentgenogram was almost certain evidence of a fistula.

The diagnosis of empyema was confirmed by the aspiration of fluid that

was chocolate brown, foul smelling, or frankly purulent. In some cases, as just

noted (p. 262), infection had been present for some time before purulent fluid

appeared.

The degree of mediastinal immobility present in any given case depended

upon the degree of organization that had occurred in the preexisting hemothorax. It was therefore roughly proportional to the length of time that had

elapsed since injury rather than to the duration of the infection or the thickness

of the purulent exudate.

Differential diagnosis.—Large extracostal or intrapulmonary hematomas,

as well as lobular or lobar atelectasis following bronchial obstruction, were

usually readily distinguished from chronic traumatic hemothorax. Pneumonia

was also readily distinguished. Infolded lung sometimes offered special difficulties (p. 18.",).
IIEMOTHORAX AND HEMOTHORAC1C EMPXEMA 267

A B

FIGUKE 90.—Clotted heniothorax with spontaneous clearing. A. Posteroanterior

roentgenogram showing right-sided massive clotted heniothorax, without infection,

2 days after wounding. B. Same, 3 weeks later. Complete spontaneous clearingoccurred later in this ease, in which evidences of resorption of fluid were noted from

beginning.

MANAGEMENT OF SIMPLE HEMOTHORAX

Rationale of Thoracentesis

Tlioracentesis was part of the routine of resuscitation for four reasons, all

concerned with the restoration of normal cardiorespiratory physiology:

1. To relieve high intrapleural pressure.

2. To permit increased aeration of the pulmonary parenchyma and thus

encourage prompt reexpansion of the lung.

3. To correct shock by relieving the hypoxia that was helping to cause it.

4. To relieve the shift of the heart and mediastinum and thus both improve

the venous return to the heart and increase the volume flow of blood (fig. 01).

There were three additional reasons for continuing tlioracentesis after resuscitation as part of the management of simple liemotliorax in forward

hospitals:

1. To decrease the possibility of later clotting.

2. To encourage apposition of the lung and the thoracic wall and thus limit

the extent of infection if hemothoracic empyema should develop.

3. To prevent late fixation and contraction of the chest.

Failure to carry out aspiration of a simple heniothorax in forward hospitals

often presented surgeons working in rear areas with complicated problems of

organizing heniothorax and hemothoracic empyema, problems which could be

solved only by radical surgery. The management of empyema was the responsi-
THORACIC SURGERY

B

FiGfHio 91.—Management of hemothorax by thoraccntesis. A.

Schematic showing of massive hemothorax with collapse of involved lung and shift of mediastinum with partial collapse of

nninvolvcd lung. B. Expansion of involved hing after removal of

blood by simple aspiration of chest. This procedure, in addition

to greatly increasing vital capacity, also indicates amount of

intrapleural hemorrhage.
HEMOTHORAX AND HEMOTHORACIC EMPXEMA 269

bility of surgeons in base hospitals and hospital centers, but its prevention was

usually the responsibility of surgeons in forward bospitals.

Very early in the war, the practice of air replacement after thoracentesis

was condemned, and all the attention was devoted to the policy of early, vigorous aspiration. Certain objections to thoracentesis that had been advanced

before the war proved entirely theoretical:

1. The military experience showed that there was no risk of causing

renewed bleeding by thoracentesis: no case is on record in which this happened.

This might have been expected. The two chief sources of hemorrhage in chest

wounds were extrapuhnonary (from the chest wall or the mediastinum) and

pulmonary. The existence of a hemothorax, however, had no effect on extrapulmonary bleeding, while the reason that pulmonary bleeding usually ceased

spontaneously was not the effect of the hemothorax but, the lowered pressure m

the pulmonary artery and its branches (p. 153). Many more errors were made

in World War II by not aspirating the chest than by aspirating it and taking

the remote and theoretleal risk of recurrent hemorrhage.

Only one case is on record in the Mediterranean theater in which there

seemed to be any connection at all between aspiration of a hemothorax and

secondary hemorrhage, and, in this case, the relation was entirely on a posthoc-ergo-propter-hoc basis. Intrapleural bleeding occurred 10 days after

closure of a sucking wound of the chest, after 2,850 cc, of bloody fluid had been

aspirated over a 3-day period. Just as preparations were being made for exploratory thoracotomy to determine the source of the bleeding, the hemorrhage

ceased as abruptly as it had begun, and recovery thereafter was entirely

uneventful.

2. The risk of infection after a properly performed thoracentesis proved

negligible.

3. The concept that only small amounts of fluid could be removed at one

time proved completely false. Withdrawal of 1,000 to 1,500 cc, at one sitting

usually caused no symptoms but, instead, produced relief of symptoms. Occasional patients complained of a tight feeling, pain in the chest, dyspnea, or

dizziness after large amounts had been withdrawn, but these symptoms disappeared as soon as aspiration was discontinued and seldom recurred when

the procedure was resumed 21 hours later.

If hemorrhage continued or recurred (fig. 92), thoracotomy was indicated.

Eeaccumulation of 1,000 to 1,500 cc. of blood within a short period after the

first aspiration of the chest was likely to be associated with failure to maintain a satisfactory blood pressure and with a falling hematocrit. In these

circumstances, simple aspiration could not be expected to be effecti ve.

Technique of Thoracentesis

Since the purpose of the first aspirations of the chest was to relieve pressure and to aid in the restoration of normal cardiorespiratory physiology, it

was not necessary to empty the chest completely. At the end of 18 or 72 hours,

74C-Ö411—on 20
2(0 THORACIC SURGERY

FIGCHE !)2.—Schematic showing of recurrent hemothorax after

thoracentesis.

aspiration was carried out at least once daily, in order to empty the pleural

cavity as rapidly and as completely as possible. If thoracentesis had been

instituted as soon as the casualty was seen, not more than three to five daily

aspirations were usually necessary.

The patient was transferred to the base as soon as he was fever free and

the chest had been completely or almost completely emptied. If he was received

in a fixed hospital with clinical or roentgenologic signs of fluid, aspiration was

resumed and was continued until the chest was empty or until it was clear that

other measures would be necessary.

A single negative aspiration was not accepted as conclusive. Often three

or four punctures had to be made before a loculated pocket was found. If

several punctures produced no results, another surgeon attempted aspiration the

next day. The effort was not abandoned in any case in which there was roentgenologic evidence of fluid or a suggestive pleural shadow until repeated attempts to locate and remove the fluid had been made. The fact that blood had

clotted (fig. 93) did not necessarily interfere with its aspiration.

Results of Thoracentesis

The results of early, vigorous thoracentesis in hemothorax were excellent

from the beginning. If this was the chief or the only complication of a thoracic

wound, the great majority of casualties who were treated by this method could

be returned to duty within G to 8 weeks after wounding.
HEMOTHORAX AND HEMOTIIORACIC EMPYEMA 271

^p^>

FiomtE 03.—Schematic showing of massive clotted hemotliorax.

Aspiration of blood is still possible when process of organization is

still incomplete, but when physical signs and roentgenologic findings

point to a large accumulation of intrapleural fluid and only small

amounts of blood can be aspirated, further attempts at evacuating

chest are unlikely to be successful. If patient is dyspneic or shows

signs of early infection, thoracotomy and evacuation of clots must

be undertaken promptly. Usually, however, it is safe to wait for

surgery (decortieation) at the base.

Results improved as time passed. In August 1943, it was estimated that

about 6 percent of casualties with uninfected hemotliorax observed at the chest

center at the 21st General Hospital, located near Naples, required decortieation.

By the end of the war, the only casualties in this group who required decortieation were those in whom massive clotting had begun shortly after wounding.

At this time, the operation was chiefly used in complicated cases of hemotliorax

and in liemothoracic empyema. The most reasonable explanation of the improvement was the excellent treatment of hemotliorax in forward areas, including prompt, vigorous thoracentesis; measures to promote early pulmonary

reexpansion; and a material reduction, in the number of thoracotomies performed at initial wound surgery for the evacuation of hemothoraces.

While a hemotliorax could become infected and empyema could develop

earlv enough to require treatment in an evacuation hospital or even, occasionally, in a field hospital, these complications did not usually ensue until the

patient had reached the base section. Both complications are therefore

discussed elsewhere (p. 275).
272 THORACIC SURGERY

CLINICAL PICTURE AND DIAGNOSIS OF HEMOTHORACIC

EMPYEMA

Ilemothoraces, as already pointed out, represented the largest hematomas

with which the body had to deal in combat-incurred wounds. The fact that

they were far too largo to vascularize rapidly might very well have played a

part in their pronounced tendency to infection.

When infection supervened in either the liquid or the clotted variety of

hemothorax, it was not always easy to make a distinction between infected hemothorax and hemothoracic empyema. The precise differentiation depended on

changes in the visible characteristics of the pleura! fluid. These changes did not

always occur immediately (p. 206). The infection was classified as hemothoracic empyenia as soon as gross pus or purulent exudate was observed in the

aspirated material.

There were distinct differences between the hemothoracic empyema of combat-incurred wounds and the postpneumonic or metapneunionic variety of

empyema. In the latter variety, tveo features were prominent:

1. Infection of the plcural space was initiated upon essentially normal

pleural surfaces.

2. The preexistent pathologic changes were in (he luno-.

Hemothoracic empyema had the following characteristics :

1. The pleural space was seldom normal. It had been altered in varying

degrees by the fibrinous deposit that resulted from the presence of blood in

the pleural cavity. Posftraumatic empyema was therefore not primarily an

infection of the pleura per se but an infection originating jn pleural dead space

occupied by a hematoma enclosed in a fibrinous capsule.

The antecedent status of the pleural space Mas a point of great importance.

Infection developing within a pleural cavity which has not been the site of a

significant hemothorax is always a more favorable type than hemothoracic

empyema which develops in a preexisting pleural clot or a neglected liquid

hemothorax. In the former type, the restraining membrane or peel commonly

observed in all pleural irritative, phenomena dates from the onset of the infection. In the hemothoracic type, the peel antedates the clinical evidence of

infection and may be well on to maturity before treatment is started.

2. The lung was collapsed and compressed because of the presence of

intrapleural blood. There were no changes caused by disease in it, and by the

time empyenia developed, healing had usually occurred in any pulmonary

wound. It was repeatedly observed at decorfication that the lung had returned

to normal, as evidenced by its ability to expand, even when it had sustained

extensive lacerations and contusions. There had been time for this recovery

to ensue. When empyema developed in a liquid hemothorax, the average time

between wounding and demonstration of pus by thoraoentesis or at operation

was 15 davs. In the clotted variety it was 18 davs.
HEATOTIIORAX AND HEMOTHORACIC EHI'YEHA 273

3. The constrictive pulmonary investment-—that is, the rind which enclosed

the hemothorax—was responsible for failure of the lung to reexpand.

4. The purulent exudate thickened more slowly in the hemothoracic than

in the postpneumonic or the metapneumonic variety of empyema.

5. Loculation was more frequent in the hemothoracic variety of empyema,

and total empyema occurred more readily.

6. Even in patients with extensive hemothoracic empyema of several weeks'

duration, there was no reaction in the costal periosteum, the ribs were never

triangular, and the fingers were never clubbed as in the variety of empyema in

which there was no antecedent trauma.

All of the circumstances associated with a combat wound are favorable for

the development of empyema. They include the wound itself and the tissue

destruction that accompanies it; the contamination introduced by the missile

and the debris brought into the wounds with it; in many instances, the presence

of pathogenic bacteria; tissue necrosis; the presence of an intrathoracic foreign

body; pneumothorax or hemothorax, with resulting dead space in the pleural

cavity: and the ideal culture medium furnished by a clotted or an organizing

hemothorax. Neither chemotherapy nor antibiotic therapy could in themselves

overcome these circumstances. Only good surgery could meet the situation.

EMPYEMA IN THE WORLD WARS

There was a vigorous discussion of empyema at the 1946 meeting of the

American Association for Thoracic Surgery (6), in the course of which much

emphasis was put upon the differences in the infections of the pleural cavity

encountered in the two World Wars. The presentations on chronic organizing

hemothorax, hemothoracic empyema, and decortication were prepared by the

thoracic surgeons who had had the widest experience in this field during World

War II. The discussion was participated in not only by these surgeons but

also by a number of other surgeons, among them Dr. Evarts A. Graham, who

had had the widest experience in chest trauma and postinfluenzal empyema in

World War I.

Graham contended that no comparison was possible between the empyemas

of Woi'ld War I and World War II because there was no similarity between

them. The surgeons of World War I, he said, were called upon to treat empyemas which were, in the Hippocratic sense, true abscesses of the pleural cavity.

The empyemas encountered by the World War II surgeons were pleural infections attenuated by drugs. In other words, the World War II surgeons dealt

with conditions never before seen. If Hippocrates could listen in on the discussion, Graham concluded, he would not know what the World War II surgeons

were talking about.

The surgeons of World War II naturally took issue with this point of

view. They contended that hemothoracic empyema was true empyema, and they
274 THORACIC SURGERY

pointed out that their first patients, as well as some of their later patients, were

treated without benefit of chemotherapeutic or antibiotic agents. Many of

these casualties, they emphasized, were very ill and highly toxic, and problems

of management were quite as serious as those encountered in World War I.

The clinical and other distinctions between the empyemas encountered in

the two World Wars were well stated by Dr. Carl Eggers:

1. Chronic empyema was the chief problem of thoracic surgeons in World

War I, -while posttraumatic hemothoracic empyema was apparently the chief

problem of these surgeons in World War II.

2. The patients with chronic empyema encountered in World War I were

chronic invalids. They had survived measles, influenza, lobar pneumonia, and

the other diseases that were widespread in Army camps and that were frequently

complicated by bilateral bronchopneumonia. They had withstood prolonged

sepsis. They had usually undergone drainage operations for acute empyema.

Structural organizing changes had frequently taken place in the chest wall, the

pleura, and even the lung. As a result, their resistance was materially lowered.

3. In World War II, patients who developed hemothoracic empyema after

combat wounds of the chest were usually in good physical condition. They

had normally functioning organs. Their chest walls were usually intact or

almost intact and w

Tere therefore mobile. Their lungs were usually uninvolved; if there was any pulmonary involvement, it was usually traumatic and

not infectious. These casualties might have lost blood and been in shock, but

their resuscitation had been uniformly excellent, and their resistance was generally good. In short, there was a striking difference in the general condition

and the surgical risk presented by the casualties of the two World Wars.

In discussing the procedures possible in empyema in the two wars, Eggers

pointed out that it would not have been possible, in World War I, to insert a

rib spreader after making the incision, which was part of the technique of

decortication in World War II. It would have been impossible because the

ribs were usually fused and were firmly embedded in the thickened parietal

pleura. Resection of portions of all the ribs overlying the pleural cavity was

therefore prerequisite to mobilization of the chest wall. In World War II, the

chest wall was practically always mobile. In World War I, the parietal pleura

was often half an inch or more in thickness. Mobilization of the compressed

lung, the most important surgical objective, had to be accomplished by reflection of the thickened tissue forming the angle of reflection from the parietal

pleura onto the lung. Then, if it were possible, the remaining layer of tissue

compressing the lung was peeled off. Often this was not possible. Then the

solution was to make crisscross incisions into it, Complete reexpansion of the

lung occasionally followed this procedure but, as a rule, success was only

partial.

The degree of success achieved in individual patients in World War I,

Eggers concluded, depended not only upon the surgery performed but upon
HEilOTHORAX AND HEMOTHORACIC E3IPYEJIA 275

the condition of the pulmonary parenchyma. If the lung was librotic, as it

frequently was, complete ^expansion could not possibly occur. From this

standpoint, conditions in World War II were very much more favorable, a

point of view which the World War II surgeons present did not accept.

MANAGEMENT OF INFECTED HEMOTHORAX AND

HEMOTHORACIC EMPYEMA

General Considerations of Treatment

Aspiration, with or without the instillation of penicillin, was occasionally

used in small infected hemothoraces in the Mediterranean theater, but it was

never a theater policy. This method was used only when cultures were sterile,

compression of the lung did not exceed 25 percent, and the patient's condition

was good. If a purulent exudate appeared, drainage was instituted at once.

The unwise use of continued aspiration was an invitation to chronic empyema.

In World War I, the patients who were thus treated endured months and years

of suppuration and, if they survived, eventually required multistagecl deforming obliterative operations. Such patients were scarcely ever seen in World

War II.4

In some European chest centers, a so-called irritating pack was occasionally

used in chronic empyemas in which the cavities were small or of moderate size,

in the belief that maintenance of an acute inflammatory state would produce

an obliterative pleuritis more rapidly. This method, which is usually employed only as a supplement to a small Scheele thoracoplasty, was not used in

the Mediterranean theater.

Intercostal catheter drainage as the sole method of treatment of empyema

was never considered adequate. The catheter was promptly blocked by large

amounts of partially degenerated clot, fibrin, and exudate, and drainage simply

ceased. Early in the war, some surgeons employed catheter drainage as a

preliminary to rib resection, but as experience increased, it came to be appreciated that if drainage was indicated, almost the only contraindication to ribresection drainage was that the patient was too ill to tolerate it as a primary

procedure.

Selection of Therapeutic Method

When treatment of infected hemothorax and hemothoracic empyema became standardized in the Mediterranean theater, three methods were employed :

1. Rib-resection drainage alone.

1 The basic difference, of course, was that in World War I the empyemas encountered were of the

synpneumonic or metapnenmonic varieties. In World War II, the empyemas "were chiefly caused by

infection of hemothoraces. They occurred in healthy plcural cavities and in association with healthy

lungs.—F. B. B.
276 THORACIC SURGERY

2. Primary decortication; that is, a procedure to eradicate infection or

empyema by securing immediate normal expansion of the lung, without preliminary drainage of the pleura! cavity.

?>. Secondary decortication; that is, a procedure for the same purpose after

adequate rib-resection drainage for several weeks.

The choice of treatment depended upon several factors:

1. The size and location of the empyema cavity. If the cavity were small,

unilocular, and basal, rib-resection drainage alone was usually adequate.

2. The percentage collapse of the lung and its distribution. To World

War II thoracic surgeons, the status of the lung was of primary importance.

Their position was based on the truism: "As goes the lung, so goes the pleural

space."

If collapse involved 50 percent or more of the lung, primary decortication

was the method of choice, particularly if the pulmonary apex was involved

in the collapse. Because of the increased technical difficulties if apical collapse

ensued after rib-resection drainage, collapse at the apex was considered a more

important indication for primary decortication than a similar degree of basal

collapse.

The common method of estimating the percentage of pulmonary collapse

was based upon the distance of the lung border from the lateral thoracic wall

as it was observed in posteroanterior roentgenograms. The measurement was

frequently found to be, in error and was nearly always found to be a minimal

estimate. The lung was usually collapsed for an equal distance from the anterior and the posterior thoracic walls. In most instances, if the lung border

did not. approximate the lateral thoracic wall by a third of the width of the

hemithorax, the. collapse was usually found to bo 50 percent or more. A consistent lack of correlation was found between the percentage collapse of the

lung as determined by roentgenograms and as observed at operation (fig. 94).

3. The. status of the patient. A few patients were so seriously ill as the

result of massive pleural infection that a procedure of the magnitude of decortication could not. be considered as a primary procedure. This operation

sometimes lasted 3 hours or more, and there was a considerable loss of blood

during decortication of the visceral pleural surfaces.

Most patients treated by primary decortication had had fever to 102° or

103° F. daily for several days or longer before operation. When other features

of the illness were favorable, pyrexia was not regarded as a contraindication

to its performance. Much more important was the estimarion of the general

status of the patient, and Ids ability to withstand surgery as shown by simple

observations of the color of his skin, his appetite and nutrition, his general

strength and alertness, and his response to transfusion.

4. The results of rib-resection drainage when it had been used as a primary

procedure. In these cases, it was observed that if satisfactory results were to
HEMOTIIORAX AND HKMOTHOKACIC E.Ml'VEMA 277

'«w - .«am»'" " ~ """""^Ki

|B

FIGTHIO 04.—Decortication in hemothoracic empyema. A. 1'osteroanterior

roentgenognun showing original extent of empyema. 1>. Same, 2 weeks after

thoraeotomy and decortication, which resulted in complete cure. At operation,

degree of pulmonary collapse was found to he considerably greater than indicated

in figure 90A.

follow, they would, be evident within the first 4 to 6 weeks after operation (fig.

95). If the lung expanded rapidly within that period, so that it seemed reasonable to anticipate continued complete obliteration of the cavity, no further

surgery was considered necessary. If progress during this period was not satisfactory (fig. 9G) and the collapse of the lung remained at 50 percent or more,

secondary decortication was considered indicated, not only to prevent possible

or probable chronic empyema but also to reduce the duration of pleura!

suppuration.

These considerations applied to all cases of empyema as well as to infections of clotted hemothoraces. Because of the tendency to loculation in both

lesions, there was little reason, for assuming that all septa would be broken and

all loculi drained through, the relatively small wound made at rib resection.

This was true whether the purpose of the procedure was to provide an outlet

for frank pus or for drainage of a clotted hemothorax. Rib-resection drainage

was a satisfactory procedure, in short, only when the cavity was so small that

all parts of it were readily accessible.

Multiple empyemas associated with fistula formation in a traumatized lung

that had fully reexpanded offered a real therapeutic challenge. The precise

origin of the pathologic process in such cases was frequently not clear. The

blowouts might have occurred primarily along the missile track. Another

theory was that a primary vascular injury might have resulted in areas of

pneumomalacia that later ruptured, thus giving rise to isolated fistulas with

separate encapsulated pockets of empyema.
278 THORACIC SURGERY

B R L

FIGURE 0-3.—Management of hemothoracic empyema by rib resection drainage. A.

l'osteroanterior roentgenogram showing massive liquid bemothoraeic empyema on

left just before operation. B. Same, 4 weeks after institution of drainage by rib

resection. Lung is now almost completely expanded. This patient went on to recovery without further surgery.

Decortication was obviously not the solution in this group of cases, and

great care was required in the institution of drainage. A misplaced incision

could result in unnecessary mutilation or even introduce a real threat to life.

Attempts to drain one cavity through another, however closely adjacent the two

cavities might be, were usually ill-conceived and might well cause complications by tearing into a lung that was normal or only slightly involved. The

best technique in this kind of case was drainage by multiple rib resections.

DECORTICATION OF THE LUNG

Development and Rationale

The first decortication recorded in World "War II was performed in the

North African Theater of Operations, U.S. Army, in April 1943, by Major

Burford, on a patient with an uninfected organizing hemothorax, 5 weeks after

injury (vol. I). The smooth recovery and successful end result in this case

elucidated many previously obscure problems of clotted hemothorax. Thoracotomy had sometimes been undertaken before this date for removal of the

clot, but the operation was seldom successful, as might have been expected,

for it made no attack upon the essential pathologic feature of clotted hemothorax ; that is, the fibroblastic membrane or peel. It was the continued presence of this constrictive pulmonary investment that prevented reexpansion of

the lung compressed by it.
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 279

Fi<ai:i: !)0.—Posteroanterior roentgenograni showing massive liquid empyema on

right side 4 weeks after institution of

rib-resection drainage. Lung is still collapsed. Patient later required secondary

(leeortieation.

The rationale of decortication was incontrovertible:

1. The continued presence of an organizing hemothorax prevents pulmonary reexpansion.

2. The intrapleural mass must therefore be removed.

3. A line of cleavage exists between the pleural surfaces and the membrane

until such time as the process, if not interrupted, becomes chronic in the

pathologic rather than in the chronologic sense.

i. Decortication, which removes the compressing membrane, if performed

before the process becomes chronic, will result in immediate and total pulmonary reexpansion and will also obliterate all pleural dead space.

In the beginning, decortication was undertaken only on the indication of

uninfected organizing hemothorax. At a number of operations, however, unexpected loculations of pus were found, and inadvertent decortication for infected hemothoraces and hematothoracic empyema proved the suitability of

the operation for both of these conditions. The extension of the operation to

these conditions was perfectly logical. The basic pathologic process was the

same in both. Microscopic examination of the rind over the pleura in early

empyema showed it to be identical, cytologically and chronologically, with the

rind in noninfected hemothoraces.

With the advent of penicillin and the demonstration of its usefulness by

Maj. Champ Lyons, MC, the next step in the evolution of decortication was

natural, the use of the operation without preliminary drainage in massive

empyema. The first deliberate primary decortication for hemothoracic

empyema was performed by Maj. (later Lt. Col.) Paul C. Samson, MC, under

penicillin protection, in March 1944. It was a complete success.
THORACIC SURGERY

Decortication was then extended to cases in which concomitant lesions justified operation even if the size of the clotted hemothorax or the empyema

present would not, in themselves, have warranted the operation. In many

residual empyemas, other persistent pulmonary processes required surgical

correction, including obliteration of bronchial fistulas: wedge resections for

multiple fistulas; or, occasionally, the same procedures for posttraumatic

abscesses.

The rationale of early decortication in properly selected cases of sterile

organizing hemothorax, infected hemothorax, and posttraumatic or hemothoracic empyema rapidly led to the concept that it was not tenable to consider

that a patient with massive hemothorax was convalescing satisfactorily merely

because he showed no signs of infection. Such, a point of view took no cognizance of the primary concern of the surgeon: namely, the early restitution

of pulmonary function and the prevention of the crippling effects of chronic

fibrofhorax.

The most effective reply to the arguments of those who advocated a more

conservative approach, to the therapy of posttraumatic empyema was the not

insignificant case fatality rate in adequately drained cases in which progress

was apparently satisfactory. Progress in even the most competently managed

case was unpredictable, and the road from drainage to complete cure was beset

with many dangers. Chronieity could develop at any stage, and at the best,

the elapsed time between drainage and cure, was a matter of many weeks, and

often of many months.

The rediscovery and reapplicafion of total pulmonary decortication (vol.

I) to organizing hemothorax and to hemofhoracic empyema resulted in a

prompt decrease in the duration of recovery after chest wounds and a reduction in the number of potential pulmonary cripples. In properly selected cases,

decortication was almost invariably followed by prompt eradication of intrapleural fibrosis and sepsis and prompt, pulmonary reexpansion.

As Col. Edward D. Churchill, MC, pointed out in the discussion of decortication at the 1046 meeting of the American Association for Thoracic Surgery

(p. 273), the principle for which the Empyema Commission fought in World

War I was to wait to establish drainage until a generalized empyema had become localized. In World War II, the procedure was the exact reverse : It was

to take a localizing empyema and convert it into a generalized pleura! contamination in order to achieve prompt reexpansion of the lung. When the principle

was thus stated, Colonel Churchill concluded, it Mas as startling as it was

important.

In the excitement of this discussion, three points of major importance in

the management of the hemofhoracic empyema encountered in World War II

were not explicitly stated:

1. There was no emphasis on the status of the mediastinum. As Graham

had pointed out in World War I, when the mediastinum had become fixed,
HEMOTHORAX AND HEMOTIIORACIC EMPYEMA 281

drainage was indicated and safe. "When it was still labile, drainage was not

indicated and could be lethal.

2. The status of the pleural space depended upon the status of the lung,

according to the truism, already mentioned: "As goes the lung, so goes the

pleural space."

3. The point emphasized in Colonel Churchill's discussion, that it was safe

to take a localizing empyema and convert it into a generalized pleural contamination in order to achieve prompt reexpansion of the lung, was possible

only because penicillin was available and was capable of protecting the pleural

cavity against bacterial, invasion.

Indications

Before the concept of decortication for organizing hemothorax, infected

hemothorax, and empyema could be properly formulated, it was necessary to

bear in mind certain fundamental facts :

1. The essential nature of the pathologic process. The demonstration of

the flbroblastic membrane that invested the pleura explained the chronicity of

many hemothoraces with infection, made clear the object of treatment, and

pointed to the procedure that would achieve the desired results.

2. The efficacy of penicillin in protecting against and controlling invasive

infection, so that surgery could be safely applied at the optimum time to secure

maximum functional results.

?>. The selection of cases on the basis of strict indications. This was not

a procedure for promiscuous use. After decortication was first introduced, the

initial wave of overenthusiasm, as often happens, Jed to its use in some patients

in whom it was not indicated. The original excess of enthusiasm was soon

tempered by experience, and the scope of the operation was properly delimited

and its indications defined.

There were four chief indications for decortication:

1. Unhifected organising liemotlwrax.—Patients in this group were treated

conservatively for periods ranging from ?> to 6 weeks. During this time,

repeated aspirations were carried out. EACH if all the blood in the pleural

cavity could not be removed and some clotting had already occurred, the

removal, from time to time, of as little as from 50 to 100 cc. of currant-jellylike material through a large caliber needle was found to be advantageous.

Breathing exercises (vol. I) were also instituted, in an effort to aid reexpansion

of the lung.

Between the third and sixth weeks of conservative treatment, the patient's

status was carefully appraised. If aspiration was yielding only a few cubic

centimeters of blood and serum and if roentgenograms failed to show progressive improvement, decortication was regarded as indicated if the patient presented some or all of the following symptoms and signs: Diffuse pulmonary

pain or discomfort; dyspnea on exertion; and poor thoracic expansion, with
282 THORACIC SURGERY

Sfc.

TgfFi(;rnK !)7.—Management (if clotted hemothorax with retained foreign body.

A. Posteroanterior roentgenogram showing extensive left hemothorax, with foreign body in left lung. B. Same, showing clotted hemothorax of moderate size

after 2 weeks' trial of aspiration. A clotted hemothorax of this size would not.

in itself, have constituted sufficient indication for decortication at end of 2 weeks,

but surgery was considered indicated because of missile in lung.

retraction, and narrowing of the intercostal spaces. A generalized hazy appearance on the roentgenograms provided additional support for decortication.

Patients with organizing hemothorax associated with retained foreign

bodies a centimeter or more in diameter often presented good expansion of

the upper lobe by the third or the fourth week, although a lower lobe might

still be partly compressed by organizing hemothorax. In cases of this kind,

the combination of an organizing hemothorax, even of moderate degree, and

of a retained foreign body was regarded as sufficient indication for decortication and removal of the missile (figs. 97 and 98).

2. Infected organizing hemothorax.—Decortication was undertaken, as

soon as the patient's condition permitted, in all cases in which the pulmonary

collapse was more than 25 percent, particularly if the collapse involved the

apex. Although infection sometimes became evident by the 10th to the 12th

day after wounding, it usually manifested itself at a somewhat later date.

Positive smears or cultures frequently could not be obtained, and presumptive

evidence of infection had to be based on signs of increasing toxieity, mounting

fever, or rapid enlargement of the hemothorax. Massive clotting was likely

to be present in these cases, and a policy of delay often led to the development

of empyema.

Many surgeons took the position that bacteria were consistently present

in hemothorax, even if cultures were negative and even if frank suppuration

did not supervene. If this concept were correct and the intrapleural mass
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 283

FIGURE 97.—Continued. C. Same, 2 weeks

after deeortication. Progress after operation

was entirely satisfactory and patient went on

to complete cure.

were left in situ, it seemed logical to postulate that true latency might result

from foci of infection left deep in the hemothorax.

If this latter hypothesis were correct, then it could be further postulated

that in the postwar period, patients with fibrothorax or neglected organizing

hemothorax would present the persistent roentgenologic finding that in the

past has been erroneously termed "thickened pleura," It is characteristically

present in patients subject to recurrent febrile episodes caused by recrudescence

of activity in foci of infection in the chest, as well as in patients who have

become chronic respiratory invalids.

3. Posttraumatio (hemothoracic) empyema.—As already pointed out,

the distinction between hemothorax with infection and frank hemothoracic

empyema was not great in many cases. In frank empyema, the infection

might have been present for a longer period of time or might be more virulent.

In general, the patients were more critically ill than those with infected hemothoraces, and the aspirated material was more grossly purulent. All the patients on whom cleeortication was performed on the indication of empyema had

clinical evidence of infection; that is, fever, anorexia, malaise, and other signs

of toxicity. The majority were acutely and seriously ill, and at operation all

were found to have purulent fluid in the pleural cavity.

The type of organism recovered from the pleural fluid was not a factor

in the decision for or against cleeortication. Clostridial empyemas were

treated by the same routine as other empyemas. The percentage of negative

cultures was probably no greater than would be encountered in any series of

empyemas. Negative cultures were to be expected after chemotherapy and

antibiotic therapy had been employed.

Focal points of intense reaction were occasionally seen in hemothoracic

empyema, and miliary abscesses were occasionally observed in the older portion

of the organizing clot. On the whole, however, these layers (fig. 79) were

remarkably free from inflammatory reaction. For all practical purposes, the

pleura and the layers of adjacent organized clot, with their blood supply, had
281 THORACIC SURGERY

Illliällll^

I'muia: !)S.—Management of clotted hemothorax with retained foreign body.

A. Posteroanterior roentgcnogram showing clotted hemothorax on right, without

infection, and foreign body in right lung. 15. Same, 2 weeks after decortieation and

removal of foreign body. There is no residual hemothorax. and lung is fully

expanded.

cleared themselves of infection. This observation helps to explain why such

good results could be obtained by decortieation even when there was frank

suppuration in the center of the organizing mass.

4. Other iiid/'eafiorix.—Persistent bronehopleural (istulas, esophagopleural

fistula?, and transdiaphragmatic biliary fistulas were not frequent, but all

played their part in the genesis of chronic empyema and therefore demanded

energetic management. Early decortieation, with excision and closure of the

fistula, gave excellent results. In a few cases, decortieation under penicillin

protection was combined with the excision and closure of small intrapuhnonary

abscesses (up to 5 cm. in diameter) associated with empyema.

Penicillin, with its established bacteriostatic properties and its resultant

ability to diminish the dangers of invasive infection at operation in the presence of acute intrapleural infection, proved to be the adjunct which had long

been desired to render early surgery safe in such cases. Perhaps the most

valuable role of penicillin was in the management of chronic empyema, in

which it afforded efficient protection against spreading infection when a radical

operation such as decortieation was undertaken for the obliteration of a chronic

empyema cavity.

A precise estimate of its benefits was naturally not possible. It seemed

reasonable to assume, however, that, when the surgeon was obliged to work in

a potentially or actually infected field, penicillin protection often prevented

serious wound infections and other complications. When it became available,

it was possible to pursue a rational plan of therapy in infected hemothorax

and hemothoracic empyema, directed toward the achievement of (1) early
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 285

pleuropulmonary lysis, (2) total ablation of infected tissue, (3) complete pulmonary reexpansion, and (4) absolute obliteration of residual pleural dead

space. Under penicillin protection, all of these objectives could be achieved

by a procedure relatively free from the risk of septic dissemination.

When penicillin became available, in the spring of 1944, the indications

for decortication in hemothoracic empyema became stabilized. Rib resection

with drainage was considered wisest when the pleural infection was limited

to the basal portion of the thorax or when, it was small and definitely eneapsuled. If these empyemas were drained adequately, persistent cavitation seldom developed. If complete obliteration of the cavity and complete pulmonary reexpansion did not take place promptly, however, the patient was

regarded as a candidate for decortication.

Preliminary rib-resection drainage was also used in patients who were

too ill and too toxic to be subjected initially to open thoracotomy and

decortication.

Decortication without preliminary rib-resection drainage had a number

of advantages:

1. Complete pulmonary expansion occurred at once, with the immediate

elimination of all intrapleural dead space.

2. Chronic empyema, which was a distinct possibility after rib-resection

drainage, was prevented.

3. Weeks and months of disability were eliminated, as was the risk of

serious and even fatal complications, such as brain abscesses.

4. The patient was spared a great deal of discomfort and inconvenience,

and the hospital staff was saved the time and effort required by repeated

dressings.

At least three factors were responsible for the poorer results in secondary

decortication:

1. The patients requiring preliminary drainage were, as a group, more

seriously ill than those who did not require it. In particular, they were likely

to be much more toxic.

2. The intrathoracic wounds were generally more severe.

3. The interval between wounding and decortication was longer in secondary decortications, because of the original poor condition of the patients and

the additional time necessary for the drainage operation and recovery from

it.

Two questions arose in connection with the selection of cases for

decortication:

The first question was whether it would be possible to develop a peel in

the particular case. This was not a question that could be answered positively.

Timing of surgery played an important part in the possibility. Roentgenograms did not furnish a clue, nor did a study of the parietal, pleura at a preliminary drainage operation. As a matter of fact, the pleural membrane was
THORACIC SURGERY

usually thicker, and the pulmonary collapse more pronounced, than the films

suggested. Unsuspected pleural pockets were also often found.

The answer to the second question, whether or not the lung would reexpancl,

depended upon the extent and type of pulmonary damage and whether or not

infection was present. The description written by the forward surgeon might

be helpful in estimating the extent of the pulmonary injury. If the injury

was a contusion, a roentgenogram taken immediately afterward, before the

development of hemothorax, was also helpful. Again, timing was a factor. If

decortication were performed too soon after wounding, the lung would not

have had time to heal after injury and regain sufficient elasticity to permit

adequate reexpansion. If a homolateral pneumonitis was present, decortication

was not performed until it had cleared up, not only to give the lung a chance

to recover but also to avoid the risk of introducing organisms into the bloodstream by opening (he lung; sept icemia could easily result. As these statements

indicate, the expansile ability of the lung could not be settled by generalizations

but had to be estimated in the individual case.

Timing

As early as 1904, Violet (7) had stated that if decortication were to be

employed, it should be employed promptly, as soon as it was evident that an

empyema would not undergo spontaneous cure and before the walls of the cavity

had become rigid and separated by too wide a space. Lilienthal (<§), in 1915,

had resorted to the operation in a matter of weeks, but most American surgeons

who used it believed that it should be employed only after many months had

elapsed and after other methods of treatment had failed. In 1928, Lockwood

(9) reported that there were more failures in cavities that had lasted from 6 to

18 months than in those of longer standing« He had himself achieved partial

success with decortication in an empyema of 21 years' standing, and he had

had some good results in cases which had lasted for 16 years.5

The surgeons in the Xorth African theater who first performed decortication for organizing hemothorax originally thought that a period of at least 8

weeks should elapse from wounding to operation. Their reasoning was that

clearing of the pleural space would occur in a great many instances within this

period. It proved fallacious as applied to all but small cavities. Eventually, by

the trial-aiid-error method, it was found that the optimum period for operation

in uninfected chronic traumatic hemothorax was between 3 and 5 to 6 weeks

after wounding. If infection occurred, especially if it were of the rapidly

developing type, operation was clone earlier.

The timing was logical for several reasons :

1. If operation was deferred for 5 or 6 weeks, many patients who originally

had seemed candidates for decortication showed satisfactory resolution. The

= Those observers, it should be noted, were dealing with the type of empyema associated with the

pneumonias, not with the hemothoraeic variety of World War II.—F. B. B.
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 287

size of the clot played a part in this decision. In perhaps 90 percent of all

decortications, the intrapleural clot exceeded 1,000 cc. in volume. It was not

conceivable that a mass of such size could be absorbed within 5 or 6 weeks, or

even within a much longer period.

2. In uninfected cases, a rind less than 3 weeks old was usually so thin and

so poorly defined that it had to be wiped off the pleural surface or stripped

awaj' piecemeal. It could seldom be removed in toto, as was desirable.

3. If operation was postponed for more than 5 or 6 weeks after wounding,

the increasing cellular intimacy between the rind and the visceral pleura made

the operation technically difficult. By the fifth or the sixth week, hemo-organization and fibroplasia had advanced to the point at which the membrane was

substantial enough to be handled with ease. Extensions into the pleural and

subpleural tissues, and sometimes complete syneehiae between the rind and the

pleura, made clean separation difficult and even impossible, and tears of the

lung were frequent.

The length of time necessary for complete definition of the rind varied from

patient to patient. In some instances, decortication was performed successfully

within 10 to 14 days after wounding. At the other extreme, it was also performed successfully from 12 to 14 weeks after wounding, and the time was

extended to eA^en longer periods in some hospitals in the Zone of Interior

(p. 405). On the whole, the best results were obtained within 3 to 5 or 6 weeks

after wounding.

An obvious advantage of performing decortication early in uninfected

organizing hemothorax was that infection was prevented at the same time that

recovery was expedited. The tendency to infection and prolonged disability

in organizing hemothorax weighed heavily in the decision to perform

decortication.

Since the optimum time for decortication was within 3 to 6 weeks after

wounding, evacuation to the Zone of Interior was not usually possible, and

decortication had to be performed on most patients in oversea hospitals. It was

preferably performed in a base hospital or chest center, but occasionally, if

fighting had slowed down and evacuation to the rear was delayed, it was performed in an evacuation hospital.

Preoperative Preparation

The excellent results secured by decortication in World "War II might lead

those unfamiliar with the operation to conclude that it was not major surgery.

The conclusion would be completely unwarranted. The operation was always

one of magnitude and was never performed without careful preoperative

preparation.

Preoperative measures included:

1. Identification of the infecting- organism.
y»8 THORACIC SURGERY

2. Complete roentgenologic investigation, to determine the presence of

retained foreign bodies, bronchopleural fistulas, lung abscesses, and other complicating lesions.

3. Replacement therapy. Daily transfusions were given, in. amounts of

500 to 1,000 cc, until the hematocrit level was 40 or higher.

4. Nutrition. The nutritional status was brought to as near normal as

possible by a high-caloric, high-protein diet. The serum protein is always low

in any condition in winch proteins are lost by exudation, and plasma infusions,

as well as a protein dietary supplement, were therefore employed as indicated.

5. Penicillin therapy. Penicillin was given intramuscularly in amounts of

200.000 units every 24 hours (25,000 units every 3 hours), usually for 48 to 72

hours before operation. Some patients were apparently safely prepared in 24

hours, though this was probably not long enough in most cases, and other

patients received penicillin for 14 days or more, which was usually unnecessarily

long. It was useless to wait for defervescence. That could come only with the

extirpation of the infected focus.

All of these measures were important. Compromise with any of them

would have put the morbidity and mortality of decortication on a prohibitively

high basis. The unavailability of most of these supplemental measures, as

pointed out elsewhere (vol. I), furnishes at least part of the explanation of the

poor results of decortication when it was first employed.

Principles

The principles upon which decortication was based were as follows:

1. The object of the operation was to peel off the membrane immediately

overlying the visceral pleura and to remove all blood clot and fibrin in the

pleura! cavity, thus permitting complete reexpansion of the collapsed lung.

2. To accomplish this, adequate exposure was essential.

3. The first step of the procedure was to obtain a proper plane of cleavage

between the peel and the visceral pleura, beginning at the junction of the

collapsed lung with the chest wall or over the undamaged portion of the lung.

4. The peel was removed by blunt dissection, carried out digitally or with

gauze,

5. The success of the operation depended upon complete freeing of the lung

wherever it was directly adherent to the thoracic wall and the mediastinum, as

well as along the fissural margins, so that complete circumferential reexpansion

could be obtained. The apex of the lung had to be freed, so that it would fill

the cupola of the pleura! cavity. The operation could not be regarded as a

failure if the diaphragm was not decorticated and mobilized, but if it could be

released, pulmonary efficiency was greatly enhanced. Particular attention was

paid to the redevelopment of the costophrenic sulcus.

6. Generally speaking, the greater the area of lung decorticated, the better

were the results.
HEMOTHORAX AND HEJIOTHORACIC EMPIEMA 289

7. Bronchopleural fistulas had to be closed, especially fistulas in the upper

pulmonary lobe. If this lobe remained collapsed, the operation was a failure.

8. If intrapleural bleeding occurred and complete hemostasis was not

obtained, the status of the pleural cavity would be about as it was before operation. It was best to leave the parietal pleura in situ if stripping it seemed likely

to cause excessive bleeding. The membrane in this area was thicker and more

vascular than elsewhere, and bleeding in it was not controlled by pulmonary

reexpansion. It therefore became the practice to leave it in situ in most cases,

on the ground that removal increased the surgical risks unnecessarily and did

not appreciably increase the benefits of operation.

Anesthesia

Decortication was performed under cyclopropane or nitrous-oxide-oxygenether anesthesia, always by the endotracheal technique. The services of a

trained anesthesiologist, experienced in thoracic surgery, were mandatory.

It was part of his task to administer blood to the patient during the operation, usually in the amount of 1,000 to 2,000 cc, according to the indications. It

was just as important for the patient to leave the operating room with the

hematocrit approximately normal as it was for it to be raised to normal level

before operation. This aspect of blood transfusion was quite as essential in the

end results of decortication as was its shock-preventing function.

Bronchoscopy was practically always performed at the end of the operation. It was never omitted if moisture was audible after catheter aspiration or

if pulmonary reexpansion had been difficult.

TECHNIQUE OF DECORTICATION

Management of unhealed wounds.—Unhealed wounds on the hemolateral

thorax were either closed before decortication was undertaken or were excised

and closed just before the incision for decortication was made. If the two

operations were done at the same sitting, fresh instruments were used for

decortication.

The detailed technique of decortication was as follows:

Incision and exposure.—The patient was placed in the lateral decubitus

position, with the affected side uppermost. A posterolateral intercostal incision, just below the angle of the scapula, was most often employed (fig. 99).

It usually permitted excellent exposure, without section or resection of any

ribs. There was no serious objection to removal of a rib posteriorly, but if an

anterior incision was employed, costal resection was not necessary. Most

clecortications were done without section or resection of a rib unless previous

sui'o-ery or comminuted compound fractures made it advisable to remove all or

part of one or more (fig. 100). Exposure was usually entirely adequate without
290 THORACIC SURGERY

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FIGURE 09.—Technique of decortication. Position of patient on operating table and

site of incision.

costal mutilation, and intercostal incision, -with retraction of the serratus

anterior, was the method of choice.

Entrance to the chest was usually gained through the sixth intercostal

interspace, but either the fifth or the seventh interspace could be used if a more

generous intrathoracic exposure was thought desirable at either the apex or the

base. Selection of the incision depended somewhat upon the individual thoracic habitus but was chiefly dependent upon the extent and the location of the

process to be dealt with.

The first view of the interior of the chest, after the retractors had been

slowly spread and full exposure had been secured, was of varying amounts of

liquid or clotted blood, fibrin, or purulent exudate.

Release of lung.—As soon as the pleural cavity was entered, the lung was

freed widely from the parietal pleural rind about the region of the incision.

If this precaution was not taken, extensive damage to the lung could be caused

when the ribs were separated. Great caution was necessary if there were many

adhesions.

Since the lung was often compressed into the posterior gutter, much of the

separation at this point was behind and mesial to the membranous envelope.

Since the peel on the parietal pleura was usually left in situ (p. 289), it was

important during the process of paraincisional mobilization of the lung that

the proper line of cleavage be established. This was between the layers of the

fibroblastic membrane and not between the pleura and the peel (fig. 79).

As soon as the necessary dissection had been accomplished, rib spreaders

were introduced and the blades were widened gradually. It was important

that they be spread gradually, especially if a rib had not been sectioned or

resected, to allow for muscular relaxation and prevent costal fracture, pleural

tears, and muscle avulsion.

Exploration.—All liquid exudate, fragments of blood clot, and masses of

fibrin were evacuated, and all loculi were broken down. The cavity was then

carefully examined for retained foreign bodies, fragments of cloth and other

debris, and bronchopleural fistulas. After it was certain that a fistula did not

exist, the cavity was thoroughly irrigated with physiologic salt solution.

Further inspection was then undertaken. All anatomic landmarks were

obliterated, and the underlying lung was relatively immobile. Typically, the
HEIIOTHORAX AND IIEJIOTHORACIC EMPYEMA 291

FIGURE 100.—Techniques of decortication showing alternate

methods of entering pleural cavity: Intercostal incision (a), and

rib resection (b). The sixth intercostal space 'was the most common site of entrance into the pleural cavity for decortication.

inner or younger surface of the peel had a brownish-red surface, with the

appearance of shagreen leather. The contours were smooth.

Decortication.—The first step of decortication was a sharp incision

through the fibroblastic membrane down to the visceral pleura (fig. 101).

This step was facilitated if the anesthesiologist used moderate positive pressure,

to brace the lung against the incision. The incised edges of the membrane were

grasped by forceps and decortication was begun. As soon as the peel was completely disrupted in any segment, herniation of the underlying lung, under

pressure, through the incision demonstrated the desired plane of cleavage

(fig. 102).

Once a cleavage plane had been established between the organizing peel

and the visceral pleura, dissection was continued digitally, or with small, firmly

packed gauze pushers, or with small bronchoscopic sponges attached to long

hemostatic forceps (fig. 103). The main pressure was always directed toward

the rind. If the fingers were used, the palmar surfaces were turned toward the

rind, and dissection was accomplished by sweeping motions. The pleura underlying the peel was nearly always thin, transparent, and expansile, and beginning

reexpansion of the lung could be observed almost as soon as the regional peel

was released.

Oozing was likely to be considerable from the visceral pleura, because of

the numerous capillaries torn during the dissection and the gaping ends left on
THORACIC SÜKGERY

FIGURE 101.—Technique of deeortieation. Sharp incision through

libroblastic peel clown to visceral pleura. Edges of incision are

now grasped with instruments, and dissection is begun.

FIGURE 102.—Technique of decortication. Hernia tion of lung

through incision in peel as anesthesiologist uses moderate positive

pressure. Majority of lung is still compressed by intact peel.
HEMOTIIORAX AND HEMOTIIORACIC EMPYEMA 29S

' 'tis' 'Ar iHBmSir S^^Smmll "Mk *% 'A fei '^^WB^nBlF^CTlSJSm^gMj^y

EIGTJKE 103.—Technique of decorticatiou. Removal of peel by

blunt dissection. At this point in the operation, nearly all of the

peel lias been dissected free from visceral pleura and elevated.

Exposed pleura is grossly normal, as is lung.

the pleural surface. It could usually be controlled by warm, moist packs,

supplemented by gentle pulmonary expansion under positive pressure.

If the peel was several weeks old, it was usually laminated, and great care

had to be taken that the pleura was exposed in every area and that no laminations were left in situ. Reexpansion was inhibited if this precaution was

omitted. These scattered islands, while thin, were surprisingly tough, and their

removal was essential, for they caused crossings and infoldings of the lung that

materially hampered complete pulmonary reexpansion. Crosshatching of the

membrane, with piecemeal removal, was not a satisfactory substitute. If islands of thin, tough membrane remained in situ after removal of the primary

peel, the correct procedure was to remove them separately.

Decorticatiou was carried to the edge of the collapsed lung, where the peel

was reflected onto the parietal pleura. After the fissures and apex had been

freed, the lung was separated from the diaphragm, mediastinum, and pericardium, down to the hilus and the pulmonary ligament. This was another

extremely important step of the procedure.

The diaphragm was almost always elevated and fixed. If it could not be

decorticated completely without difficulty, it was freed cireumferentially and

thus mobilized. Decorticatiou was never omitted if diaphragmatic disruption

or fistula formation was suspected.

746-!)41*-—Cü —-21
294: THORACIC SURGERY

/

FiGiKE 104.—Technique of decortication. Lung completely liberated. "When inflated by positive pressure, it rills the heniithorax.

The costophrenic and cardiophrenic sulei were examined, to make sure that

they were free of clots and membrane. Their reestablishment increased the

motion of the diaphragm and aided in pulmonary reexpansion.

As already mentioned, no attempt was made to remove membrane adherent

to the parietal pleura because of the risk of bleeding (p. 290). The costal segment of peel, however, was scraped and scrubbed with gauze, to remove fibrin

and to provide a smooth surface. Great care was taken in decorticating the

fissural margins, about fistulas, and at the sites of healed pulmonary lacerations.

Transdiaphragmatic fistulas were excised and closed.

Management of the lung".—After the initial release of the lung, it was

expanded at intervals throughout the operation under increased positive pressure. This gradual method was preferable to attempts at sudden, complete reexpansion at the end of the operation. Such attempts were always ill-advised

and could be harmful.

The visceral pleura was kept moist, and atelectatic areas of the lung were

gently stroked as it was reexpanded. As a rule, the lung almost completely

filled the pleural cavity before the chest was closed (fig. lOi), though it was

sometimes necessary to rearrange the lobes before they occupied their normal

positions.

After the lung had been completely freed, airy necessary pulmonary surgery was carried out. Although every effort was made to protect the visceral

pleura, it was almost impossible to avoid small tears and areas of traumatism.
HEMOTHORAX AND HEMOXHORACIC EMPYEMA 295

FIGURE 105.—Management of clotted hemothorax by decortication. A. Posteroanterior roentgenogram showing massive clotted hemothorax on right after

4 weeks of observation without improvement. B. Same, 4 weeks after primary

decortication. There is no residual hemothorax. Foreign bodies are in chest wall.

The leaks were plugged with fibrin foam or repaired with interrupted sutures

of fine silk on atraumatic needles. If tears were overlooked, or if plugs and

repairs were not completely successful, the multiple drainage provided at the

end of the operation could be depended upon to maintain expansion until the

openings were occluded.

Single superficial fistulas were closed after the edges had been freshened.

Long sinus tracts were laid open as far as possible, and the lining membrane

was curetted before the lung was closed in layers. Superficial closure of sinus

tracts was not adequate.

Bib fragments in the lung, foreign bodies in the chest wall (figs. 105 and

106) and lung, and indriven rib fragments were also removed if their size warranted it or if they were readily accessible. It was seldom possible to identify

intrapuhnonary foreign bodies while the lung was still compressed by the rind

of an organizing hemothorax, but they could usually be located and removed

without difficulty after decortication (fig. 107).

Infected hematomas and lung abscesses were usually opened, and the

necrotic lining membrane was dissected free and removed. The remaining dead

space was obliterated by closure in layers with fine silk, nylon, or cotton.

A routine search for areas of infolding (p. 183) was carried out at the conclusion of all decortications. Exploration was particularly necessary when,

although the pleura appeared grossly normal, the lateral fringe was abnormally

blunt or the lingula was unusually short or a lower lobe was relatively small.

In all correctly performed decortications, the lung was freed from its points

of attachment along the parietal or the diaphragmatic pleura; when this had

been accomplished, areas of infolding were promptly evident. The freeing
296 THORACIC SURGERY

A B

Fic.uiiE 106.—Management of massive liquid hemnthoracic empyema. A. Posteroanterior roentgenogram showing hemothoracic process in left liemithorax. B.

Same. 4 weeks after primary deeortieation. Foreign bodies are in chest wall.

Complete cure resulted.

X

B

FIGURE 107.—Technique of deeortieation. A. Dissection of rind over upper lobe of lung

B. Lung incised over foreign body which has been lixed by finger compression.
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 297

of points of attachment between the visceral and parietal surfaces at the costophrenic fringe might not permit unfolding of the involved fringe if basal

distortion was extensive. In such a case, there might also be a symphysis between the opposed diaphragmatic surfaces of the visceral pleura. The attachment of one visceral surface to another was usually much iess firm than the

attachment between visceral and parietal surfaces. The surgeon, therefore,

could readily slip his finger into the groove. Here it would encounter an intrapleural tunnel, covered only by a veil of thin adhesions. Release of these

adhesions permitted unfolding of the involved portion of the lung and restoration of its normal contour.

Complete reexpansion of the lung, with obliteration of intrapleural dead

space, was the best possible insurance against a complicating empyema. Any

compromise with this ideal was an invitation to failure. An operation that

ended without bringing the lung into absolute contiguity with the chest wall

and without making certain that it remained there had failed to achieve its

purpose. It was a fallacy to assume that half measures in this direction would,

by the generous intervention of Providence or something else equally unlikely,

result in. cure. Unless a complete operation was performed, the patient might

be left in a situation only slightly more favorable than his original state.

Final steps.—When all of these procedures had been accomplished, the

inner thoracic walls were carefully inspected and palpated, to be certain that

their surfaces were perfectly smooth. Tags and cuffs of tissue were removed

as they were encountered; they encouraged pocketing and the creation of dead

space.

Two or three of the intercostal nerves above and below the incision were

injected with procaine hydrochloride solution (1- or 2-percent). The pleural

cavity was thoroughly lavaged with at least 1,000 cc. of physiologic salt solution and then was dried by aspiration. After it was certain that it was empty

and that there were no bleeding points, the lung was brought gradually to

complete expansion and then was tested again for air leaks.

Modifications of technique.—The technique just described was followed

in most decortications. Some surgeons varied it in small details. Thus, some

thought it essential to free that portion of the lung which, while not encased,

was slightly adherent to the chest wall beneath the reflection of the peel to

the surface of the parietal pleura or was adherent to the diaphragm and the

mediastinum. An. occasional surgeon removed all three elements forming the

capsule of the pleural pocket; that is, the visceral, diaphragmatic, and parietal

elements. When this technique was followed, the visceral element was completely removed before, by a return to the original incision, a plane of cleavage

was found between the parietal element and the chest wall. The separation,

which was quickly accomplished with the finger or a blunt instrument, was

continued until the previous field of dissection was encountered along the line

at which the visceral element was reflected onto the parietal pleura,
THORACIC SURGERY

Drainage.—The sites for drainage were selected with the aim of obliterating dead space and maintaining pulmonary expansion. Soft rubber tubing,

with an internal diameter of 10 nun., was used in all areas except the second

interspace. Here, a de Pezzer catheter (No. 12 or No. 14) was used. The tip

of the catheter was cut off, so that just the flange remained, and the tube was

brought out anteriorly in the midclavicular line. A second drainage tube

was used in the eighth interspace in the posterior axillary line. It was introduced for 21/2 or 3 inches, and the proximal end was tacked to the parietal

pleural wall, about 6 cm. from the skin surface, by a single silk suture. In

infected hemothorax or empyema, a third tube was used in the fifth or sixth

interspace in the midclavicular line, and a fourth tube was sometimes used in

the seventh interspace in the midclavicular line.

If there had been a previous rib resection for drainage, the site of election

for the posterior drainage tube usually corresponded with the site of previous

drainage. In such cases, the margins of the wound were freshened, the tube

introduced through it, and airtight closure accomplished about it. The drainage tube introduced at the first operation was sometimes removed 3 or 4 days

before clecortication, in anticipation of this procedure.

Closure.—Closure was accomplished in layers after the lung was completely within the chest. Sutures were placed in the inner layer of the incision

but were not tied until the ribs had been approximated with lion-jawed forceps

or retractors. Pericostal sutures were not used.

Local penicillin instillation.—Penicillin solution, in roughly equal

amounts, was introduced into each drainage tube in infected cases. Each cubic

centimeter of the solution contained 1,000 units of penicillin. The total amount

used was from 25,000 to 50,000 units in 100 to 200 cc. of physiologic salt solution. All tubes were clamped when the patient left the operating room. The

posterior tube was kept clamped for 4 to 6 hours, to permit contact between

the penicillin and the tissues for this period of time. The other tubes were

connected with water-seal bottles as soon as the patient was placed in bed.

POSTOPERATIVE MANAGEMENT AFTER DECORTICATION

General measures.—The postoperative management of a patient who had

undergone pulmonary clecortication was much the same as the regimen instituted after any other major thoracic operation. The reaction to operation was

usually minimal, and the temperature and the pulse remained generally level

in most cases (fig. 108). Even if empyema recurred, the temperature elevation

was usually minimal.

Replacement therapy, in the form of blood, plasma, or dextrose infusions,

was employed as necessary in each case. Return to a full diet, high in calories

and protein, was usually possible within 24 hours after operation.
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 299

FIGUEE 108. Typical tempcratni'e charts of patients with hcmothoraeic empyema

treated by primary decortication with penicillin coverage. Xote absence of postoperative reaction and prompt defervescence in all cases.
300 THORACIC SURGERY

As soon as he had fully reacted, the patient was elevated on a backrest,

and the importance of deep breathing, forced expiration, and voluntary coughing, vhich had been explained to him before operation, was reiterated. These

were all essential measures in the maintenance of pulmonary reexpansion.

Many surgeons regarded early ambulation as an important phase of the

postoperative regimen. Some failures after decortication, in fact, were attributed to the immobility required by management of fractures of the extremities

in traction. Thereafter, orthopedic surgeons were requested to manage these

injuries in some way that would permit movement about the bed, at least.

Postural consciousness was stressed during the period of bed rest, and

motion of the. shoulder and arm was encouraged in the early postoperative

period, before formal exercises were begun. Return to full activity was as

rapid as was consistent with progress.

Penicillin therapy.—Intramuscular injections of penicillin were given by

the dosage schedule used before operation until the drainage tubes had been

removed and the patient had been afebrile for at least 2 or 3 days. This usually

required that it be given for 10 to 14 days after operation.

Drainage.—The drainage tubes required close supervision. They were

useful only as long as they functioned to maintain pulmonary reexpansion and

to obliterate intrapleural dead space. They were essential for these purposes.

Once these purposes had been achieved, the tubes simply acted as unnecessary

foreign bodies. If the tubes had been placed correctly and hemostasis had been

satisfactory, so that there was no undue oozing, it was only occasionally that

any trouble was encountered in maintaining satisfactory drainage.

If a fistula developed, the anterior tube was kept in place as long as the air

leak persisted, which might, sometimes be as long as from 10 to 14 days. In

none of these cases did intrapleural infection develop.

Complications.—Recovery was usually without, incident, but fistulas and

empyemas or recurrent empyemas were occasionally encountered. The low

incidence of postoperative empyema was attributed both to good surgery and

to penicillin protection.

If infection developed, as shown by a change from serous to purulent

drainage, the postoperative empyema was usually basal and small. Dependent

drainage was instituted at once. After a 2-inch resection of the eighth rib, a

large airtight tube was inserted in the posterior axillary line and was attached

to a water-seal bottle, to prevent secondary collapse of the luno-.

DECORTICATION IN EMPYEMA OF NONTRAUMATIC ORIGIN

The experience with decortication in postpneumonic empyema in World

War II was limited, one reason being (table 14) that the number of such cases

was limited.

The rationale of the use of this operation in this variety of empyema was,

however, entirely clear. If one compares the description of the histologic
IIEMOTIIORAX AXT) HEMOTHORACIC EMPYEMA 301

appearance of the fibrinofibrous membrane in such cases in World War I (#),

it is evident that there is little difference between it and the membrane observed

in the posttraumatic empyemas of World War II. This similarity, together

with the fact that, at least in the early stages of postpneumonic empyema, the

pleura is essentially normal, suggested the use in World War II of decortication in early, carefully selected cases of subacute or impending chronic postpneumonic empyema, When the indication for surgery was total or subtotal

empyema with collapse of the apex, loculation of the exudate was a further

reason for considering decortication.

The thoracic surgeons who revived decortication in World War II believed

that it would be technically possible to employ it in early or subacute tuberculous empyema, but their wartime experiences provided no opportunity to

test the theory. It will be remembered that decortication had been originally

used by Delorme (10) in 1893 for a "tuberculous" abscess of the chest wall with

intrapleural extension (vol. I).

Although postpneumonic empyema was only a minor problem in World

War II, enough of it was observed to evaluate the role of penicillin in its management during the acute stage. Observations at the various thoracic centers

showed that this agent was a valuable adjunct, but that it did not take the place

of adequate surgical drainage or, in the selected cases just mentioned, of

decortication.

SPECIAL STUDIES OF PULMONARY DECORTICATION

Approximately 1,500 pulmonary decortications were performed in the

Mediterranean and European theaters during World War II on the various indications outlined earlier in this chapter (p. 281). It is known that the surgical

mortality rate was less than 2 percent. Lack of facilities and the general circumstances of wartime prevented a followup of these patients, but analyses of

several series show that superior results were obtained. There was no doubt

that decortication gave better results than methods used earlier. There was

also no doubt that the results in primary decortication without drainage were

much better than the results of secondary, postdrainage decortication (p. 310).

As already pointed out (p. 240), the incidence of empyema in the Mediterranean theater was far lower than even the most optimistic had dared to hope.

The very favorable rate was the result of a totally integrated program of

management of chest wounds that reflected credit on all echelons of medical

care, particularly forward echelons.

The reduction in the incidence of posttraumatic empyema as the war

progressed could not be attributed to any single therapeutic advance. Instead,

it was due to a combination of improvements. The most important of these was

the increasing emphasis put upon adequate debridement of chest wounds and

74G-94JT—G5 22
302 THORACIC STROJKRY

FIGURE 109.—Comparative results of management of empyema in World Wars I and

II. A. Typical patients with chronic empyema in Zone of Inferior hospitals in World

War I (,?).

upon early, rapid, vigorous evacuation of the pleural cavity and prompt reexpansion of the lung. Another extremely important consideration was the decrease in the number of ill-advised thoracotomies in forward areas. The

acceptance of the concept that a hemothorax is for all practical purposes a

hematoma carried with it an implied warning as to how to avoid pleural sepsis,

a warning that eventually was widely heeded. Fewer and fewer hemothoraces

that required multiple aspirations were encountered in base hospitals in the last

year of the war. The use of pencil]in in forward areas no doubt favorably

influenced the empyema statistics, but good surgery was the chief explanation

of the improvement.

In base hospitals, the proper management of large clotted hemothoraces further tended to reduce significantly the incidence of empyema. The prophylaxis

of chronic empyema was, in fact, one of the most important functions of a chest

center. Early pulmonary decortication was of great value in accomplishing

this purpose as well as in curing empyema that had become established.
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 303

Wk

s

m •

FIGUBE 109—Continued. 3!. Typical World War II casualties after primary decortication for posttraumatic empyema. In each of these cases, recovery was without

complications, and patients were left with no residual disabilities.

The most striking and most convincing evidence of the value of decortication was the almost total elimination of the group of unfortunate victims of

World War I (fig. 109A) who spent the post bellum years doggedly undergoing

one major surgical procedure after another or living through a shortened lifespan of chronic invalidism due to recurrent episodes of suppuration. Many of

the casualties treated by decortication in World War II (tig. 109B) were sent

back to full duty, and a considerable saving in human suffering as well as in

military manpower was thus effected.

Criteria of cure.—Several criteria of cure w-ere set up in decortication

for organizing hemothorax, infected hemothorax, and hemothoracic empyema:

1. The lung must be fully expanded at operation or within 2 weeks thereafter and the pleura! cavity must be completely obliterated within 2 weeks of

operation, as demonstrated by roentgenologic evidence (figs. 110, 111, 112, and

113) and by cessation of fluctuation in the water-seal drainage apparatus.

2. There must be no clinical, or roentgenologic evidence of occurrence,

persistence, or recurrence of empyema during the period of postoperative

observation, which ranged from i to 12 weeks.

3. There must be no evidence of embol ic spread of infection.
30i THORACIC SURGERY

i

I'TOUKE 110.—Management of hemothorax by secondary deeortication. A. Posteroanterior roentgenogram .showing massive liquid hemothorax on left before

operation. Treatment by rib-resection drainage had been ineffective. B. Same,

4 weeks after decortication. Primary cure occurred.

jS>-

FIGURE 111.—Management of hemothoracie empyema by primary decortication. A.

Posteroanterior roentgenogram showing massive clotted right-sided empyema before

operation. B. Same, showing practically normal chest 3 weeks after primary

decortication.
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 305

?IM|R

t B

FiGuiiE 112.—Management of hemothoracic empyema by decortication. A. Posteroanterior roontgenogram showing early massive hemothoracic empyema just

before operation. P>. Same, 2 weeks after primary decortication. Note that lung

has completely reexpanded and there is no evidence of residual empyenia.

i*

FiciuitK 113.—Management of clotted hemothorax by primary decortication. A.

Posteroanterior roeutgenogram showing large clotted hemothorax on right. P>.

Same, 3 weeks after decortication. Complete cure resulted.
306 THORACIC SURGERY

Earliest Operations

An analysis of the first 25 decortications performed in North Africa, all

by surgeons of the 2d Auxiliary Surgical Group, showed that all the patients

were seriously ill and that the outlook in many of them was distinctly unfavorable. The single death in the series occurred 8 weeks after operation and was

not related to it. In spite of the gloomy prognosis, there were 18 primary

cures. In every instance, the temperature and the pulse returned to normal

levels within 7 to 10 days after operation and there they remained. At the

same time, there was a striking improvement in every patient in general appearance, in appetite and nutrition, in a rapidly restored sense of well-being,

and in the capacity for a resumption of essentially normal activity.

One of the five recurrent empyemas was explained, at least in part, by the

fact that the patient was treated in traction for a fractured femur and was

almost completely immobile throughout the postoperative course. In the other

four patients with empyema, the original cavities were greatly reduced in size

and became progressively smaller during the period of observation after

operation.

Of the 24 survivors, 2 were returned to full duty and 7 to limited duty in

the theater, with the recommendation that their status be reviewed within 90

days. The other 15 were evacuated to the Zone of Interior, 5 because of recurrent empyema and 2 because of concomitant wounds. All were in good

condition when they left the theater.

Decortication at the 21st and 300th General Hospitals

An analysis of 125 decortications performed at the 21st and 300th General

Hospitals in the Mediterranean theater, between 1 April and 20 December 1944,

showed no surgical deaths and only one complete failure in one of the earliest

cases. There were no instances of invasive infection, and the only two wound

infections were superficial.

Primary healing, with complete pulmonary restoration, occurred in over

90 percent of the cases in which the lung was normal at operation. The same

results were accomplished in just over 75 percent of the group in which infrapleural infection had been present before operation. On the other hand, when

the lung was involved in the original pathologic process, empyema was recurrent in 40 percent of the cases. Practically all of the recurrent empyemas,

however, were basal and small, and they therefore responded well to rib resection and drainage. It seems fair to say that, with the exception of the single

complete failure, all the patients in this series who did not obtain a primary

cure at least benefited materially from decortication.

Decortication at the 12th and 36th General Hospitals

In a followup study of 140 of the 160 decortications performed at the 12th

and 3Gth General Hospitals in the Mediterranean theater. Map "William M.
HEMOTHORAX AND HEMOTHOKACIC EMPYEMA öOi

Tuttle, MC, Capt. (later Map) Hiram T. Langston, MC, and Maj. Robert T.

Crowley, MC, published the following data:

There were no deaths in the 140 patients followed up, and, so far as could

be determined, there were no deaths in the 20 not followed up.

In the 140 patients followed up, the hemothorax was organized but not

grossly infected in 89. In all of the other 51 cases, infection either was known

to be present before operation or was encountered unexpectedly at operation.

In 90 percent of the total (1G0) series, the intrapleural mass exceeded 1,000 cc.

in volume.

In 90 of the 140 patients followed up, pulmonary reexpansion was complete

within the first 24 hours, and in 18 others, it was complete within the next 24

hours. Twenty-six patients required 72 hours or more for complete reexpansion, and in the G remaining patients, the results from this standpoint were not

satisfactory.

Of the 89 patients with organizing uninfected hemothoraces. 8 developed

empyema after decortication. Most of the infections were merely small pockets

that responded readily to drainage. All were either completely healed when

the patients were evacuated or were progressing so favorably that it was

thought that no further surgery would be necessary.

Recovery was without incident in 25 of the 51 patients who had grossly

infected hemothoraces before operation. In 23 cases, small residual empyemas

recurred, ranging in volume from 30 to 200 cubic, centimeters. These pockets,

as in the group just described, were either completely obliterated before the

patients were evacuated or were progressing so satisfactorily that no further

surgery seemed likely to be required. In the three remaining cases, additional

surgery seemed inevitable.

The only other complications in the series were two wound infections. Although both patients had had preoperative empyema caused by CJostridkun

icelchiL neither infection was severe. The absence of serious wound infections

in this series is rather remarkable when it is recalled that many of the operations lasted from 1 to 3 hours and that the infected material traversed the

wound during most of this time.

Penicillin became available while the operations in this series were in progress and was used in 77 cases. They are not consecutive; even when restrictions on its use were removed, it was employed only on indications. Of the

eio'ht patients who developed empyema after decortication of a presumably

uninfected organizing hemothorax, five received penicillin during the immediate postoperative period and three did not. All 25 patients who recovered

uneventfully after decortication performed in the presence of infection received

it, which suggests the value of this form of therapy. Sulfonarnides were not

used in any case in the series.

The duty status of 3 of the 140 patients was not known when the report

was made. Six were returned to full duty and 64 to limited duty in the theater,

in a number of instances with the recommendation that their status be reviewed
808 THORACIC SURGERY

in 90 days. Twenty-three other men could have been returned to duty in the

theater as far as their thoracic wounds were concerned, but associated wounds

made this impossible. The remaining 44 patients had to be evacuated to the

Zone of Interior because of the severity of their chest wounds.

Comparative Results of Rib-Resection Drainage and Decortication

An analysis of 94 cases of hemothoracic empyema treated by surgeons of

the 2d Auxiliary Surgical Group after the indications for decortication had

been stabilized permits a comparison of the results obtained in hemothoracic

empyema by rib-resection drainage, primary decortication, and secondary

decortication.

Eib resection was the method of treatment in 72 cases, in 6 of which

secondary decortication was necessary later. The other 22 patients were treated

by primary decortication.

Rib-resection drainage.—Excluding the 6 cases in which rib-resection

drainage was followed by secondary decortication and which will be discussed

separately (p. 310), 66 patients, 5 of whom died, were treated by rib-resection

drainage.

Of the 66 patients, 59 had small or moderately large empyemas, many of

them basal. The majority still had small residual cavities when they were

evacuated to the Zone of Interior, but progressive obliteration had occurred, and

it was not thought that any of the patients would require further surgery.

The other seven patients had massive infections, and primary decortication

would have been the treatment of choice had their condition permitted it. In

some cases, their serious status was due to associated wounds rather than to

empyema. Satisfactory pulmonary reexpansion occurred in only four of the

seven cases.

In one of the three failures, a large fistula in the right main bronchus

opened into a persistent, large empyema cavity. The fistula would ordinarily

have been closed and secondary decortication performed, but an associated

laceration of the dorsal spine, with paraplegia, made the prognosis hopeless.

In the two remaining cases, exploratory thoracotomy was carried out, in the

hope that decortication could be done, but in both, the infectious process was

already chronic, and operation was not considered feasible. All three patients

were evacuated to the Zone of Interior, with recommendations for later surgery.

One of the 5 deaths in the 66 patients treated by rib-resection drainage was

caused by a metastatic brain abscess, which is one of the hazards of empyema

treated by this method. Two deaths were due to overwhelming pleura! infection secondary to esophagopleural fistulas, and two were due, in large part, to

severe associated wounds.

Primary decortication.—All 22 patients who underwent primary decortication had massive involvement of the pleural cavity, 4 on the basis of liquid

hemothoraces and 18 on the basis of clotted hemothoraces.
HEMOTHORAX AND HEMOTIIORACIC EMPYEMA 309

In a few instances, decortication had to be deferred longer than was considered desirable because of the gravity of associated extrathoracic wounds.

In one case, the delay was (53 days. One or two patients did not come under

observation until more than a month after wounding. Excluding these

patients, the timelag between wounding and decortication ranged from 7 to 31

days and averaged 20 days. This timelag included a purposeful delay of 2 to

4 days after the diagnosis of empyema was made, to prepare the patients for

operation.

The results in these 22 decortications were as follows:

A prompt cure was obtained in 18 cases, in 16 of which the empyema had

originated in clotted hemothoraces. Included in these 18 cured patients were

2 who had small lung abscesses, each of which was associated with a foreign

body and a bronehopleural fistula at the site of the abscess. In each instance,

the foreign body was removed at decortication, the walls of the abscess excised,

and the residual defect, including the fistula, closed in layers. There were no

postoperative complications in either case.

In the four remaining eases in which primary decortication was done,

there was a postoperative recurrence of empyema. All four patients were then

treated by rib-resection drainage, with the following results:

In two cases, the recurrent cavity was small, and in both instances, it was

almost completely obliterated when the patients were evacuated to the Zone of

Interior. One of these patients had a late bronehopleural fistula, which closed

spontaneously. It was not thought that additional surgery would be necessary

in either instance, Why the empyema recurred in these two cases is not clear,

for in both, complete expansion of the lung was obtained at operation.

In the third case, the cause of the recurrence was readily apparent, A

large lung abscess was found at operation, surrounding a large foreign body

and also the site of a bronehopleural fistula, To excise the abscess completely

would have required lobectomy, and the patient's condition was too critical

for such radical surgery. The fistula was closed, but the infection was not

eliminated, and recurrence was regarded as inevitable. The recurrent cavity

was small, but the closure of the fistula broke down, and further surgery would

be necessary in the Zone of Interior.

In the fourth case, the cause of the recurrence was also apparent. This

patient had a large lung abscess. It involved almost half of the lower and

middle lobes on the right side and was also the site of a bronehopleural fistula.

Partial lobectomy was performed on each of the affected lobes, and the fistula

was closed. The remaining lung reexpanded normally after decortication, but

the recurrence was expected because of the large amount of dead space left after

lobectomy. Both the original and the recurrent infections were caused by

Escherichia coll. The patient was seriously ill, and it was debatable, before the

first operation, whether primary decortication or rib-resection drainage should

be performed. He did not improve after decortication and lobectomy, and death

occurred on the 30th postoperative day, from persistent and overwhelming
310 THORACIC SURGERY

intrapleural infection. There was no response to either penicillin or the sulfonamides. This was the only death in the 28 patients treated by decortication.

Secondary decortication.—In all six cases in which secondary decortication was employed after rib-resection drainage, the operation would have been

done primarily had the patient's condition permitted it; in three cases, drainage was done for empyema neeessitatis. In live of the six cases, the empyema

had developed in liquid hemothoraces.

In all six cases, although drainage was apparently adequate, there was

either no reexpansion, or only unsatisfactory reexpansion, of the lung, and

decortication was resorted to because chronic empyema seemed to be impending.

The duration of drainage before decortication ranged from 26 to 53 days and

averaged 37 days. The timelag from wounding to the secondary operation

ranged from 44 to 64 days and averaged 52 days.

The outcome in these six cases shows again that primary decortication

gives better results than the secondary operation. Prompt recovery ensued

in two cases, but empyema recurred in the other four. On the other hand,

these four operations cannot be considered total failures. They were performed because there was no significant pulmonary reexpansion, in spite of

adequate drainage, and because in each instance more than 50 percent of the

lung was collapsed. Even though the empyema recurred, it was thought that

the purpose of decortication had been accomplished: In two cases, chronic

empyema was positively prevented, and the anticipated duration of continued

pleural suppuration was materially reduced. In the other two cases, while

the situation was improved, it was thought that additional surgery would be

necessary.

Conclusions.—The results obtained with decortication in these various

series might bo compared with the results reported by Nicholson and Scadding

(11) in 291 wounds of the chest treated in British hospitals in the Middle

East between November 1941 and May 1943, before decortication came into

use. Ilemothorax became evident in 187 cases and became infected in a third

of these. The case fatality rate in 52 infected hemothoraces uncomplicated

by pulmonary or subphrenic suppuration and managed by standard conservative measures was almost 20 percent, while at the time of the report, only 12 of

the surviving patients were known to be entirely well.

Two points concerning the advantages of decortication over drainage operations for organizing hemothorax and hemothoracic empyema, although they

have been made before, should be stressed again :

1. In favor of decortication was the short interval, usually from 6 to 8 weeks,

necessary to effect a cure, compared with the weeks of suppuration, changes

of drainage tubes, and daily dressings necessary in other methods. With

their wounds cleanly and solidly healed, and their lungs fully expanded, the

patients were well on the way to recovery within 2 to 3 weeks after operation.

2. In pleural infections treated by drainage, the road from the institution

of drainage to a complete cure was not only long, it was also beset with dan-
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 311

A :

A

FIGURE 114 (ease 1).—Spontaneous clearing of clotted hemothorax. A. Postcroanterior roentgenogram showing clotted hemothorax of moderate size, without infection,

2 weeks after injury. B. Same, 1 month later. Chest was almost completely cleared

without surgery or additional thoraccnteses.

gerous pitfalls. Chronicity might eventuate at any stage, and death might

occur from a number of causes, including metastatic brain abscess. With this

method, the outcome was uncertain as long as a vestige of the empyema cavity

remained.

CASE HISTORIES

Case 1.—A soldier who sustained a perforating gunshot wound of the right hemithorax

on 14 June 1944, with a laceration of the right lung, developed a hemothorax of considerable size. The wounds were debrided, and a sucking wound of exit was closed. A flapper

valve intercostal tube was inserted after 800 cc. of blood had been removed from the chest

by thoracentesis.

Drainage was unsatisfactory, and the tube was removed 48 hours after wounding.

Roentgcnograms 14 days after injury showed a moderately large, clotted right hemothorax

(fig. 114A). There was no evidence of intrapleural infection.

Repeated aspirations yielded only a few cubic centimeters of serum and fragments of

clot, but, because of the moderate size of the hemothorax and the absence of any evidence

of intrapleural infection, spontaneous clearing was allowed to progress. Recovery was

smooth, and within G weeks after wounding the chest was almost clear (fig. 114B). The

soldier was returned to duty on 17 August 1044, 2 months after he had been injured.

Comment.—This case illustrates the successful outcome of a hemothorax of moderate

size, without infection, treated conservatively. Clotting occurred in spite of the prompt

removal of blood by aspiration.

Case 2.—When this soldier was wounded in action on 6 February 1944, lie sustained

a severe penetrating wound of the left thorax, with a laceration of the left lung. Initial
m riioiunc SURGERY

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FIGURE ll."i (case 2).—Management of clotted homothorax by decortication.

A. rosferoanterior roentgenogram showing massive clotted hemothorax. without infection, hut with no tendency toward clearing after (i weeks. Repeated

thoracenteses were not effective. B. Same. 10 days after primary decortication.

This patient went on to complete cure and was returned to duty. Foreign

body was in chest wall.

therapy consisted of dehridement of the wound and left thoracentesis. A metallic foreign

body in the chest wall was left in situ.

Repeated thoracenteses were ineffective. Only small amounts of scrum and fragments

of clot could be obtained. Roentgenograms (fig. 1:15A) showed persistence of pleural fluid,

with no evidence of resorption after 6 weeks. Thoraeotomy with pulmonary decortication

was then performed. A complete cure was obtained (lig. 115B), and (he soldier returned

to duty 3y2 months after wounding.

Comment.—On the surface, there seems little difference originally between this case

and the case just described (case 1). In both, clotting occurred, and additional aspirations

were unsuccessful. Conservative treatment was practiced in both, with practically complete

resolution at the end of (i weeks in the first case, while in the second, no tendency toward

resolution was evident. Decortication produced highly satisfactory results, and might,

perhaps, have been employed earlier. If no tendency toward clearing was observed at the

end of the third week after wounding, it was the general experience that it was unlikely

to occur.

Case 3.—This soldier sustained a shell-fragment wound of the right chest on 31 May

1044. He had a sucking wound, a laceration of the lung, and a hemopneumothorax. all on

the right side. Thoraeotomy was performed in a forward hospital, with removal of the

shell fragment in the lung, suture of the lung, and evacuation of the blood in the right

pleural cavity.

When the patient was admitted to a chest center 11 days after wounding, he was

desperately ill from massive empyema. The thoraeotomy incision was reopened and the

empyema drained through the bed of the rib that had been resected at initial wound

surgery.

Drainage was apparently adequate, but the lung did not reexpand satisfactorily, and

chronic empyema was evidently impending. Decortication was therefore performed G weeks
HEAIOTHOKAX AND HEMOTHORACIC EMPl'EJIA 313

•^^

FIGDKK 110 (case 4).—Management of liemothoracic empyema by primary deeortieation. A. Posteroanterior roentgenogram showing right-sided hydropneumothorax, with 50-percent compression of lung. Fluid component secured by aspiration soon became thick and purulent. Ninth rib had been partly resected when

thoracotomy was done immediately after wounding in forward hospital. B. Same,

2 weeks after decortication. Regeneration is evident in this roentgenogram.

Complete cure was obtained, with total pulmonary reexpansion and total obliteration of empyema cavity.

after the drainage operation. The lung was freed without difficulty from the fibrinofibrous

membrane which encased it. As soon as this was accomplished, reexpansion was entirely

satisfactory. Convalescence was without incident, and the end result was excellent.

Comment.—This patient was far too ill for such a major procedure as decortication

when he was seen in the chest center 11 days after wounding. Rib-resection drainage was

lifesaving. but it was not sufficient to accomplish a cure. In World War I, this soldier

would have become a chest cripple. Decortication saved him from this fate in World War II.

Whether the thoracotomy performed at initial wound surgery was necessary is at least

debatable. He might have been better off without it.

Case 4.—This soldier, who was wounded in action on 4 June 1944, suffered a severe

penetrating shell-fragment wound of the right thorax, with a laceration of the right lung

and right hemopneumothorax. A foreign body was seen in the lung. Thoracotomy was

performed at a forward hospital on the day of injury. The foreign body was removed and

the pulmonary laceration sutured.

The immediate convalescence was uneventful, but a few days after operation, a clotted

hemofhorax was found on the light side (flg. 11GA). The patient was toxic, and his temperature rose daily to 101° or 102° F. Purulent fluid was eventually recovered from the

chest, and Stai)]n)]oeoccits an reu H was cultured from it. Thoracotomy and decortication

were done at once, without preliminary drainage. Recovery was uneventful, and the end

result was excellent (flg. 116R).

Comment.—This is another case in which prompt decortication saved the casualty from

a long period of drainage and disability, and perhaps from chronic invalidism. It is also

another case in which the patient might have done better without thoracotomy as part of

the initial wound surgery.
314 THORACIC SCRGERY

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FIGI;P.E 117 (case 5).—Management of clotted hemotlionix by primary deeortieation. A. Posteroanterior roentgenogram 33 clays after wounding, showing diffuse

left-sided obscuration and narrowing of intercostal spaces caused by organizing

clotted liemothorax. Tboracenteses had been ineffective. B. Same, 5% months after

primary decortication, showing essentially normal left hemithorax.

Case 5.—A 27-year-old soldier sustained an accidental sucking wound of the left

anterior thorax during bayonet practice on 11 June 1913. A tension hemopneumothorax

was managed by water-seal drainage for IS hours. The sucking wound was trimmed and

closed. Repeated tboracenteses produced no fluid.

When the patient was admitted to a thoracic surgery service on 10 July, the left chest

was flattened anteriorly, and there was a slight scoliosis concave to the left. Expansion

was appreciably limited. Horizontal expansion measurements showed the following differentials : Ensiform cartilage to spine on right, IV-j. inches, on left % inch; nipple to spine

on right, 1 inch, on left Vi inch. Breath sounds were distant over the entire left chest.

For the past 2 weeks, the patient had been complaining of increasing dyspnea on exertion. He was now incapacitated for any activity except the most minor exercise, and he

was showing no appreciable improvement.

Analysis of serial roentgenograms showed a persistent diffuse obscuration on the left,

with the greatest density at the base. The rocntgenogram taken on 14 July (fig. 117A)

showed diffuse clouding. The intercostal spaces were narrowed, and there was a slight

scoliosis concave to the left. There had been no essential change in these findings for the

preceding 2 weeks.

On 10 July 1913, 35 days after injury, thoracotomy and decortication were performed.

More than 500 cc. of clotted, degenerating blood was found occupying the space in the left

hemithorax from the apex to the base and forward to the midaxillary line. The peel adherent to the visceral pleura was 3 mm. thick, and that adherent to the parietal pleura,

which was left in situ, was 5 mm. thick. After decortication had been accomplished, there

was immediate and almost complete reexpansion of the lung under slight positive pressure.

A few bubbles of air escaped from a small tear in the visceral pleura, which was easily

repaired.

Under the microscope, the visceral layer of rind showed adult fibrous tissue, with many

penetrating capillaries, which were larger and more numerous on the visceral pleural

surface.
I-IEMOTHORAX AND HEMOTHORACIC EMPYEMA 315

Frequent thoraeenteses were carried out for the next 5 days. Roentgenograms 20 clays

after operation showed a small residual lateral pneumothorax, with complete pulmonary

reexpansion at the base. Measurements taken 30 days after operation showed the horizontal expansion from the ensiform cartilage to the spine to be 1% inches on the right and V/i

inches on the left. Expansion from the horizontal nipple to the spine was 1 inch on each

side.

The patient was discharged to limited duty 60 days after operation. A followup roentgenogram on 6 January 1944 (fig. 11TB) showed the left thorax to be essentially normal.

Comment.—In this case, clotting apparently occurred almost immediately, for prompt

and repeated thoracenteses produced no fluid. The patient was well on his way to becoming

a chest invalid when thoracotomy and decortication were performed. As this case shows,

the risks of removing the thicker and more vascular parietal peel need not be taken. It

was left in situ at operation, and the patient made an excellent recovery. Repeated thoracenteses were employed after operation because drainage had been omitted.

Case 6.—A 10-year-old German prisoner of war sustained perforating wounds of the

left chest from a high explosive shell fragment. The small wound of entry was located

in the second interspace in the midclavicular line and the slightly larger wound of exit,

in the eighth interspace in the midscapular line. Neither was sucking.

The wounds were debrided 24 hours after injury. At this time, roentgenograms revealed a left-sided hemothorax that was causing approximately 45-percent collapse of the

lung. No fluid was obtained on thoracentesis.

For the next 8 days, the patient ran a febrile course, the temperature on one occasion

reaching 103.2° F. Repeated aspirations during this period yielded only fragments of clot

and shreds of fibrin. Smears and cultures were negative.

A roentgenogram 9 days after injury (fig. 118) showed the left hemithorax obscured

and the lung compressed. The following day, a catheter (No. 22) was inserted into the

left pleural cavity, but neither fluid nor clot could be evacuated.

Because of the continued fever and toxicity, it seemed probable, in spite of consistently

negative cultures, that infection was developing in an organizing hemothorax. Thoracotomy and decortication were therefore performed 14 days after wounding. The pleural

cavity was filled with clots and with loculated pools of thick, sirapy blood. The hemothorax was, as usual, larger than the roentgenograms had indicated. The lung was held

immobile by a 2-mm. peel of fibrin, which was undergoing early organization. Decortication was technically tedious and difficult because of the thinness and friability of the peel.

It stripped easily, but piecemeal removal was necessary. The underlying visceral pleura

was grossly normal and did not bleed. No attempt was made to decorticate the parietal

pleura. The wounds of entrance and exit in the upper lobe were solidly healed, and the

fibrin peel over both areas was left undisturbed. When the diaphragm was freed, it

immediately resumed its normal excursion. Before decortication, positive pressure up

to 15 cm. IFO did not result in any pulmonary expansion. After decortication, the lung

expanded promptly and filled the hemithorax.

Drainage was instituted through two intercostal tubes. The anterior tube was removed

at the end of 24 hours and the posterior tube on the third day. The patient then became

ambulatory. Roentgenograms on the seventh day after operation showed complete pulmonary reexpansion. When the patient was evacuated to a prisoner-of-war camp on the

14th day after operation, he was in excellent condition.

Cultures of the clot and peel removed at decortication were negative on both aerobic

and anaerobic media.

Comment.—This case is an illustration of the prophylactic use of decortication.

Obviously, infection was impending in an organizing hemothorax, and while the operation

is somewhat more difficult as early as 14 days after wounding, because the rind is not yet

well organized, it can be safely performed.
316 THORACIC SURGERY

FiGUitE US (ease (i).—l'osteroanterior roentgenogram showing organizing- clotted heniot borax on left

side. Note apical compression and almost öO-percent pulmonary collapse.

Case 7.—A 34-year-old soldier sustained a sucking- wound of the right posterior thorax

on 23 September 1043. The wound was closed immediately by an occlusive dressing, and

24 hours later, primary closure of the pleura was performed. Water-seal drainage was

continued for the next 48 hours.

On 27 September. 1.800 cc. of air and fluid were aspirated from the right hemithorax.

The following day, roentgenograms (tig. ll'.)A) showed a large amount of blood in the

right pleural cavity, with a 7ö-percent collapse of the lung. On 30 September, 100 cc. of

bloody fluid was aspirated, with considerable difficulty. A second attempt to evacuate the

chest with intercostal water-seal drainage produced only 200 cc. of bloody fluid in 24 hours.

On •"> October, all that could be obtained on aspiration was 20 cc. of sterile fluid. At this

time, a lateral roentgenogram (tig. HOP,) showed extensive obscuration at the base and

multiple fluid levels, characteristic of intrapleural infection. The patient continued toxic

and febrile.

On 7 October, right-sided posterior thoracotomy was performed after two small granulating wounds of the right posterior chest wall had been excised and closed with a separate set

of instruments. Short posterior segments of the seventh and eighth ribs were removed,

and the pleural cavity was entered through the seventh intercostal space. The lung was

found bound down with characteristic organizing exudate and approximately 00 percent

collapsed. The pleural cavity was filled with liquid blood, serum, masses of fibrin, and

blood clot in various stages of degeneration.

When the peel was removed from the visceral pleura, there was immediate and almost

complete reexpansion of the lung under slight positive pressure. The lacerations at the

sites of the througli-and-through pulmonary wounds were repaired with fine silk. Drainage

was instituted. Immediate bronchoscopy was productive of a moderate amount of bloody

mucoid secretion.
HEMOTHORAX AND IIEMOTHORACIC EMPYEMA 317

KM

FIGI'RE 119 (ease 7).—Management of

organizing clotted hemothorax by decorticatiou. A. Posteroanterior roentgenogram

G days after wounding showing extensive

right-sided hemothorax. Xote compression

of apex of lung. B. Lateral roentgenogram

3 days later showing extensive obscuration

at left base and characteristic multiple

fluid levels. C. Posteroanterior roentgenogram 30 days after decortication. Right

lung has completely reexpanded, but there

is still basal pleural reaction present.

Recovery was uneventful except for an unexplained, transient temperature elevation to

103° P. on the third postoperative day. There was no wound infection and no evidence at

any time that an empyema was developing. Roentgenograms 30 days after operation (fig.

HOC) showed complete pulmonary reexpansion, with a moderate residual pleural reaction

at the right base. The patient was fully ambulatory when he was evacuated on 11

November.

Pleural fluid cultured at operation showed a heavy growth of nonhemolytic streptococci.

Microscopic examination of the peel revealed dense fibrinopurulent exudate, beneath which

was a characteristic thickened membrane of organizing fibrin, showing fibroblastic and

angioblastic proliferation.

Comment.—In this case, thoracentesis was not begun until the fourth day after wounding. In spite of roentgenologic evidence of hemothorax, aspiration was increasingly less

productive, and there was clear clinical evidence of infection. This is another instance of

the successful performance of decortication shortly after wounding as a means of avoiding

the development of empyema.

Case 8.—A 22-year-old staff sergeant sustained shell-fragment wounds of the anterior

right thorax, right buttock, and right wrist on 10 November 1013. He was expectorating

bright red blood when he was received in an evacuation hospital. Because of pronounced

abdominal rigidity, a laparotomy was performed 12 hours after wounding. No injuries
318 THORACIC SURGERY

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HP

B

FICUHE 120 (case 8).—Management of

clotted hemothorax with retained foreign

body and bronchopleural fistula by primary decortication. A. Fosteroanterior

roentgenogram 6 days after wounding

showing extensive right-sided hemopneumothorax with compression of pulmonary

apex. B. Lateral roentgenogram taken G

days after wounding showing characteristic multiple fluid levels and large intrathoracic shell fragment. 0. Posteroanterior roentgenogram 6 days after

decortication, closure of bronchopleural

fistula, and removal of shell fragment.

Lung has completely reexpanded.

were found. Thoraeentesis immediately after operation yielded 500 cc. of blood, which

was used for autotransfusion.

For the next 10 days, bloody fluid and air were frequently aspirated from the right,

hemithorax. On IG November, an abrupt attack of dyspnea was relieved by aspiration of

1.500 cc. of air. Clinically, there was no doubt of the existence of a bronchopleural fistula.

Roentgenograms (fig. 120A, B) showed a partially collapsed lung with numerous intrapleural adhesions and extensive hemopneumothorax with multiple fluid levels. A large

intrapulmonary shell fragment was seen indistinctly at the inner end of the ninth rib

posteriorly (fig. 120A).

"When the patient was admitted to a thoracic surgery service on 30 November, he was

comfortable except for moderate dyspnea. Shortly after admission, 1.250 cc. of air was

removed from the pleural cavity. Final manometric negative pressures of 12, G cm. ILO

were maintained in spite of episodes of coughing.

Daily thoraceuteses for the next 3 days yielded a total of 1,200 cc. of air and of 500 cc.

of dark brownish-red fluid. The temperature rose to 102° F. daily. Two smears and a

culture revealed many gram-positive intracellular and extracellular nonhemolytic

streptococci.

Because of increasing toxicity and other clinical evidences of infection, thoracotomy

was performed on 4 December. The pleural cavity contained G00 cc. of degenerating
HEMOTHORAX AND HEMOTHORACIC EMPYEMA 319

blood and exudate. The lung, which was partly collapsed, was immobilized by a firm

organizing peel partly covered by yellowish-green exudate. The apex of the lung was encased in a tubular sheath that was attached to the cupola of the thorax. After complete

visceral decortication, the shell fragment seen in the roentgenograms was easily found and

removed from the right lower lobe; it measured 20 by 7 by 5 millimeters. A posterolateral.

moderate-sized bronchopleural fistula in the upper lobe was repaired with interrupted

sutures of line silk. Drainage was instituted before closure.

The lung was completely reexpanded within 48 hours. Roentgenograms on the sixth

postoperative day (fig. 1200) showed no abnormality except a triangular area of density

in the right cardiophrenie angle. The collection of pleural fluid which it represented was

promptly absorbed.

The patient was ambulatory 7 clays after operation and was asymptomatic when he was

evacuated to the rear G weeks after wounding.

Comment.—In this case, because of increasing toxicity, decortication was performed

31/2 weeks after wounding. Thoracotomy would have been indicated, in any event, for the

repair of the persistent bronchopleural fistula ; and the foreign body in the lung was of

sufficiently large size to require removal also. The combined procedure was carried out

expeditiously and without difficulty, and convalescence was uneventful. This is another

instance of prompt recovery after decortication as compared with a probable long period of

invalidism and disability if conservative measures had been used and if the infection of

the organizing hemothorax had been allowed to progress to empyema.

Case 9.—A 2-1-year-old Italian officer, a prisoner of war, on 10 July 1043 sustained an

extensive perforating sucking wound of the right posterior thorax, with compound comminuted fractures of the right scapula and the third, fifth, and sixth ribs. The wounds

were dehrided, but the pleura was not closed.

By 17 July, increasing pressure was evident in the right hemithorax, and little clinical

relief was afforded by repeated aspirations. Roentgenograms (fig. 121A) showed complete

collapse of the right lung, cardiac shift, and subtotal comprw sion of the left lung. Wide

EIGUKE 121 (case 0).—Management of tension hemopneumothorax and total liemothoracic empyema by secondary decortication. A. Posteroanterior roentgenogram

8 days after wounding showing enormous right-sided tension hemopneumothorax,

with mediastinal herniation; cardiac shift to left; complete collapse of right lung;

subtotal compression of left lung. B. Same, 23 days after institution of dependent

rib-resection drainage. Right lung is still totally collapsed.
320 THORACIC ST'KGERY

FIGURE 121.—Continued. C. Technique of right pulmonary decortication : (a) Appearance of totally collapsed right lung, which is completely immobilized by thick sheet of

organizing fibrin and exudate, so that individual structures are scarcely discernible. After

initial sharp dissection, a small flap of thick, organizing peel has been elevated by blnnt

dissection. Positive pressure lias caused a slight herniation of lung through opening,

(b) Mobilization of lung and diaphragm after complete decortication of visceral pleura.

Visceral pleura is essentially normal and lung is expansile but, not yet completely reoxpanded. The ridge represents line along which thickened fibrous rind was reflected from

visceral onto parietal pleurae. D. 1'osteroanterior roentgenogram 11 days after decortication. All drainage has ceased, and lung now completely rills pleural cavity.

mediastinal herniation and depression of the right diaphragm completed the picture of

massive tension hemothorax.

The patient's condition became increasingly serious. The intrapleural tension was

controlled between 20 July and 31 July by the use of an intercostal water-seal catheter,

but the lung on the right continued collapsed, and a total empyema developed.

The patient was received in a thoracic surgery center on 2 August. The following day,

0 cm. of the tenth rib was resected, and a large tube was placed in the pleural cavity and

connected to a water-seal bottle. For the first 24 hours, there was evidence of a small

bronchopleural fistula. For the next 14 days, negative intrapleural pressure of from 10 to

15 cm. H2O was constantly maintained. Total collapse of the right lung (fig. 121H) persisted for more than 4 weeks, in spite of the negative pressure, adequate drainage, and

frequent intrapleural irrigations with aqueous solution (1:3,000) of Azochloramid (chloroazodin). Bronchoscopic examination showed no bronchial obstruction.
HEMOTIIORAX AM) HEMOTIIORAOIC EMI'YEMA 321

Sequestreetomy on the scapula was performed on 24 August. On 2 September, rightsided posterior thoraeotomy was performed, with complete visceral decortication (flg. 121C).

As roentgenogranis had shown, the lung was found totally collapsed, and its margins could

not be identified. It did not reexpnnd on positive pressure, and the diaphragm remained

depressed and immobile. By combined blunt and sharp dissection, a proper cleavage plane

was established between the visceral pleura and the adherent organized peel, which was

5 to OS mm. thick. The visceral pleura was normally thin, but slight loss of transluceney,

with subpleural scarring, was observed in occasional areas. There was considerable oozing

from the pleural surface.

Removal of the investing peel from the diaphragm mobilized it completely. When the

lung, including the entire mediastinal surface of the upper lobe, had been completely freed,

slight positive pressure produced 80-percent reexpansion. Drainage was instituted.

By the fourth day after operation, both drainage tubes had been removed, and the

lung completely filled the pleural cavity. Convalescence was entirely uneventful. Two

weeks after operation, roentgenogranis (fig. 121D) showed the right lung to be well aerated.

There was considerable resorption of the extensive peripheral reaction during the next 6

weeks. The reaction was to be expected, since no attempt had been made to remove the

thick organizing peel from the parietal pleura.

When the patient was heard from by letter 3 months after operation, he had no complaints referable to the chest and was in excellent general condition.

Comment.—This is another instance of a desperately ill patient who did not respond

to conservative treatment and who, as the result of decortication. was spared weeks and

months of invalidism. Had conservative treatment been continued, he might have lost his

life. The conditions found at operation made it clear that only decortication could have

permitted the lung to expand.

Case 10.—A 26-year-old soldier, on 21 September 1043, suffered a perforating sucking

wound of the left posterior thorax, with compound comminuted fractures of the seventh,

eighth, and ninth ribs posteriorly. On the day of injury, the sucking wound was closed

surgically by using a strip of latissimus dorsi to reinforce the intercostal muscles. The

skin was left open. Five days later, although the patient seemed to be recovering satisfactorily, anterior roentgenograms showed, in addition to the rib fractures, a probable encapsulated area of pleural fluid superimposed on the cardiac shadow. They also showed a

moderate amount of pulmonary infiltration that was considered due to bleeding.

On the 10th day after wounding, the patient became suddenly and rapidly dyspneic and

complained of a sensation of tightness in the thorax and abdomen. When he was received

in a thoracic surgery center shortly afterward, his temperature was ranging from 100°

to 102° F. The left hemothorax had increased greatly, and there was some cardiac shift

to the right. The immediate aspiration of 1,500 cc. of dark blood produced great subjective

improvement. Smears and cultures were negative.

During the next 4S hours, although no additional blood could be aspirated from the

chest, there was evidence of increasing intrapleural pressure. Roentgenograms (fig. 122A)

showed increased left-sided obscuration, with further cardiac and mediastinal shift.

Left posterior thoraeotomy was performed on 5 October, 14 days after injury. Fragmented portions of the three fractured ribs were removed, and the pleural cavity was

entered through the eighth intercostal interspace. The lung was 75 percent collapsed.

The pleural space was filled with about 1.000 cc. of firmly clotted blood; there was practically no liquid blood. A thin layer of fibrin, which showed early organization, was

removed from the visceral pleural surface.

Posterolaterally, there was a laceration in the left upper lobe, 3 cm. deep, which contained four fragments of ribs. The lung bled briskly when these were removed. The

laceration was repaired with fine silk. Anterior and posterolateral intercostal water-seal

drainage was instituted. Closure of the chest wall was difficult posteriorly in the area in

which the wound of entrance had been excised.
322 THORACIC SURGERY

**v;

A

Fiona: 122 (ease 10).—Management of infected clotted hemothorax by early primary deeortieation. A. Posteroanterior roentgenogram 17 clays after wounding and 7

days after tlioracentesis, showing large hemorrhage on left, with cardiac shift to right.

P». Same, C weeks after decorticatiou and 2 weeks after secondary rib-resection drainage of small postoperative empyema. Pulmonary field is now clear, and posterolateral

empyema has been well drained.

Both grossly and microscopically, the organizing exudate showed miliary abscesses.

Culture of the blood clot removed at operation was positive for aerobic hemolytic StaphyloCOCCIIS aiircus.

Within 48 hours, thin, purulent drainage was evident from the lower tube. At this

time, roentgenograms showed the lung to be well expanded at the apex. Laterally, an

oval area of obscuration was seen, which later proved to be a small loculated empyema.

By the seventh day after operation, the posterior portion of the incision, in the area in

which the entrance wound had been excised, had become grossly infected. By the 14th

day, it was evident that the localized empyema just described was connected with a small

bronchopleural fistula and that intercostal drainage was not adequate. The following day,

a 1-j-cm. segment of the ninth rib was removed, and the empyema cavity was opened widely

and packed.

Convalescence thereafter was rapid. The small bronchopleural fistula closed spontaneously. When the patient was evacuated to the Zone of Interior G weeks after the

second operation, roentgenograms (fig. 122B) showed good pulmonary expansion and

almost complete clearing of the lateral and basal obscuration.

Comment.—This case is an illustration of the difficulties and complications which could

arise when tlioracentesis was delayed. It was not resorted to in this case until the 10th

day after wounding, when the patient was seriously ill, and when, as later ineffectual

aspirations showed, organization of the clot had already begun. The seriousness of his

condition, with evidence of beginning infection, was considered a justification for early

decorticatiou, only 14 days after wounding. Miliary «abscesses were already present: at

operation, and empyema developed later, but the cavity was small and the response to

standard measures was good. This is another patient who would undoubtedly have gone

on to a long period of established infection if decorticatiou had not been resorted to

promptly.
BEMOTHORAX AND HEMOTHORACIC EMPYEMA 323

EiGur.E 123 (case 11).—Management of infected clotted hemotliorax, complicated

by segmental pulmonary necrosis and retained foreign body, by early primary decortieation. A. l'osteroanterior roentgenogram, 10 clays after wounding and after induction of

diagnostic pneumoperitoneum for localization of foreign body. Note large left-sided

hemotliorax, which has increased in size in spite of repeated thoracenteses. B. Same,

8 weeks after wounding and 6

1

/. weeks after primary decortication, segmental lobectomy,

and removal of shell fragment.

Case 11.—A 19-year-old soldier sustained a penetrating wound of the left thorax on

the Salerno beachhead on 11 September 1913. There was no hemoptysis or dyspnea at any

time. Roentgenologic examination on 10 September showed a hemotliorax of moderate

size and a large shell fragment lying well posteriorly at the level of the tenth interspace.

At this time the patient was somewhat toxic. His fever increased progressively,

the highest elevation being 103.4° F. Repeated aspirations were productive of only small

amounts of old, sterile blood. After diagnostic pneumoperitoneum on 20 September, roentgenograms (fig. 123A) showed that fluid was increasing in the left thorax, in spite of

repeated thoracenteses.

On 23 September, left posterior tlioracotomy was performed through the sixth intercostal space, after removal of posterior segments of the sixth and seventh ribs. The lung

was collapsed, and there was extensive clotting of the hemotliorax, with early organization.

The shell fragment, which was intrapleural and had no clothing attached to it, measured

22 by 10 by 11 millimeters. It lay in a loculus of clotted blood mixed with greenish exudate,

which had a foul odor. After the pleural cavity had been emptied, decortication showed

the visceral pleura to be relatively normal. The lower half of the lower left pulmonary lobe

was so badly lacerated and necrotic that segmcntal lobectomy was necessary. Drainage

was instituted. Bronchoscopy at the end of the procedure produced bloodstained mucus.

Cultures of the organizing blood clot showed a mixture of staphylococci and anaerobic

nonhemolytic streptococci.

After operation, the lung reexpanded well at the apex, but a loculated pocket of serosanguineous fluid developed in the axilla. It cleared with aspiration.

For the first 11 days after operation, the temperature ranged from 101° to 103° F.

By the end of this time, drainage from the posterior intercostal tube had become purulent.

When the tube was removed on 10 October, after drainage had apparently ceased, there

was an immediate febrile flareup, and roentgenograms showed increased basal obscuration.
•K24 THORACIC SURGERY

On Hi October, open thoracotomy, with rib resection, was performed and tube drainage

was instituted. The small basal empyema was rapidly obliterated, and roentgenograms

taken on 13 November (tig. 123B) showed complete left-sided pulmonary expansion, with a

minimal pleural reaction at the base. The patient was in excellent condition when he was

evacuated to the Zone of Interior a few days later.

Comment.—In this case, decortication was performed in the face of existing infection

and pulmonary necrosis. Convalescence was stormy, but the postoperative empyema was

basal and readily cleared with the proper drainage. This case represents one of the few

in the Mediterranean theater in which segmental lobectomy or any other excisional pulmonary operation was necessary."

References

1. Xeurosurgery and Thoracic Surgery. Prepared and edited by the Subcommittees

on Xeurosurgery and Thoracic Surgery, Committee on Surgery, Division of Medical Sciences, National Research Council. Philadelphia and London : W. P>. Saunders Co.. 1043.

2. Dunham, E. K., Stevens, F. A., Graham, E. A., and Keller, W. P. : Empyema. In

The Medical Department of the United Stales Army in the World War. Washington:

Government Printing Office. 1927, vol. XI, pt. II, pp. 33-392.

3. D'Abreu, A. L.: War Wounds of the Chest. In War Surgery Supplement Xo. 3,

War Injuries of the Chest and Abdomen, Brit. J. Surg., 1952, pp. 3S3-403.

4. Edwards, E. R., and Davies, H. M.: Traumatic Hemothorax. Lancet 2: 073-675,

30 Xov. 1940.

5. Sellers, T. H.: Late Results of Missile Injuries of the Chest Treated in Britain.

Penetrating Chest Wounds Treated at Leicester Thoracic Unit. In, War Surgery Supplement Xo. 3, War Injuries of the Chest and Abdomen, Brit. J. Surg., 1952, pp. 403-408.

6. Samson, P. C, 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.

7. Violet (de Lyon) : De la decortication pulmonaire dans Fempyeme chronique. Arch.

gen. de inert. 193 (vol. 1, series 10) : 657-078, PJ04.

8. Lilienthal, H.: Empyema : Exploration of the Thorax With Primary Mobilization

of the Lung. Ann. Surg. 62 : 309-314, September 1915.

9. Lockwood, A. L.: The Empyema Problem. Arch. Surg. 16: 297-321, January 1928.

10. Delorme, E. : Xouveau traitement des empyemes chronique. Gaz. d' hop. 67 :94-

90, 25 Jan. 1894.

11. 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.

0 The reader is referred to chapter XI (p. 441) for Ions-term follow-up studies on casualties whosf

chest wounds were complicated by hemothorax and hemothoraeie empyema.
CHAPTER VII

Management of Retained Intrathoracic Foreign

Bodies, Mediterranean (Formerly North

African) Theater of Operations

Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.

INCIDENCE

Experience in the Mediterranean Theater of Operations, U.S. Army, during World "War II showed that, exclusive of those in the heart and pericardium,

-which are discussed separately (p. 49), retained intrathoracic foreign bodies

could be anticipated in approximately one out of every four penetrating chest

wounds.

The remarkable paucity of recorded cases of retained foreign bodies after

World War I leads to two possible assumptions, (1) that the majority of patients from whom missiles were not removed remained symptom-free, or (2)

that they were unaware of their condition. In view of the general apprehension

known to be felt when casualties were aware that they were harboring foreign

bodies, the second assumption seems likely as the explanation of a considerable

number of cases.

INDICATIONS FOR SURGERY

Experience with retained intrathoracic foreign bodies in civilian practice

was not of great help to military surgeons because in civilian practice, the

patient could be observed and the object removed electively if it became symptomatic. In military practice, the surgeon had to decide with reasonable

promptness whether the patient could be safely returned to duty with the

foreign body in situ, which meant that he had to predict the chances of the

development of future complications, including infection.

Wounding agents.—Generally speaking, if the foreign body was a bullet,

it w-as less likely to cause complications than if it were a shell fragment or rib

fragments.

Bone fragments from fractured ribs furnished a special problem. Such

fragments, set in motion by the impact of the missile, were far more apt to

produce lung damage, because of their irregular, jagged surfaces, than metallic

foreign bodies. They were more frequently found in the lung than were metal74G-!M1V—65 23 325
326 THOUAGIO SURGERY

lie objects. They "were not usually seen on preoperative roentgenograms, and

unless they presented themselves on inspection or palpation, they were often

not recognized at operation. A prolonged search for theni, such as might be

undertaken for known metallic objects, was therefore seldom carried out. If,

however, they were seen in the lung through the pleural defect after debridement had been completed, particularly if there were extensive lacerations of

the pulmonary parenchyma, it was best to remove the fragments and repair the

damage without delay.

This was particularly true when the bone fragments were partly in the

parenchyma, and partly in the pleural space, a location in which they were

likely to produce considerable trauma as the lung reexpanded and came into

contact with the chest wall. The result was an air leak in some cases, and

provision of an avenue of infection in others. Fortunately, bone spicules partly

in the lung and partly in the parenchyma were usually found and removed

without difficulty.

Accessibility of objects.—If it was necessary to explore the pleura in the

course of initial wound surgery in thoracic wounds, the obvious course was to

remove any accessible foreign objects, regardless of size. This course, however,

was not justified if only debridement was required, nor was it employed in the

emergency treatment of sucking wounds.

The majority of foreign bodies were located in the periphery of the lung,

where their removal was often—though, not always—simple because they were

accessible (vol. I). The mere presence of an object in the parenchyma, however, was not in itself an indication for its removal.

Size of objects.—The size of the object also played a part in the decision

for or against removal. Early in the war, and especially with the establishment of the first thoracic surgery center in the North African theater, the policy

was adopted of removing all shell fragments 0.8 cm. in diameter or larger seen

on posteroanterior roentgenograms. At this time, it was thought that removal

would be simple because the location, by palpation, of objects of this size would

furnish no difficulty. Later, when the experience was evaluated, it was found

that it furnished a. great deal, and the policy was therefore changed, so that

only foreign bodies of 1.5 cm. in diameter or larger were removed routinely.

This policy, which avoided a great deal of pulmonary trauma, proved increasingly satisfactory, and added experience furnished no reason to alter this limit

in the absence of other indications for surgery.

There was never any question that very large objects (over 1.5 cm. in

length) should be removed, either in the forward or the base area—that is,

during other procedures or elective!y—as soon as possible. Here, the question

was one of timing, not of indication. If the objects were small, not more than

1 or 2 cm. in length, they could be let alone unless they were near the heart, a

large vessel, or the esophagus; then they were removed. If foreign bodies

near vital structures were let alone until complications had developed, their

removal was hazardous.
RETAINED INTRATHORACIC FOREIGN BODIES 327

Infection.—It was recognized that the lung and pleura tolerate foreign

bodies well and that many of these retained objects were sterile. Many of them,

however, were not, for fragments of ribs, bits of clothing, and other debris were

often carried into the chest with the missile and furnished a nidus for infection.

Infection was particularly likely when the object was irregular. On the other

hand, foreign material was not necessarily a source of infection. In one series

studied in the Mediterranean theater, a little over half of the foreign objects

removed had bits of clothing about them, but in no instance, aside from 4 cases

in which lung abscesses had already developed, could positive cultures be

obtained from the missile cavity. Unfortunately, it was not possible to predict,

without surgical investigation, in which cases foreign material other than the

missiles was present and, if it were, in which cases infection would develop.

Pulmonary infection associated with a retained foreign body was also an

indication for surgical intervention. Exploration of the chest and removal

of the foreign body before infection developed practically always was followed

by a speedy recovery, whereas the delayed treatment of a pulmonary abscess

about a foreign body was attended with grave risks.

It was necessary to consider the possible presence of a foreign body in any

instance of prolonged pulmonary suppuration after wounding. In an occasional case, a drainage tube which had not been securely anchored and had

slipped into the chest might be the cause of the trouble. This possibility made

it particularly important that the record state clearly the presence and location

of all such tubes.12

Clinical considerations.—Hemoptysis associated with a retained foreign

body was a positive indication for its removal (fig. 71).

Pain was a difficult symptom to evaluate. In most instances, it was connected with the wound in the chest wall and had no connection at all with the

presence of the object, though it was not always possible to convince soldiers of

this fact.

Psychic manifestations, in fact, played an extremely important part in the

decision for or against removal. Many men were seriously disturbed by the

knowledge that they had one or more shell fragments in the chest. It was

repeatedly observed that a patient who harbored a large foreign body in the

thigh, for instance, and a very much smaller one in the pulmonary parenchyma,

ignored the former and became lung-conscious because of the presence of the

latter. Reassurance by the surgeon that the pulmonary object was unlikely to

1 Loss of drainage tubes into the pleural cavity seems to be an important cause of chronic

empyoma. The exact number of such cases encountered in Veterans' Administration hospitals is not

clear, but one of the authors of this chapter has performed several operations for this cause. The

experience suggests to him that it is important that the presence of a drainage tube be specifically

recorded each time a dressing is changed ; failure to find it on subsequent dressings would then be

an indication for roentgenologic study and an attempt to retrieve it, which is not a difHcult matter

if it is searched for immediately. Within 4S hours or longer, the pleura may seal over it and surgery

may be required for its removal.—L. A. B. III.

= The obvious solution of this problem is, of course, prophylactic—the attachment of a safety pin

or other radiopaque marker to every drainage tube.—F. B. B.
328 THORACIC SURGERY

give him trouble sometimes satisfied him, but in borderline cases, of course, no

honest guarantee could be given that he would be immune from late complications. In such cases, the policy was to remove the object.

It, was also the policy to remove the object when the patient with an intrathoracic foreign body complained of vague pains in the chest, shortness of

breath, and other subjective symptoms. If these manifestations persisted, his

emotional attitude, quite aside from any physical considerations, would obviously interfere with his return to duty, and the proper course was to remove

the retained missile.

Conclusions.—The final decision concerning removal was based on a number of factors, including the size and shape of the foreign body; whether there

were multiple or single objects; the location of the object or objects; the presence or absence of symptoms which could be attributed to the presence of the

object; and the patient's ability to withstand surgery. Objects which had been

retained from 10 to 14 days were unlikely to cause immediate trouble, and

individualizafion of each case was therefore possible. As a matter of fact, a

theater policy regarding the removal of foreign bodies was necessarily tentative; whether retained objects would give future trouble was a question which

could be answered only by followup in the future.

SURGICAL TIMING

Although there was eventually a fair amount of agreement concerning the

size of foreign bodies for which removal was indicated, the proper time for

operation remained the subject of considerable discussion until the end of the

war.

The removal of foreign bodies could seldom be justified as an indication for

thoracotomy in forward areas, especially when immediate evacuation to the rear

was contemplated. Removal of the objects within 24 to 48 hours, unless they

were encountered in the course of initial wound surgery, was generally frowned

upon. The surgical risk, the rate of infection, and the morbidity from other

causes were all increased when this practice was followed. Experience proved

that only a very few objects gave rise to any difficulty if they were left in situ

until the patient was evacuated to a fixed hospital (vol. I). It was therefore

the policy to leave them undisturbed when thoracotomy was done on some valid

indication in a field or evacuation hospital unless they were readily accessible.

When the missile could be seen under the fluoroscope to be pointing against a

large vessel and moving M-ith each pulsation, prompt removal TO obviously

indicated.

Very few experienced thoracic surgeons removed retained foreign bodies

until at least 14 days after wounding. By this time, pulmonary equilibrium

had been reestablished. Traumatic wet lung had been controlled", with reaeration of alveoli, absorption of interstitial fluid, removal of extravasated intrapulmonary blood, and reestablishment of normal tracheobronchial patency.
RETAINED INXRATHORACIC FOREIGN BODIES 329

Technically, it was far easier to locate metallic fragments in crepitant, aerated

pulmonary tissue than in the boggy, indurated tissue present soon after injury.

The lung was better able to withstand lobotomy after it had recovered to some

extent from the original injury. Finally, secondary closure of debrided wounds

had usually been accomplished within the period specified, and the absence of

granulating wounds in the chest wall greatly reduced the hazard of infection.

The general policy was to close open wounds in the chest wall by delayed primary wound closure at least 24 hours before thoracotomy for removal of retained

foreign bodies. The incision for the thoracotomy was then so planned thatthese

wounds were avoided. It was even better if the operation could be deferred

until the chest wound was solidly healed, especially if it had to be traversed in

performance of the thoracotomy for removal of the foreign body.

The status of the wound in the chest wall played a part in the end results

of removal of foreign bodies. In 102 operations in one series (p. 349), 3 of the

4 emp}-emas which developed after operation were directly attributable to the

presence of an unhealed wound in the thoracic wall at the time of operation.

By the policy of delayed surgery, the patient was in a hospital toward the

rear, where more detailed study could be made and the decision for or against

removal of the foreign body arrived at deliberately, and not under the stress of

combat conditions in a forward hospital. Better preoperative and postoperative care was also available in a fixed hospital, in which the patient

could be kept as long as was necessary. All the circumstances, therefore, were

more favorable for success than they were after a hasty operation performed as

an emergency before cardiorespiratory equilibrium was reestablished.

While foreign bodies were frequently removed without difficulty weeks and

even months after wounding, long delays were not desirable if it was clear that

the objects must be removed. When more than 2 weeks had elapsed, the increased fibrosis present around them sometimes made repair and closure of the

parenchyma! incision more difficult. Extensive intrapleural adhesions, composed of fibrous tissue, sometimes made it difficult to palpate the object within

the lung, and separation of the adhesions was likely to be time consuming and

associated with considerable oozing. In addition, the fibrous tissue reaction

which had usually developed around the object by this time itself resulted in

the creation of a space in the lung that was often difficult to obliterate.

Delay in the removal of the foreign body when its excision Avas clearly indicated was sometimes necessary because of other wounds. One patient, for

instance, with a spinal injury, also harbored a large intrapleural foreign body

6 by 3 by 2 centimeters. The size of the object furnished a clear indication for

its removal, but the condition of the patient because of his spinal injury made

it impossible to operate on him until 20 days after wounding. By this time,

the missile had produced so much erosion of lung tissue that a bronchopleural

fistula had formed; empyema had then developed: and a severe intrapleural

hemorrhage occurred and was a contributing cause of death. In retrospect, an
•Ml THORACIC SUKGERY

'''''I'^HHMk.i

FIGUKE 124 (case 1).—Retained foreign body in lung. A. Posteroanterior roentgenogram showing metallic foreign body in upper lobe of right lung immediately after wounding. P>. Same, 2 weeks after thoracotomy and removal of foreign body.

earlier attempt to remove the foreign body, in spite of the surgical risk presented by the patient, might have been lifesaving.

The following case reports are not exceptional. They are typical of the

favorable results consistently obtained when retained intrathoracic foreign

bodies were correctly handled, according to the principles of management

standardized in the Mediterranean theater.

Case 1.—A U.S. Army nurse, when struck by a bomb fragment on 20 March 1044, sustained a penetrating, sucking wound of the right chest and a right-sided hemopnournothorax. The bomb fragment lodged in the right upper lobe.

The wound of entry was debrided and the sucking wound closed, after which thoracentesis was instituted. Closure was completed by delayed primary wound closure ö days

later.

Fluoroseopie and roentgenologic localization revealed a fragment 1.5 cm. in its greatest

diameter lying in the upper lobe of the right lung (flg. 124A). Thoracotomy, without

costal section or resection, was done 4 weeks after injury, and the fragment was removed.

The patient made an uneventful recovery (fig. 124B). Her transfer to the Zone of

Interior for reassignment was for psychic rather than physical factors.

Case 2.—This patient, who was wounded by a high-velocity missile, underwent thorough

debridement at an evacuation hospital, after adequate resuscitation, and was evacuated

to a thoracic center 4 days after injury. The wound was closed on the fifth day and healing

per primam occurred. Aspiration of a hemothorax of moderate size, which had been begun

in the evacuation hospital, was continued daily until the pleural space was empty.

Accurate localization of the missile to the posterior portion of the apex of the left lower

lobe was accomplished by roentgenologic examination in two planes (flg. 125A and 15).

Thoracotomy, without costal section or resection, was performed on the 12th day after

wounding. The object was removed without difficulty.

Convalescence was entirely uneventful. One week after thoracotomy, the lung was

clear and well expanded (fig. 125C), and the pleural space contained neither air nor fluid.

Ten days after operation, the wound was solidly healed; the patient was progressively
RETAINED INTRATIIORACIC FOREIGN BODIES 331

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FicruF. 12Ö (case 2) .—Retained foreign body in lung. A. Posteroanterior roentgenogram showing missile in left lung field. The obscuration is the result of an organizing peel

on the pleural surfaces. B. Lateral roentgenogram. C. Posteroanterior roeutgenogram

7 days after thoracotomy and removal of foreign body. Lung is now completely expanded.

D. Photograph of patient 10 days after operation. Note well-healed scar and full range

of arm motion at this time.
;>>2 THORACIC SURGERY

ambulant: and lie had a full range of arm and shoulder motion (flg. 125D). Within 22

days after injury, the reparative phase of management was completed and, after a brief

period of rehabilitation, return to full duty was anticipated.

TECHNIQUES OF LOCALIZATION

Thoracotomy for the removal of foreign bodies retained in the pleural

cavity and the lungs was a safe and rational procedure only when the preoperative localization of these objects had been sufficiently accurate for their removal

without extensive manipulations and an extended search for them. Only by

the possession of reliable information concerning their location could there be

a logical surgical approach.

General considerations.—While all phases of localization -were important,

the first problem that concerned the thoracic surgeon was whether the foreign

body lay within the confines of the pleura or in the extrapleural tissues. Many

objects in the chest vail could be removed under local analgesia, and no specialized training was required for their proper management. The object which

lay within the pleural cavity necessitated a very different intellectual and technical approach from that which would be used for an entirely extrapleural

foreign body in the chest wall. Once the pleural boundary had been crossed,

the surgeon was confronted with a host of problems, such as the management of

open pneumothorax and the necessity for positive pressure anesthesia, which

required specialized training for their solution.

In a war zone, there was frequently not at hand the equipment commonly

employed in peacetime for the accurate localization of intrathoracic foreign

bodies, such as stereoscopy, the parallax method, and electric locators. That

did not mean, however, that accurate localization could not be accomplished in

almost every case if cognizance was taken of basic principles and if a systematized plan of study was followed. The plan to be described proved its efficiency

in the localization of several hundred foreign bodies in the chest observed in the

Mediterranean theater.

Physical examination.—Careful palpation, if successful, was the most

accurate possible method of determining the location of a foreign body. Palpation soon after wounding might be futile because of tenderness and spasm.

When they had disappeared, palpation was frequently very useful.

Case 3.—This patient received a chest wound from an enemy machine pistol, the bullet

coming to lie in the soft tissues of the posterior thoracic cage. It was easily visualized

(flg. 120) by posteroanterior and lateral Alms. When the patient was admitted to the

chest center, the bullet could not be palpated. As spasm and tenderness subsided, it was

readily palpable. At operation, it was found lying in the erector spinae muscles and was

recovered without difficulty under local anesthesia.

Roentgenologic examination.—The study of a patient with a foreign

body in the chest began with routine posteroanterior and lateral roentgenograms. Although in numerous instances, these two views apparently sufficed
RETAINED IXTRATTIORACIC FOREIGN BODIES

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FIGURE 12(! (case 3).—Retained foreign body in posterior chest wall. A. Posteroanterior roentgenogram showing missile probably in thoracic wall. B. Lateral roentgenograni. At operation, the missile was found in the erector spiuae muscles.

for accurate localization, in general, tliey were usually considered as little more

than scout films, to indicate the direction that subsequent investigation should

take, To rely solely upon them could easily lead to grief. That one view was

worthless for localizing purposes seems almost too obvious to mention, but

occasionally, a patient was encountered whose chest had been explored—fruitlessly—on the basis of a single film.

In the examination of the initial films, the chest was divided into sectors

(fig. 127), which, made it possible to determine certain facts at once, If the

object lay outside of these sectors, it was clear that it was extrapleural. To

illustrate:

Let it be assumed that a missile lies on the right side of the chest, in sector

B-B' (fig. 127). If only the posteroanterior film were examined, the object

could lie anywhere in the sagittal plane of the right mid hemithorax. Further

examination of the lateral film clarified the matter. If the object lay in the

anterior chest wall, it would appear in sector A'. If it were in the tissues of the

posterior chest wall, it would lie in sector C. Since, in the lateral view, it lay

in sector B', it was assumed to lie in the midcoronal plane, and to be intrapulmonary, as it proved to be:

Case 4.—This patient was struck in the right side of the chest, by a German rifle bullet.

Examination of posteroanterior and lateral films (fig. 127) showed that it lay in sector

B-B'. At operation, the missile, which was the brass jacket of a rifle bullet, was removed

from the right middle lobe.

74(i-fl4r—03 24
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FIGVI:K 127 (case 4).—Localization of intrathoracic foreign bodies by division of chest

into arbitrary sectors. A. Posteroanterior roenfgenogram .showing object in lung. B. Lateral roeiitgcnogram.

Both suspected and unsuspected foreign bodies frequently came to light

after withdrawal of fluid or air or both from the chest, with resulting reexpansion of the hing and coincidental changes in position of the object (fig. 128).

Such evidence was always looked for on serial films. Foreign bodies observed

in serial films to have dropped from apex to base were, intrapleural and extrapulmonary. A characteristic positional change related to movement of the

shoulder girdle, or of large muscle group of the chest wall furnished prima facie

evidence that the foreign body was extrapleural.

The, following case history illustrates this situation :

Case 5.—In this case, the foreign body was found in sector V> in the left side of the

chest (fig. 12t)A). It seemed, suspended high in (he center of a imemnothorax pocket, with

no visible means of support. Since it did not drop to the bottom of the pleural cavity, it

could not possibly lie free within it. When the lung was completely roexpanded (fig. 12OT-!),

there was no significant positional change; the slight change in the axis of the metallic

fragment was caused by elevation of the shoulders. This phenomenon was frequently helpful in localizing foreign bodies in and about the scapula and clavicle.

At operation, this shell fragment was removed from a location deep to the pectoralis

major muscle, just inferior to the left clavicle.

The closer the foreign body lay to the pleural surface, the more difficult

it was to be certain that it lay within the lung tissue. In fact, if it lay in

sectors other than B-B', posterolateral and anterior films were inadequate, and

recourse to supplemental procedures was necessary.
RETAINED INTRATHOKACIC FOREIGN BODIES 335

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FIOUKE 128.—Localization of intrathoraeic foreign body. A. Posteroanterior roeiitgenogram showing foreign body in undetermined location. B. Same, after expansion of

lung. The change of position of the object with the movement of the lung shows that it

is intrapulmonary.

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FiGtjjiE 120 (case 5) .—Localization of foreign body in chest wall. A. Posteroanterior

roenlgenogram. B. Reexpansion of lung. Missile has not moved. The change in its axis

is explained by the difference in the position of the shoulder girdle in the two views. At

operation, it was removed from the chest wall just inferior to the left clavicle.
836 THORACIC SCRGKRY

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Fiona: 130 (case (!).—Localization of infrapulmomiry foreign body. A. Posteroanterior roentgenogram. B. Lateral roentgenogram. At operation, the missile was removed

from the left lower lobe.

Fluoroscopy.—If. during the examination under the fluoroscope, the retained missile was observed to move the distance of an interspace with the

respiratory act, it was assumed to be intrapuhuonary. If it moved synchronously with the cardiac pulsations, then it might be in the lung- or in the

mediastinum.

Case 6.—This patient, an Italian prisoner of war, was struck in the left chest by a

high explosive fragment. On fluoroscopic: examination, the object was seen to move synchronously with the respiratory excursions, l'osteroanterior and lateral films (tig. 130)

showed it lying in sector C-C.

At thoracotomy, it was removed without difficulty from deep in the left lower lobe.

Case 7.—This patient was struck in the left chest by a high explosive fragment. Examination of the posteroauterior and lateral films placed the object in sector A-C (fig.

131). It was not possible to determine, from the films alone, that the fragment did not

lie outside the bony cage. Fluoroscopy projected the missile within the arc of the ribs

and thus in lung tissue.

At thoracotomy, the missile was removed from the left lower lobe.

Fluoroscopic examination was supplemented by spot films made by a special

technique whenever the missile was in a peripheral sector and had not been

located by other means. Under fluoroscopic visualization, the patient was

rotated so that the foreign body was brought to the position apparently nearest

to the external thoracic surface. In this profile position, as the following case

shows, it was usually possible to determine whether the object was extrapleural,

intrapleural, or intrapnlmonary. Spot films were made for more deliberate

studv:
RETAINED INTRATHORAGIC FOREIGN BODIES 337

FiGUiiio 131 (ease 7).—Localization of foreign body in lung. A. Posteroanterior

roentgenogram showing missile on left in indeterminate position. B. Lateral roentgenogram, which is equally inconclusive. Fluoroseopy was necessary in this ease to localize

the object in the left lower lobe.

Case 8.—This patient was wounded by a high explosive fragment. The foreign body

lay in sector A-B' (figs. 132A and B). When objects were in this location, it was impossible, without, supplemental studies, to be certain that they lay intrapleurally or extrapleurally. Utilizing fluoroseopy, with rotation of the patient, an additional roentgcnogram

(tig. 132G) showed that the object lay outside the lung surface. Since, furthermore, it

was projected external to the inner margin of the rib, it necessarily lay in the thoracic

wall and not within the pleural cavity. The straight line of increased density shown in the

roentgenogram in this position was due, as in similar cases, to an extrapleural hematoma

associated with the metallic object deep in the thoracic wall.

Diagnostic pneumothorax.—If the issue was still in doubt, the matter

could usually be promptly settled by diagnostic pneumothorax (fig. 133).

When air was injected into the chest and the foreign body underwent positional

changes coincidental with those observed in the lung, it was obviously intrapulmonary. If it remained in its original position, as in the following case, it was

obviously extrapulmonary.

Case 9.—This patient sustained multiple penetrating chest wounds from high explosive

fragments. Two objects lay in the soft tissues of the lower lateral chest wall (fig. 131).

The third object lay in sector B-C, in which supplemental studies are practically always

required. Diagnostic pneumothorax did not alter the position of the fragment.

The extrapulmonary location of the object, as indicated by fluoroseopy, was confirmed

by operation, at which it was removed through a simple incision over the ninth interspace.

A combination of fluoroscopic examination and pneumothorax also settled

the location of foreign bodies lying partly in the extrapleural tissue and partly

intrapleurally. This was a particularly important variety of retained object
nor THORACIC SURGERY

SB'

FIGURE 132 (case S).—Localization of foreign body in chest wall. A. Posteroanterior

roentgenogram showing missile in undetermined position. 15. Lateral roentgenograin,

which is also indeterminate. C. Roentgenogram taken after rotation of patient to bring

foreign body to profile position. It is now seen to lie in the thoracic wall.

(p. 820). In the following case, the development of a hemopneumothorax

served the purpose of an artificial pneumothorax and clarified the position of the

fragment:

Case 10.—This patient was wounded by a penetrating high explosive fragment.

Posteroanterior and lateral roentgenograms showed it lying in sector B-B'. Since it was

quite large, it was thought that accurate localization might be difficult. Later, when the

patient developed a hemopneumothorax, the definite rotation of the object (fig. 135) showed

that it must be within lung tissue.

The diagnosis was confirmed at operation.

Pneumothorax was never instituted until a competent thoracic surgeon or

other medical officer had stated that it could safely be used. Lung puncture

and hemorrhage were always possibilities. The use of this method was limited.
RETAINED INTRATHORACIC FOREIGN BODIES 339

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FIGI;I:E 133.—Localization of foreign body in chest

wall. I'osteroantorior roentgenogram after small

artificial pneumothorax. In this case, both plain

roentgenography and fiuoroseopy had failed to localize the object.

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FIGURE 134 (case 9).—Localization of foreign bodies in chest wall. A. Posteroanterior

roentgenogram showing two objects in soft tissues of lower lateral chest wall and a third

possibly within the lung parenchyma. B. Lateral roentgenogram showing the position of

the third fragment was not altered by diagnostic pneumothorax. It was removed at operation by a simple incision over the ninth interspace.
340 THORACIC SURGERY

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FIGUKE 135 (case 10).—Localization of foreign body in lung. A. Posteroanterior roentgenogram showing foreign body in indeterminate position. B. Lateral roentgenogram.

C. Posteroanterior roentgenogram showing change in position of foreign body with development of hemopneumothorax.
RETAINED INTRATHORACIC FOREIGN BODIES 841

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FIGURE 136.—Localization of foreign body in diaphragm. A. Posteroanterior roentgenogram of chest and upper abdomen. V>. Left lateral roentgenogram. C. Oblique view

after induction of artificial pneumoperitoneum. The diaphragm is shown in profile in this

film, and the foreign body is clearly seen embedded in it. The localization was found correct at operation.

A special technique was required, in which relatively few medical officers were

trained, because of the decreasing use of pneumothorax in the treatment of

tuberculosis.

Diagnostic pneumoperitoneum.—Foreign bodies about the diaphragm

were notoriously difficult to localize. It was frequently necessary to induce a

diagnostic pneumoperitoneum to establish their exact location (figs. 136, 137,

and 138). Once it had been induced, posteroanterior and lateral films were

made in the upright position, sometimes supplemented by oblique films and films

in the lateral decubitus. If these studies produced even a single view showing
m THORACIC SURGERY

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FIGTJBE 137 (case 11).—Localization of foreign body in diaphragm. A. Fosteroanterior

roentgenogram showing foreign body in vicinity of diaphragm. P>. Fosteroanterior roentgenogram after pneumoperitoneum showing object possibly in abdomen. C. Lateral roentgenogram showing foreign body in diaphragm.

the foreign body above the diaphragm, it was evident that the location was intrathoracic and not subdiaphragmatic, as the following cases show:

Case 11.—This patient sustained a wound of the left chest from a high explosive fragment. Fosteroanterior and lateral views (fig. 137) showed it lying in sectors A-B', in

the vicinity of the diaphragm, a location in which accurate localization was always

more difficult. After pneumoperitoneum had been induced, additional films left the location still undecided. A third film (fig. 137C) definitely located the object in the superior

substance of the diaphragm.
RETAINED 1NTRATH0RACIC FOREIGN BODIES 343

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FIGUKE 138 (case 12).—Localization of foreign bodies. A. l'osteroantorior roentgenogram showing three foreign bodies in right chest (No. 1 extrapleural, No. 2 in undetermined

location, No. 3 in abdomen). B. Lateral roentgenogram showing same positions. C. Profile

roentgenogram after pneumoperitoneum. Object No. 2 in this film is seen projected in the

lung tissue; at operation, it was found in the middle lobe of the lung. D. Oblique roentgenogram showing right costal margin. In this view, object No. 3 lies outside the substance of the liver.
;;14 THORACIC SURGERY

B

Fioriii-: l.'S!>.—Localization of foreign body in mediastinum. A. Lateral roentgenogram

showing foreign body in mediastinum. At operation, it was found to be associated with

abscess formation. B. Fosforoanterior roentgenogram 2 weeks after tlioracotomy, removal of object, and evacuation of abscess. Recovery was uncomplicated, without mediastinal or pleural complications.

In this case, as in a number of similar cases, the oblique view was decisive.

Case 12.—In this case, as in the preceding case, it was necessary to induce pneumoperitoneum to secure exact localization of three foreign bodies (fig. 138). Fosteroanterior and lateral films showed one object to be extrajileural. lying in the soft tissues of the

chest wall. The second object lay in the anterior costophrenic region above the diaphragm,

though whether it was intrapulmonary or intrapleural was not clear. A profile view (fig.

13NC) projected the missile in lung tissue, thus proving that it did not lie in the intercostal

soft tissues. A third object lay outside the substance of the liver (fig. 13SD).

At. tlioracotomy, the second object was found lying in the substance of the middle lobe

of the lung.

Pneumoperitoneum, like pneumothorax, had to be used with care and judgment. It was never employed in the presence of infra-abdominal infection. If

abdominal surgery had been performed recently, satisfactory air caps, because

of adhesions, were not usually seen over and around the liver. If the object

was on the left side, a 2-gm. close of sodium bicarbonate given orally 15 minutes

before the films were made frequently produced enough gaseous distention for

a satisfactory outline of the left diaphragm. In an occasional case, both

pneumothorax and pneumoperitoneum had to be employed diagnostically to

achieve definitive localization of the object.
RETAINED INTRATHORACIC FOREIGN BODIES 345

A B

FIGIRIC 140 (case !:>) —Localization of foreign bodies in lung and mediastinum. A.

Fosteroanterior roentgenogram showing one foreign body in lung and other either in lung

or mediastinal tissue. B. Lateral roentgenogram showing same indeterminate location of

second object. At operation, it was found just under the mediastinal pleura.

Localization of mediastinal foreign bodies.—Mediastinal foreign bodies

sometimes offered difficulties of localization (figs. 139 and 140). They were

most often found in sector C-B' and in this location were frequently observed

to move synchronously with the cardiac pulsations. On the left side, in this

location, they might be either cardiac or pericardial problems. Differential

diagnosis required careful study and consideration:

Case 13.—This patient received multiple wounds of the extremities and the right side

of the chest when a shell exploded close to him. Examination of the posteroanterior film

(fig. 140A) showed two foreign bodies. The first lay in sector B-B' and was clearly in the

intrapulmonary substance. The second lay in sector C-B', which made it necessary again

to differentiate between an intrapulmonary and a mediastinal location.

At operation, the second object was found in the mediastinum, just under the mediastinal pleura.

The evaluation of mediastinal foreign bodies was also important from

another standpoint, the possibility of injury of the esophagus. If this suspicion existed, operation was a matter of extreme urgency. Overlooked esophageal perforations were attended with a very high mortality. Moreover, the

surgical approach was different from that employed in the removal of intrapleural, intrapulmonary, and other mediastinal foreign bodies. Patients were

questioned explicitly concerning any symptoms which might point to esophageal

injury, particularly dysphagia.

It was difficult to differentiate some intrapulmonary missiles from missiles

located in the mediastinum, but, since the surgical approach was the same in

both instances, the differentiation was academic rather than practical.
M6 THORACIC SURGERY

k

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FK;UI:E 141.—Localization of foreign body in intrapleural space. A. I'osteroanterior

roentgenogram showing object in either intrapleural or intra pulmonary location. B. Lateral roentgenogram, which also does not differentiate the position. At operation, the object

was found free in the intrapleural space. In this case, clotted hemothorax prevented the

use of diagnostic pneumothorax.

SURGICAL TECHNIQUE

The fundamental surgical principle of adequate exposure was particularly

important in the removal of foreign bodies from the lungs. Skin and muscle

incisions had to he wide enough to permit access to at least two interspaces when

the bony thoracic cage was exposed. If precise localization had been accomplished and if the lung was adherent to the chest wall, it was sometimes possible

to remove the object without entering the free pleural space.

When the object was deeply embedded in the lung, an opening into the

pleura was necessary and had to be large enough to permit palpation and adequate exposure,

A posterior incision was usually employed, without division or resection of

the ribs. A short incision was made into the lung, at the point at which localization procedures, confirmed by palpation, had indicated that the foreign body

was nearest the surface. When operation was performed soon after wounding

(within 14 daj's), there was, as a rule, little or no reaction about it,

Localization was sometimes less accurate than desirable because the presence of a clotted pneumothorax prevented the use of diagnostic pneumothorax

(fig. 141). Hemothorax or hemothoracic empyema sometimes complicated the

situation at operation also. Decortication, in some cases, had to be carried out

before a search for the object was undertaken, as it was not possible to palpate a
RETAINED INTRATHORACIC FOREIGN BODIES 347

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FIGITHE 142 (case 14).—Iutrapleural foreign body associated with massive

rosteroanterior roentgenogram showing iutrapleural metallic object (arrow)

ted clotted hemothorax, which went on to massive liemothoracie empyema.

days after removal of foreign body and deeortieation of lung. Recovery was

empyema.

with assoB. Same,

: complete.

fragment through the inelastic rind. If the hemothorax involved only a single

lobe, deeortieation was also preferable to an extended and difficult search for

the foreign body. Associated abscesses were either curetted out or, if the lesion

was peripheral, were managed by wedge resection.

Closure was by the silk technique throughout. The lung was closed in two

layers, the pleura being inverted with the second layer. Sutures were placed

in the intercostal muscles and tied after the ribs had been approximated. Pericostal sutures were avoided.

The chest was ordinarily drained with both anterior and posterior intercostal water-seal tubes. The use of the anterior tube, which was usually removed within 48 hours, insured prompt expansion of the upper lung. The

posterior tube was kept in place for ;-> or 4 days.

In the early experience, penicillin was used intrapleurally, but this practice was subsequently discarded, and the antibiotic was used systemically before

and after operation.

The following case history illustrates the successful management of foreign

bodies associated with massive empyema :

Case 14.—This patient was struck in the right chest by a bomb fragment on 26 March

1044, sustaining a severe penetrating wound, with hemothorax. A metallic foreign body

was retained in the affected area.

The wound was debrided, and repeated aspiration was employed. This procedure, at

first effective, later ceased to be useful, and the patient developed fever and other symptoms

and signs of sepsis. Roentgenograms revealed a right clotted hemothorax in addition to

the retained foreign body (fig. 142A). Material aspirated from the right chest became
34-8 THORACIC SURGERY

progressively more purulent and more offensive in odor. Cultures grew proteolytic

elostridia.

Under penicillin protection, a thoraeotomy was done 21 days after injury, with removal

of the foreign object and decortication of tlie lung.

Recovery was prompt and uneventful (flg. 142B). The patient was discharged to full

duty on 5 June 1044, about 10 weeks after injury.

ANALYSIS OF CASES

In a series of 1.058 penetrating wounds of the chest observed by surgeons

of the 2d Auxiliary Surgical Group in the Mediterranean theater, an experience which may be assumed to be typical, there were 291 retained intrathoracic

foreign bodies, exclusive of foreign bodies in the heart and pericardium. Of

these, 39 were intrapleural and 252 intrapuhnonary and mediastinal. Since

the great majority of these patients were under observation in thoracic surgery

centers for periods ranging from a week to 2 months after injury, this series

offered an excellent opportunity to determine what happens to retained intrathoracic missiles within this period after wounding.

Preoperative Complications

The following complications, which developed during the periods of observation, represent the ill effects of retained foreign bodies:

In the 252 intrapuhnonary and mediastinal foreign bodies, there were 4 delayed or recurrent hemoptyses; 2 secondary intrapleural hemorrhages from the

lung; 18 late or recurrent bronchopleural fistulas; 4 lung abscesses; 2 mediastinal abscesses associated with the retained objects; and 30 empyemas.

In the 39 intrapleural foreign bodies, there were 15 empyemas.

The total complications in these 291 cases were thus 75 in number, 25.8

percent; 60 were associated with the 252 intrapuhnonary and mediastinal objects and 15 with the 39 intrapleural objects.

There was no correlation in this study between the incidence of complications and the size and configuration of the missiles. There was also no correlation as to location except in one regard, that missiles located in the periphery

of the lung gave rise to a higher incidence of complications than those in the

hilus. This observation was at variance with the popular concept that a missile

lying in close proximity to vascular or bronchial structures in the hilus was

more likely to give rise to complications than a missile in the periphery. The

explanation may be that missiles that lodged at or near the hilus were missiles

that had lost their momentum. Those that tore through it usually lacerated

the major divisions of the pulmonary artery or vein, with rapid death by

exsanguination. Surgeons who worked in field hospitals almost never saw a

casualty with damage to a major pulmonary vessel. These casualties did not

live long enough to be hospitalized.
RETAINED IXTRATIIORACIC FOREIGN BODIES 349

These figures are significant in view of the numerous discussions concerning the relative incidence of empyema in intrapleural versus intrapulmonary

retained foreign bodies. In the 39 intrapleural cases, empyema occurred 15

times, an incidence of 38.5 percent, In the intrapulmonary group of 252

objects it occurred 30 times, an incidence of 11.9 percent, -which is strikingly

close to the overall incidence of empyema in chest wounds in the Mediterranean

theater. This observation corroborated the opinion generally held by thoracic

surgeons that intrapleural foreign bodies were far more likely to give rise to

trouble than intrapulmonary missiles.

The majority of the complications, almost 75 percent, developed during the

second and third weeks after injury. Aside from the empyemas, the earliest

complication observed was a lung abscess which appeared a week after injury.

Only 4 complications, none in the intrapleural group, developed earlier than

10 days after wounding. The earliest complications were usually hemorrhage,

atelectasis, pneumonitis, and pulmonary embolus. Lung abscess was extremely

uncommon (at all times), though in this series it was the first complication

to be observed, 7 days after wounding.

Results of Surgery

Surgery was carried out in 102 of these 291 retained foreign bodies, in 15

instances for intrapleural objects and in 87 for objects in the intrapulmonary or

mediastinal tissues (fig. 143). In five instances, the object was not removed,

for various reasons, and in four instances, it was not found at the site expected

from the preoperative localization.

There were no deaths in the 102 operations and no instances of permanent

disability or deformity. The 13 postoperative complications were distributed

as follows: 3 wound infections; 4 empyemas (3 small, resulting from subjacent

extension of the wound infection to the pleural cavity and 1 basal, unrelated

to wound infection) ; 1 clotted hemothorax; 1 atelectasis; 1 secondary hemorrhage; 2 bronchopleural fistulas; and 1 thrombophlebitis. None of these complications resulted in prolonged disability.

About half of the retained objects, as previously mentioned, were found

with associated cloth fragments at the site of lodgment, but, except in the four

lung abscesses, no positive cultures were obtained from the missile cavities.

Conclusions

Although the series is small, these figures are important, since they overturn many misconceptions as to the innocuousness of retained intrathoracic

missiles. An incidence of 15 percent of significant complications within the

first 60 days after wounding points to the fact that the retained missile is, on

the contrary, a real source of danger to the host and must be considered seriously

in the reparative management of every case. On the other hand, the fact that

so few complications developed earlier than 10 days after wounding justified
350 THORACIC SURGERY

if

J^ fC^-as.--' '7" Si«*.*

«Si--

äfek..

€1

FiGUiiE 143.—Specimens of metallic foreign bodies removed

from lung's and pleural cavity.

the policy of waiting- until the patient had arrived in a fixed hospital to remove

the missile.

This comparison definitely favors the removal of retained foreign bodies,

though not statistically. The incidence of postoperative complications, when

surgery was done at the thoracic surgery center in this series was approximately

13.4 percent, while the incidence of complications encountered when the foreign

bodies were not removed was 15 percent. Statistically, this is a totally insignificant difference, almost an argument, in fact, for leaving these objects in situ.

Clinically, however, the balance is all in favor of their removal at the proper

time and on the proper indications. The complications of retained foreign

bodies are all debilitating, and many of them are potentially fatal. The properly staged removal of these objects, however, is attended with a minimal

mortality—there were no deaths in this series—and with a low morbidity.

Much remains to be learned concerning the question of retained foreign

bodies in penetrating thoracic wounds. This analysis of a small series of cases
RETAINED INTRATHORACIC FOREIGN BODIES 351

is not conclusive, and final statistics are not yet available. The analysis, however, does show the fallacy of the opinion that it can be confidently anticipated

that such objects will do no harm, and it also vindicates the Mediterranean

theater policy of removing all objects larger than 1.5 cm. in their greatest diameter, preferably within the first 14 clays after injury, after the patient has

been evacuated to the base.

Final appraisal must await long-term followup studies on both the group

in which the object was retained and the group in which it was removed.3

s The reader is referred to chapter XI (p. 441) for long-term followup studies on casualties with

retained foreign bodies in the chest.
CHAPTER VIII

Management of Retained Foreign Bodies in the

Heart and Great Vessels, European

Theater of Operations

Divight E. Harken, M.D.

ANATOMIC LOCATION OF MISSILES

Over a 10-month period in World War II, thoracic surgeons working- in

the thoracic surgery center set up in the 160th General Hospital, 15th Hospital

Center, Cirencester, Gloucestershire, European Theater of Operations, U.S.

Army, performed 134 operations for the removal of missiles retained in and

about, the heart and great vessls. There were no deaths in the series, and all

patients were discharged with normally functioning hearts.

The experience of World War II confirmed the difficulty, commented upon

elsewhere, of accurate localization of metallic foreign bodies in relation to

wounds of the heart. In about half of the patients referred to the chest service

at the 160th General Hospital as harboring foreign bodies within the heart,

the objects were found, after careful fluoroscopic examination, to be extracardiac. Furthermore, early in the experience on this service, it was found

at operation that about a third of the fragments thought to be intracardiac were

extracardiac. Even on exploration, it was not always easy to determine

whether an object lay within the pericardium or within the auricle; this was

particularly true if an infected hematoma was present.

The location of the 134 foreign bodies in this series, as proved by operation,

was as follows (fig. 144) :

Of the 56 foreign bodies in and about, the heart, 13 were intracardiac, 26

were entirely within the pericardium, and 17 partly within the pericardium

but chiefly within the lung. Of the 13 foreign bodies removed from the

chambers of the heart (fig. 145), 7 were in the right ventricle, 4 in the right

auricle, 1 in the left ventricle, and 1 in the left auricle.

The great vessels were involved, directly or indirectly, in 78 cases. In

seven instances, the missiles were intravascular; the three of these which became

embolic are discussed in detail elsewhere (p. 380). In 35 instances, the fragments lay on the great vessels or within the vascular walls. In 17 cases, they

were directly adjacent to the vessels but were chiefly within the lung. In 19

353
354 THORACIC SURGERY

FIGURE 144.—Gross location of foreign bodies removed from

cardiac and vascular structures at 160th General Hospital.

Stippled: missiles impinging on structures. Black: intrastructural missiles. Crosshatching: embolic missiles.

instances, they were within the mediastinum but were not in direct proximity

to the great vessels.

The fact that no missiles were encountered within the lumen of the thoracic

aorta and that in only one instance was a missile found in the left ventricle

seems to warrant the assumption that the direct entrance of foreign bodies

of any considerable size into either of these areas was seldom compatible with

survival. The anatomic distribution of these missiles suggests further that

fragments small enough to enter the left ventricle as migratory foreign bodies

were probably swept out of it by the high systemic pressure, in contrast to

those which entered the right ventricle, where physiologic circumstances were

more favorable for their lodgment.

Over the same 10-month period during which these 134 successful operations were performed, 4 unsuccessful operations were undertaken for the

removal of foreign bodies in and near the heart. In two instances, the missiles
RETAINED INTRACARDIAC FOREIGN BODIES

RT. AURICLE RT. VENTRICLE

fe»>sF

LT. AURICLE

Ml

llllllll llll|l llll|llll lllljllll lllllllll Hill! IHflll lifMIip lllljllll lllllllll ill lllllllll lllllllll lllllllll Ullplll imp

3 A 5 6 7 8 9 ' i|o' 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8

FIGUKE 145.—Missiles removed from chambers of heart, with

their location.

could not be recovered at cardiotomy, and in the other two instances, exploratory pericardiotomy revealed that their removal would have been attended

with unjustifiable risks.

In 15 other patients in whom foreign bodies in or about the heart were

encountered, operation was not undertaken, for one reason or another, and the

objects were permitted to remain in situ.

FOREIGN BODIES IN AND ABOUT THE HEART

Indications for Surgery

The diagnostic confusion, already mentioned, of determining whether a

retained missile was or was not within the heart added to the difficulties of

assessing the risk to life and health of retained intracardiac missiles. In spite

of numerous isolated reports of foreign bodies which have lodged in the heart
356 THORACIC SURGERY

and remained asymptomatic, there is also considerable evidence in the medical

literature that these objects may be lethal. Experimental evidence, furthermore, suggests that their presence may give rise to bacterial endocarditis.

As the "war progressed, therefore, a working policy for the management

of intracardiac missiles was formulated from the medical literature, from a

limited amount of experimental work previously done on animals, and from

the individual surgeons' own concepts and their accumulating experience. Although the policy was originally based upon somewhat uncertain premises,

it was substantiated by the clinical evidence secured in the various chest centers

in the European theater during the course of the Avar.

The indications for the removal of foreign bodies in and about the heart

were chiefly based on possible risks, which included embolism, bacterial endocarditis, recurrent pericardial effusions, and myocardial damage. The development of symptoms and the existence of cardiac neurosis also served as

indications.

The risk of embolism.—The development of embolism from a foreign

body or from the thrombus associated with it was not merely a theoretical

possibility. Several such accidents had been recorded in the prewar literature,

and at least two are known to have occurred in the European theater during

World War II. One of these cases is included in the series analyzed in this

chapter. The missile lay in the interauricular septum and right auricle

and was removed from the auricle: the thrombus was found in the left auricle.

Hemiplegia occurred in this case soon after wounding. In the second case,

reported by Lt, Col. Arthur D. Nichol, MC, the embolism arose from a missile

in the left ventricle. It is significant that the hemiplegia which followed it

appeared more than 2 weeks after wounding.

The risk of infection.—The removal of retained intracardiac objects because of risk of the development of bacterial endocarditis was, as already

intimated, partly based on the results of experimental work on dogs. The

implantation of foreign bodies in various locations in the heart was followed

by the development of bacterial endocarditis characterized by typical bacterial

valvulitis and of septic embolic infarcts. The experimental evidence was

limited, but it was naturally feared that foreign bodies retained in the human

heart might give rise to the same consequences.

Clinical support for this hypothesis was confined in this series to a single

case: The patient ran a course suggestive of subacute bacterial endocarditis,

with spiking fever, tachycardia, and one acute episode of pain in the right

upper quadrant associated with jaundice. Eesponse to surgical removal of

the missile and the attached thrombus from the right auricle was immediate

and dramatic. Although the patient was almost moribund when operation

was undertaken, his recovery was prompt and uncomplicated.
RETAINED INTRACARDIAC FOREIGN BODIES 357

The bacteriologic support for the indication of infection in this series

of cases is somewhat more conclusive. No cultural studies were made in 4 of

the 13 intracardiac foreign bodies. There was growth of bacteria on cultures

made from only one of the live fragments removed from within the right

ventricle; this particular foreign body lay in an abscess within a mural

thrombus in the ventricular chamber. Cultures were also positive for pathogenic organisms in three of the four cases in which foreign bodies were removed

from within the auricle. One of these missiles was found in a small abscess

in the center of a mural thrombus in the right auricle.

It cannot be said positively that the infected niduses in these cases

represented true bacterial endocarditis, nor can it be said that the infections

present would eventually have produced it. Nonetheless, the findings seemed

to furnish further support for the removal of intracardiac missiles because of

the possible development of infection.

The risk of recurrent pericardial effusions.—The risk of recurrent pericardial effusion as an indication for the removal of intracardiac foreign bodies

has been repeatedly stressed in the medical literature and is well established.

On the other hand, in the only two instances of pericardial effusion observed

at the 160th General Hospital, the symptoms were not severe enough, and the

fragments were not large enough, to justify surgical intervention.

The risk of myocardial damage.—Myocardial damage was clearly evident in three cases in this series. The damage to the right ventricular wail

overlying the site of a migratory missile noted in the following case seems of

special significance in several respects. In particular, it demonstrates that

the mere presence of a foreign body in a cardiac chamber can produce considerable damage to the overlying myocardium in a period of 3 months, and it also

indicates that surgical removal of the object does not. of itself, cause myocardial

injury of any consequence :

Case 1.—A 29-year-old infantry sergeant was injured in the right lower posterior

chest on 21 July 1944, in the lighting' about Saint-L6. Fluoroseopic and roentgenologie

examination (lig. 14G) showed a metallic foreign body lying in the anterior portion of

the right ventricle, just to the left of the midline, and pulsating with the heart. An

electrocardiogram 4 days later (lig. 147) showed no abnormalities except for inverted

T-waves in the right-sided precordial leads (CFi. OF», and CF;!). By S August, the T-waves

in CFi had become upright, and the tracing appeared entirely normal.

First operation.—Operation was performed on 15 August in the dorsal decubitus

position (flg. 14S). When the missile was grasped through an incision in the right ventricle, it was jerked from the grasp of the forceps by the movements of the myocardium

and was lost to both sight and palpation in the bloodstream.

Roentgenograms taken immediately after the operation (lig. 140) showed the missile

lying in the right auricle, over the opening of the inferior vena cava. Another electrocardiogram on 17 August (fig. 150) showed elevated ST segments in leads I and II. which

fell by 1 September. Later, the T-waves also became sharply inverted in leads I and II

and in the left-sided precordial leads CF4 to CF«. It was speculated that while this damage

74G-941''—05 25
o.)8 TiioitAcio suitcKin:

FIGURE 140 (case 1).—Koentgenograms showing original position of frag

incut in rightventricle. A. I'osforoanfoi'ior view. It. Lateral view.

!:!li!:i?-:::v-:«ÖiiiiilK :■■ :-"= :.:."

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FIGURE 147 (case 1).—Electrocardiograms taken before first

eai'diotomy. Roman numerals indicate limb leads and Arabic

numerals precordial leads CF, to CKY,.
IiF/iAIXFI) IXTIiACARDlAC FOKkTGX l'.ODIES

Fici'itK 14S (enso 1).—Positioning of patient Mt successive cardiotomies. A. Dorsal

doctibitus (soon from above). 15. Fatoral docubitus ( riiiht side up). C. Koverse Tren-

(Ti-U'iilniTir position with elevation of right side.

might be related to the surgical incision made in the rigid ventricle near the septum, in

the anterior surface of I lie heart, il might also result from an associated pericarditis.

Second operation.—At a second cardiotomy on Hi Xovoniber. •"> months after the first,

with the iiatient in lateral deenbifus (hg. 14N). the missile was visualized and palpated in

the right auricle, jusr above the entrance of the inferior cavil. Again it escaped, this time

falling back info the right ventricle (tig. 151). Incidentally, a significant diagnostic point

is demonstrated by the roenlgomigrams taken after operation: They were not made in the

true lateral position, and the impression was that the missile was in the chest wall. Had

these been the lirst roentgenograms taken, considerable diagnostic confusion might have

been caused.

ElectroeardiogTMphic examination (tig. 152) showed no specific acute change after the

second cardiotomy. There was merely a progressive return toward normal of the T-waves

ami of leads 1 and II and CV:. and CK.

Third operation.—On 1!» February V.HÖ. at the patient's own request a third eardiotomy was performed. The anterior approach was used, as in the lirst operation, but this

time the patient was placed in flu' reverse Trendelenburg position (tig. 148). The sear

FmrisE 14!) (case 1).—Roentgenograms showing position of fragment

in right auricle after lirst (unsuccessful) operation. A. l'osteroanierior

view. 1!. Lateral view.
361' THORACIC mum

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FioriiK 1Ö0 (case 1).—Electroeanlin.nTams taken after first (unsuccessful ) canliotomy. See fisnre 147 for kev.
RETAINED INTRACARDIAC FOREIGN BODIES mi

FIGURE 151 (case 1).—Roentgenograms showing fragment' again in right

ventricle after second (unsuccessful) cardiotomy. A. Posteroanterior view.

P>. Lateral view.

of the first incision in the right ventricle, made G months earlier, was found solidly lien led.

This was demonstrated visually (plate 1) as well as clinically by the colored motion pictures taken at the operation. The considerable fibrous pericarditis that had developed

did not limit cardiac motion or obstruct the blood flow. Near the apex of the right ventricle, however, the muscle wall was thin, flabby, and discolored (plate II). The missile

was palpable in the right ventricular cavity, just under the area of myocardial damage,

which presumably had been produced by the friction of the muscle wall over the fragment

during the 3 months after the second operation.

The heart was opened through the area of damage and the shell fragment (fig. 14."))

was grasped by forceps and was removed with only moderate difficulty (plate III). Intracardial manipulations were carried out in three episodes, over a period of about 3

minutes. Showers of extrasystoles were noted during the removal of the missile (iig. 153).

In spite of the successive migrations of this foreign body (fig. 1.1-1), this patient suffered no significant cardiac damage (fig. 1 .">.">) and was in excellent condition (fig. 1.10)

when he was discharged to the Zone of Interior.

m

FIGURE 1-12 (case 1).—Electrocardiogram taken after second ( unsuccessful) cardiotomy. SOG figure 147 for key.
:uy TlIOIiACIC ^I'HdF.RV

PLATE I Cease 1) (right).—Appearance

of heart at inslaiit of incision into right

ventricle (compare with (iguro 1-!(>A).

PLATE II (case 5) (left, bottom).—

Techniiine of dislocation of heart from

pericardia I sac.

PLATE III (case 5) (right, bottom).—

IMarked ventricnlar dilatation following

dislocation of heart. This photograph, like

plate II. was taken during the operation.

These plates should be compared with the

electrocardiographic tracings taken during

operat ion (lig. 17.'!).

iswmSh

^"--•"«4'Wi
RETAINED IXTRACARDEVC FOREIGN BODIES

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FiGi-iiE lö-'i (case 1).—Electrocardiograms taken during

fill eardiotomy at fimc of removal of fragment Itimi ri,

figure 1-1-7 for key.

third

,'111 ve

and

ntric

suceessle. See

EIGT-KE 1Ö4 (case 1).—Migration of foreign body at successive cardiotomies. A. Movement from right vent viele to right auricle as shown by dotted arrow; first operation in

dorsal decubitus. 15. Movement from right auricle back to right ventricle; second operation in left lateral decubitus. depicted by dotted arrow. ('. Missile in right ventricle at

third operation, in reverse Trendolonburg position, with elevation of right side. Solid

arrow designates site of successful surgical removal of foreign body through- anterior wall

of right ventricle1.
364 THORACIC STUGERY

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FroritF. l.V> (ease 1).—Electrocardiograms taken after third

and successful eardiotomy with removal of fragment from right

ventricle. See figure 147 for key.

KM? lap

FIOCKE 1ÜG (case 1).—Patient just before evacuation to Zone of Interior, after three cardiotomie.s for removal of retained intraeardiae

missile.
RETAINED INTRACARDIAC FOREIGN BODIES 365

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FIGURE 157 (case 2).—Electrocardiograms taken before cardiotomy showing left ventricular damage from retained missile in left

ventricle. See figure 147 for key.

Case 2.—Another instance of myocardial damage occurred in the only case in the series

in which the foreign body was in the left ventricle. Roentgenokymographic studies showed

diminished amplitude of pulsation at the apex and passive left ventricular dilatation

during systole, suggestive of an early ventricular aneurysm or hernia. Electrocardiographic studies (fig. 157) showed a persistent pattern characteristic of extensive damage

to the anterior left ventricular wall, consisting of low voltage, deep Qi, absent Ri and

inverted TV, together with inverted and W-shaped QRS complexes and sharply inverted

and coved T-waves in the left-sided precordial leads.

At operation, the foreign body was found in the left ventricle, as the roentgenograms

(fig. 158) had shown, in a cystic zone of myocardial damage 1.5 cm. in diameter. It was

ballotable in the defect in the cardiac wall, and parodoxical pulsation of this area of the

ventricle was noted. A mural thrombus, which was not disturbed, permitted removal

of the missile without hemorrhage. The myocardial defect, after closure, was covered over

with two superimposed pericardial grafts.

In this case, electrocardiographic tracings taken at frequent intervals during the operation showed no evidence of cardiac irritability at any time except for a few ventricular

extrasystoles during the process of endotracheal intubation. It was believed that removal

of the missile and repair of the myocardial defect prevented progression of the myocardial

damage and averted possible rupture of the heart. Direct inspection at operation left no

746-041''—05 26
THORACIC SURGERY

FIGUKE 158 (case 2).—Preoperative roentgenograms showing retained missile in left

ventricle. A. Posteroanterior roentgenograin. B. Lateral roentgenogram.

doubt that the risk of rupture of the myocardial hernia was real and that it was aggravated

by the presence of the foreign body in it.

Case 3.—A third instance of damage to cardiac structures by a retained foreign body

was observed by llaj. Fred J. Jarvis, MC. In this instance, the wall of the right ventricle

underwent such a degree of degeneration from the presence of the underlying migratory

missile that death ensued.

Other indications for surgery.—Two additional factors sometimes assumed importance in the decision to remove intracardiac foreign bodies. One

was pain, the other cardiac neurosis.

Pain was associated with some of the pericardia! foreign bodies in this

series, but with only one of the intracardiac missiles. In this case, the object

had migrated from the auricle to the ventricle. A similar case was observed

by Lt. Col. (later Col.) Laurence Miscall, MC.

Cardiac neurosis sometimes became a pressing indication for surgery. In

spite of every effort to reassure them, all the patients in this series with foreign bodies in or near their hearts wanted them removed. Their apprehensions bore out Grey Turner's (1) remark, "In addition to the characteristic

cardiac symptoms * * * there may be neurotic manifestations which mainly

depend on the attitude of the patient to the knowledge that lie harbors a foreign body in one of the citadels of his well-being."

Size and location were other factors which influenced the decision for and

against surgical intervention. Small foreign bodies left in situ were regarded

as less hazardous than larger ones, and it was also thought that they were associated with less risk of myocardial damage. An additional reason for leaving them undisturbed was that they became encapsulated more readily and

more firmly than larger missiles and were therefore technically more difficult
RETAINED INTRACARDIAC FOREIGN BODIES

FIGUHE 159 (case 4).—Freoperative roentgenograms showing retained

fragment in left auricle. Rarliopaque oil is seen in empyema pocket.

A. 1'osteroanterior view. B. Lateral view.

to remove. For these reasons, small, silent foreign bodies in and near the

heart were allowed to remain in situ in 15 cases at the 160th General Hospital

during the period in which 13 similar fragments were removed surgically.

Combined indications.—As might have been expected, more than one indication for surgery was sometimes present, as the following case history

demonstrates:

Case 4.—This soldier, following injury by a shell fragment in the left anterior aspect

of the chest, developed an empyema, from which both hemolytic Staphylococcus aurcits and

Clostridium welch U were cultured. He had been treated by decortication followed by open

drainage at the 160th General Hospital. In the 6 months after injury, he had three massive

episodes of bleeding and two minor episodes. He also had bouts of pyrexia to 103° F.,

which did not appear to be connected with his empyema. Posteroanterior and lateral

roentgenograms (fig. 159) revealed a shell fragment in the left auricle. Electrocardiographs studies before operation (fig. 160) showed right axis deviation with low Rl and

deep S,. low diphasic T,. and upright, pointed T, and T, The precordial leads were normal. The abnormalities suggested damage to the anterior wall of the myocardium but were

not helpful in localizing the missile.

\t operation (fig. 161) on 18 Hay 1945, the empyema was found to communicate with

a laceration in the pericardium and the underlying left auricle; the auricle was adherent

to the pericardium. A laceration in the auricle was plugged by a large, infected, intracardiac hematoma. The missile, which was 2 by 1 by 1 cm. and was surrounded by cloth,

lay in this clot. It was readily removed from the left auricle, together with the cloth

and the infected clot. Cl. wclehVt and Esehcrlehht coli were grown on direct culture from

the material removed.

Ifter operation, the empvema rapidly resolved and there were no further episodes of

hemorrhage or pyrexia. Serial electrocardiograms (flg. 162) showed deep and sharp inversion of Ti and inverted T in CF0 but no other significant change.

This case appears to embrace most of the indications for removal of an intracardiac

foreign body (including an extensive thrombus), a potential embolus, gross intracardiac

contamination and infection, pericardial involvement, and damage to the myocardium with

repeated hemorrhages.
THORACIC SURGERY

FIGURE 160 (case 4).—Electrocardiogram taken before operation showing possible damage to anterior myocardial wall. See figure 147 for key.

FIGURE 161 (case 4).—Technique of removal of retained shell fragment from left

auricle. A. Patient in right lateral decubitus. B. Laceration of left auricle plugged by

infected hematoma. C. Closure of laceration by pericardioauricular sutures.
RETAINED INTRACARDIAC FOREIGN BODIES 369

FIGURE 102 (case 4).—Electrocardiogram after left auricular cardiotomy and

removal of intra-auricular shell fragment. See figure 147 for key.

Principles of Surgery

A successful attempt to remove a foreign body from the heart depended

upon the observance of certain fundamental principles governing exposure

of the involved area and manipulation of the heart itself. The most important of these principles were:

1. Adequate, direct exposure of the affected area. This necessitated the

use of a variety of approaches (fig. 103), depending upon the special problem

at hand. The pleura was opened routinely, but no standard or inflexible cardiac

approach was relied upon.

2. Conservation of the skeleton of the thoracic cage. The free division

of ribs, cartilage, and sternum was often necessary to reach the heart. The

division of bone and cartilage did no harm, but it was essential that these structures be preserved in situ. Complete reconstruction of an intact chest wall was

necessary at the end of the operation. No tissue or bone was resected, and

nothing was discarded. As a result, there was neither deformity nor defect

at the end of the operation.
TIIORAOIC SURGERY

FIGURE 163.—Incisions used to obtain exposure of foreign bodies in heart. A. Anterior aspect, showing: Approach to superior vena cava and right auricle (a), and approach to anterior and lateral aspects of right and left ventricle (b). B. Posterior

aspect, showing: Approach to posterior aspect of left ventricle (a), and approach to

posterior aspect of right and left auricles (b).

3. Maintenance of a moist epieardium during the period of cardiac exposure. It was thought that the 1 percent procaine hydrochloride solution

used to keep the epicardial tissues moist might also have the additional advantage of reducing cardiac irritability.

4. Minimal dislocation of the heart from the position of optimal function.

To perform cardiac surgery with minimal cardiac dislocation often taxed the

ingenuity of the surgeon, but it was essential for a successful result.

Surgical Technique

Both the approach and the procedure for the removal of foreign bodies

in and about the heart depended upon their location. The various approaches

described were all used successfully in one or more cases in this series. Another extracardiac approach to the heart, by way of the pulmonary veins to the

left auricle or even the left ventricle, was tentatively discussed, but no occasion

to use it arose.

Right ventricle.—When the object was in the right ventricle (fig. 164),

the best approach was through the fifth or the fourth intercostal space (fig.

165), which exposed the left portion of the right ventricle and the left border

of the left ventricle. The pectoralis major was split laterally and divided

medially. The intercostal muscles were divided, and the internal mammary

vessels were ligated. The cartilage superior to the incision was divided near

the sternum, after which the rib-spreader was inserted. If additional exposure
RETAINED 1XTRACARDIAC FOREIGN BODIES 371

1

1

FIGUKK 104.—Roentgeuograms showing foreign body in chamber of right

ventricle. Before these films were made, the right hemithorax had been

cleared of an infected hemothorax. A. Posteroanterior view. B. Lateral

view.

FIGURE 105.—Technique of removal of foreign body shown in ligure Kit. A. Skin

incision over the anterior left fifth interspace with optional extension. B. Bony cage exposed: fifth and sixth cartilages divided (a), fifth intercostal space incised (b). 0. Exposure of right ventricle by incising fused pericardium (a), and exposing foreign body (b).

D. Placement of hemostatic sutures in right ventricular wall and removal of foreign body.

E. Enlargement demonstrates crossing of hemostatic sutures.
372 THORACIC SURGERY

FIGURE ICG.—Technique of combined intercostal-transsternal approach to

right aspect of right ventricle and phrenic surface of heart and pericardium.

A. Skin incision. B. Transverse section of sternum with Gigli's saw (a), incised left fifth intercostal muscle (b). C. Exposure of foreign body with aid

of Tudor Edwards' double retractor: foreign body (a), localized abscess of

pericardium (h). D. Digital stabilization of dislocated heart.

was necessary, it could be. obtained by the optional T-incision and division of

the sixth and seventh costal cartilages.

After the pericardium and pleura had been opened widely, this approach

permitted palpation of a foreign body in the right ventricle. As a rule, the

cardiac chamber was not opened, nor was any attempt made to remove the

missile, until it had been located by palpation. When it had been located, two

rows of sutures were placed immediately over the object, on either side of the

projected incision. These sutures, which served as hemostatic guy or control

sutures, were used by the assistant to prevent blood loss from the opened heart

between intracardiac maneuvers. The second row of sutures also served as a
RETAINED INTBACARDIAC FOREIGN BODIES 373

1 A

i

B

FIGUKE 107.—Roentgenograms showing missile in right auricle. A.

Lateral view. B. Posteroanterior view.

sort of second line of defense, in the event that any of the sutures in the first

row pulled out.

After the missile had been stabilized as well as possible with the fingers,

a small epicardial incision was made with the scalpel, and a pointed forceps

was thrust through the myocardial wall and spread open; an opening sufficiently large to permit the insertion of a Kocher clamp was thus created. The

foreign body was then grasped and extracted with this instrument. During

these manipulations, the assistant crossed the control sutures and thus produced

hemostasis.

Once the fragment had been removed, the inner row of control sutures was

tied across the incision. The second line of sutures was then tied over a small

free pericardial graft, over which a second, larger, free pericarclial graft was

sutured into place. Postoperative cardiac tamponacle was avoided by leaving

the lateral angle of the pericarclial incision open into the pleural space.

Chromic catgut sutures No. 00 were used, on atraumatic noncutting needles.

In retrospect, it might have been wiser to use silk for the ventricular closure.

Diaphragmatic surface of the heart.—When the foreign body lay farther

to the right or was on the diaphragmatic surface of the heart, the intercostal incision described was combined with a transverse sternal section (fig. 166).

Tudor Edwards' double retractor could be usefully adapted for this procedure.

The sternum was readily reconstituted with wire.

When the auricle or the right side of the ventricle had to be approached,

the reverse of this incision could be used by following precisely the same technique on the right side of the chest.

Right auricle.—When the missile was in the right auricle (fig. 167), a

right anterior approach was usually best (fig. 168). The third, the fourth, or

even the fifth interspace was used, depending upon the location of the foreign

body. The third interspace, for instance, was incised, with section of the
374 THORACIC SURGERY

FIGURE 168.—Technique of removal of foreign body shown in figure 167.

A. Incision for anterior approach to right atrium. B. Closure of incision with pericardioatrial and atrial sutures. C. Exposure of right

atrium (a), reflected pericardium (b).

third and fourth costal cartilages near the sternum, to provide exposure of the

upper portion of the right auricle. After the pericardium had been opened,

control sutures were placed in the auricular wall by the technique described

for their application in the ventricular wall. The auricular myocardium was

often too thin to hold sutures. If the structures were adherent, as in the case

illustrated, pericardia! tissue could be included with auricular tissue in the

second suture line.

Left auricle.—If the foreign body was in the left auricle, the approach

shown in figure 161 was used. In this case (case 4, p. 367), the laceration of

the auricle and pericardium was plugged by an infected clot, and the fusion

of the two structures made the intracardiac portion of the operation perfectly

simple.

Pericardium.—In this series, intrapericardial missiles were removed by a

posterior approach that exposed the left auricle on either the right or the left

side. This technique was not used in any intracardiac operation at the 160th

General Hospital. When the patient was placed in ventral decubitus (fig.

169), the posterior incision provided adequate exposure.
RETAINED INTRACARDIAC FOREIGN BODIES 375

FIGUEE 169.—Technique of posterior approach to pericardium and heart on

right. A. Incision with patient in ventral decubitus. B. Exposure.

In one case in which this approach was used (fig. 170), an extremely thinwalled auricle was encountered in a completely free pericardial space. Bleeding from the auricular wall was so free when an attempt was made to place

the hemostatic sutures that this technique had to be abandoned. An approach

through the auricular appendage proved equally unsafe. An extracardiac

approach was therefore devised, by exposure of the superior vena cava (fig.

171). Control tapes were placed around this vessel, an incision was made into

it, and a forceps was slipped clown the lumen and into the ventricle. This

maneuver permitted removal of the missile without difficulties.

Behavior of the Heart During Cardiac Surgery

The electrocardiographic tracings made at operation in some cases in this

series were useful in demonstrating manipulations that were not well tolerated

by the heart. These manipulations included cardiac dislocations, hemostatic

cardiac grips, and extensive maneuvers within the cardiac chambers.
QT, 76 THORACIC SURGERY

FIGL'HE 170.—Roentgenograms showing foreign body in interauricular

septum and right auricle. The widened mediastinum was found at

operation to he caused by a hcmatoma. A. Posteroanterior view. B. Lateral view.

Cardiac dislocation.—In some instances, dislocation of the heart at operation caused runs of ventricular extrasystoles, diminished cardiac output, and

transitory bundle branch block. Whether the dislocation was accomplished

manually or by means of an apical suture, it was not well tolerated, as the following- case history shows:

Case 5.—At operation, this foreign body (fig. 172) was found extracardially, In a

pericardial abscess well back on the diaphragmatic surface of the heart. The abscess

contained about. IS cc. of pus. To gain access to this area, the heart had to be lifted

out of the pericardial sac (plate II). This maneuver caused a fall in blood pressure,

accompanied by circulatory failure, which made it necessary to replace the heart frequently, after relatively short periods of dislocation, to permit a return to normal conditions before the operation could be proceeded with. Many irregularities in rhythm

occurred, which were apparently extrasystoles, and marked cardiac dilatation, particularly

of the right ventricle, also developed, so that the heart became too large for the pericardial

sac (plate III). After it was replaced, the pericardium was left partly open.

Electrocardiograph tracings taken during operation (lig. 173) showed variations in

rhythm consisting of ventricular extrasystoles (at 300), wandering pacemaker, varying

P-R interval, and A-V nodal rhythm. It was at the time the nodal rhythm occurred,

during a period of dislocation of the heart, that a particularly prolonged and alarming

episode of circulatory failure developed. After recovery, normal sinoauricular tachycardia returned (fig. 173).

An additional change in the electrocardiograms was also related to dislocation of the

heart. At 2:57 o'clock (fig. 173), the S-wave became broad and notched and the QRS

interval lengthened to 0.13 second, in contrast to the normal complexes at 2: 07 and 2: 37

before cardiac manipulations. While it is unfortunate that this abnormality was recorded

only in lead II, it may be regarded as indicating at least interventrieular block or incomplete bundle branch block, probably on the right side. The abnormal QRS complexes persisted throughout the operation, but 4 days later, observations were normal. At operation,
RETAINED INTRACARDIAC FOREIGN BODIES K77

FIGURE 171.—Technique of removal of foreign body in right auricle by incision in

superior vena cava shown in figure 170. A. Anterior skin incision. B. Third intercostal

space incision (a), section of third and fourth costal cartilages close to sternum (b), and

exposure of intercostal vessels to permit their division (c). C. Excellent exposure of

superior vena cava by this approach: pericardium incised (a). D. Incision into vessel

and removal of right auricular foreign body (a), tapes placed around superior vena cava

to control hemorrhage (b). This technique was used in this case because the pericardial

space was free and the auricular wall too thin to hold guy sutures.

the delay in conduction could be correlated, by direct visual inspection, with dilatation of

the right ventricle. This extremely unusual observation in a human subject was considered

to be caused, at least in part, by the increased time necessary for conduction of the impulse

through the greatly dilated right ventricle.

The intolerance of the heart to dislocation was demonstrated in this case in two ways,

(1) by ventricular dilatation with incomplete bundle branch block, and (2) by varying

types of arrhythmia and circulatory collapse. Obviously, dislocation of the heart may

produce torsion of the great vessels and obstruction to outflow of blood, with (1) a fall in

blood pressure resulting from the diminished cardiac output and (2) ventricular dilatation

resulting from the increased resistance to blood flow.

746-741—05 27
m THORACIC SURGERY

FIGUEE 172 (case 5).—Koentgenograms showing foreign body in

pericarclial abscess well back on diaphragmatic surface of heart.

A. Posteroanterior view. B. Lateral view.

This sort of experience led surgeons on the thoracic surgery service at the

160th General Hospital to avoid the apical suture as a means of exposing

inaccessible areas of the heart. The situation encountered in combat-incurred

wounds is quite different from the circumstances of civilian surgery,, in which

a planned approach permits precise and comfortable exposure of any part of

the heart.

Obstruction of the cardiac blood flow.—Experience showed that the classical hemostatic cardiac grips intended to provide a bloodless surgical field

were also poorly tolerated. These maneuvers disturbed cardiovascular dynamics and were therefore used only as a last resort.

The intolerance of the heart to obstruction of the blood flow was in striking:

contrast to its stability during other cardiac procedures and certain intracardiac

procedures. The surface of the heart could be manipulated, sutures taken into

the muscle, and incisions made into the cardiac chambers with little evidence

of disturbance,

Intracardiac manipulations.—More extensive manipulations inside the

cardiac chambers by the exploring finger or by a forceps inserted to remove

an intracardiac thrombus or a foreign body were less well tolerated. Sometimes

no abnormalities were noted, but marked cardiac irregularity, in the form of

multiple ventricular extrasystoles, were common. The case, already described

(case 1, p. 357), in which three carcliotomies were necessary, demonstrates this

point particularly well. As the foreign body was grasped and extracted from

the right ventricle, electrocardiographic tracing (fig. 153) showed showers of

ventricular extrasystoles from different foci in both ventricles; runs of ventricular tachycardia lasted as long as 16 seconds. Direct observation of the

irregular heart action and examination of the electrocardiogram raised the
RETAINED INTRACARDIAC FOREIGN EODIES 379

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EiGUiiE 173 (case 5).—Electrocardiograms taken during operation for removal of pericardial foreign body. See figure 147 for key. The number in the lower corner of each

segment indicates the clock reading at which the tracing was made. Note the nodal

rhythm, which occurred during a prolonged and alarming episode of circulatory failure

while the heart was dislocated (plate II).

fear of impending ventricular fibrillation, but at the end of the operation, when

the irritating- forceps and the missile had been removed from the ventricular

chamber, the tachycardia ended promptly and the P-R interval returned to

normal in three beats. All of these irregularities were relatively benign.

Other causes of cardiac irritability.—Minor evidences of cardiac irritability were observed at operation, such as extrasystoles and wanderingpacemaker, varying P-R interval, and even A-Ar

nodal rhythm, but these

phenomena were not usually accompanied by any significant clinical manifestations. These minor abnormalities were often evoked by procedures not related

to the heart, such as enclotracheal intubation, spreading of the ribs, and manipulations of the hilar and mediastinal structures. It was thought that keeping

the surface of the heart moist with warm physiologic salt solution or procaine

liydrochloride solution was important in reducing the tendency toward

irritability.
380 THORACIC SURGERY

Postoperative Management

The postoperative care of a patient who had undergone cardiac surgery

was essentially the same as the care of a patient who had undergone any serious

chest surgery. Patients who had required ventricular cardiotomy were kept

in bed for 3 weeks, even though the electrocardiographic tracings had usually

returned to normal within a few hours after operation.

FOREIGN BODIES IN AND ABOUT THE GREAT VESSELS

Indications for Surgery

The danger of erosion and suppuration as the result of the retention of

large missiles in close proximity to thoracic blood vessels was quite real. At

least three deaths are known to have occurred at other installations in the

European theater as the result of erosion from this cause. In the 78 successful

operations for removal of such missiles at the 160th General Hospital thoracic

surgery center, there was no instance of erosion. On the other hand, abscess

formation occurred in about 15 percent of the cases; clothing, bone fragments,

and other foreign material entered the body with the shell fragment in 80

percent of the cases; and pathogenic bacteria were found on 67 percent of the

material that was cultured on removal.

On the basis of these facts, it became established policy at this chest center

to remove all foreign bodies in the mediastinum adjacent to the great vessels

if they measured 1 cm. or more in two dimensions. The decision to remove

smaller objects or permit them to remain in situ was made on the indications

in each case.

Removal of the foreign bodies seldom presented any technical difficulties.

At the 160th General Hospital, operation was unsuccessful in only one case,

the third undertaken. The fact that there were no deaths in the 78 cases in

which the objects were removed seems to support the contention that their

removal was safer than their continued retention.

The only cases in this series which warrant special discussion are the three

instances of migratory intravascular objects, which will be described in some

detail.

MIGRATORY INTRAVASCULAR FOREIGN BODIES

In 1942, Straus (£) collected from the world medical literature 32 instances

of mi oratory intravascular foreign bodies and added to the collection a case

which he had himself observed. A second review of the same literature in

1945 brought to light nine additional cases that Straus did not include in his

material. Undoubtedly, other cases were overlooked in both reviews, while

still other cases have not been reported at all.
RETAINED INTRACARDIAC FOREIGN BODIES 381

FiGuiiE 174 (case G).—Roentgenograms showing .30-caliber bullet

in hilar region of left lung. The bullet was later found to be within

one of the radicles of the left pulmonary artery. A. Fosteroanterior

view. B. Lateral view.

Almost without exception, the migratory foreign bodies in these 42 cases

were bullets or shell fragments, the majority of which originated in combatincurred injuries.

The infrequency of such cases, the bizarre courses of many of the embolic

missiles, and the dramatic developments often associated with their migration

warrant a presentation of the three such cases encountered at the 160th General

Hospital thoracic surgery center, together with a brief comment on certain of

their features.

Case 6.—A 30-year-old soldier was wounded in the left infraclavicular region by a

.30-caliber machinegun bullet while in combat in Belgium on 26 December 1944. The

wound was debrided and sutured the same day at a forward installation. Roentgenograins

of the chest taken at this time revealed that the bullet was located posterior to the hilus

of the left lung.

When the patient was evacuated to the 128th General Hospital, Bishopstrow, England,

it was decided that the size of the missile and its proximity to the hilus of the lung constituted valid indications for its surgical removal. He was therefore transferred to the

chest center at the 100th General Hospital on 8 January 1945.

Initial roentgenograms (fig. 174) confirmed the previous findings. Routine fluoroscopic

studies for precise localization of the missile suggested nothing more remarkable than the

presence of a pulsating bullet intimately associated with the left liilar structures. There

seemed no doubt that it could readily be removed through a conventional posterolateral

approach.

Thoracotomy was accordingly performed through this approach on 19 January 1945.

After resection of 12 cm. of the seventh rib, the bullet could be palpated in the central

portion of the left upper lobe. Its location was confirmed by palpation by the first assistant.

When, however, the surgeon palpated the area for a second time, he was chagrined to find

that the missile had vanished. A thorough search of the entire left lung, including the

hilus, and of the posterior mediastinum and the pericardium failed to locate the bullet,

and it was suspected that it had fallen into the tracheobronchial tree. When this possibility
m THORACIC SURGERY

FIGURE 175 (case G).—Rocntgenograms taken immediately after

left thoraeotomy. The bullet now seems to be in the hilus of the left

lung. The double image of the bullet in the lateral view is explained

by its pulsation with the pulsation of the pulmonary artery. A.

Posteroanterior view. B. Lateral view.

was excluded by immediate bronchoscopy, no further manipulations were attempted, and

the chest was closed.

Recovery was completely uneventful and the patient was allowed out of bed daily

after the first 24 hours. Rocntgenograms taken immediately after operation (fig. 175)

showed that the bullet that had previously been seen in the hilar region of the left lung

(fig. 171) was now lying horizontally, just to the right of the body of the sixth dorsal

vertebra, pointing outward. The pulsations indicated that it was in contact with the area

of the pulmonary artery. It was concluded that the missile was definitely in the right

pulmonary artery.

A second thoraeotomy was performed on 20 February 1015, through the third intercostal space anteriorly (fig. 170). The third and fourth costal cartilages were divided

close to the sternum. There was no evidence of altered blood flow in the lungs. The bullet

was palpated in the hilus of the right lung at and in the mediastinum, posterior to the

superior vena cava.

The right pulmonary artery was isolated, and a tape was placed about it proximal to

the foreign body. The missile, point outward, was digitally manipulated away from the

hilus into the pulmonary artery of the upper lobe, the milking process being continued

until its point presented beneath the visceral pleura in the interlobar fissure. Here, the

pleura was nicked, and the presenting tip was thrust upward through the opening and

grasped with a Kocher clamp. The missile was then delivered in toto by slowly stretching

the terminal branches of the pulmonary arterial tree. Hemorrhage was controlled by circumferential mattress sutures of catgut in the lung at the point of removal of the missile.

The wound was closed without drainage.

The patient was up and about after the first postoperative day. His recovery was

completely uneventful, and he was returned to the Zone of Interior for rehabilitation on

30 March 1945.

Case 7.—This soldier was wounded on 14 October 1944, in action in France, by a shell

fragment that entered through the upper part of the right posterior axillary line. The

wound of entrance was debrided and closed the same day at the 60th Field Hospital.

Aspiration of a right hemothorax yielded 500 cc. of blood. Rocntgenograms of the chest

(fig. 177) revealed a foreign body in the right upper mediastinum, 3 cm. posterior to the

right sternoclavicular joint.
BETAINED INTRACÄRDIAC FOREIGN BODIES 383

FIGURE 176 (case 6).—Technique of removal from right pulmonary artery of

foreign body shown in figures 174 and 175. A. Skin incision. B. Exposure of right

pulmonary artery. Umbilical tape placed proximally around the main pulmonary

prevents escape of the bullet to opposite pulmonary artery or right ventricle. C. Milking of bullet to periphery of lung, into one of the smaller radicles of the pulmonary

artery. D. Opposing hemostatic sutures at site of removal of bullet.

After the patient reached the 154th General Hospital, Wroughton, England, a pericardial friction rub was heard. On 21 October, a bruit was discovered over the right

supraclavicular fossa, and it was noted that both the brachial and the radial pulses were

absent in the right arm. Thoracentesis, repeated on 7 November, yielded what was at first

thought to be fresh blood. It was later found to be old, changed blood of the so-called

grapejuice type.

In view of the roentgenologic and clinical findings, the patient was transferred to the

thoracic surgery center at the 160th General Hospital on 10 November 1944. There, it was

noted that the right hand was cooler than the left and was waxy-yellow. The blood pressure

in the right arm was 102/80 and in the left 122/6S mm. Hg. Fluoroscopic and roentgenologic

examination led to the conclusion that the foreign body lay in close proximity to the

innominate artery.

Surgical removal of the fragment was considered advisable because of (1) its size;

(2) its proximity to the large vessels in this region; (3) the evident vascular damage it

had caused, as attested by the bruit and the differences between the blood pressures in the

right and left arms ; and (4) the possibility that fresh bleeding had occurred into the right

pleural cavity. The latter consideration suggested that surgical intervention be instituted

promptly.
384 THORACIC SURGERY

^SWBS

FIGURE 177 (case 7).—Roentgeuograms showing retained shell

fragment posterior to right sternoelavicnlar joint in region of

innominate artery. A. Posteroanterior view. B. Lateral view.

Operation was performed on 12 November 1944 under endotracheal gas-oxygeii-cther

anesthesia. A U-shaped incision was made over the right upper anterior chest (flg. 17S).

The sternum was exposed. The internal mammary vessels were divided and ligated in the

second intercostal space. The right pleural cavity was opened widely. The deep surface

of the sternum was cleared of underlying structures, and the bone was split with a powersaw longitudinally in the midline, from the suprasternal notch down to the level of. and

out through, the second intercostal space. When the segment of sternum, with the clavicle

and the first two ribs attached, was reflected upward and outward, excellent exposure of

the superior mediastinum and the base of the neck was secured.

The superior vena cava and the innominate veins were retracted with tapes. The

innominate artery was isolated at its point of origin from the aorta, and a tape was placed

about it for hemostatic purposes. It was then dissected free up to its bifurcation into the

carotid and subclavian arteries. Tapes were placed about each of these vessels. It was

not possible to palpate the foreign body within the upper portion of the innominate artery,

the wall of which was intact and free from scars. The artery was incised longitudinally,

and the foreign body was removed. The portion of intima which had been in contact with

it showed evidences of patchy destruction. After thrombi had been removed from the

lumen of the vessel, bleeding was free, both proximally and distally.

The incision in the artery was closed in two layers, with interrupted No. 000 silk

sutures. The first layer included the entire wall. The second sutures were introduced

through the adventitia and media; a bite was taken on either side of the incision as each

suture was placed, but the sutures did not pass through the lips. Fibrin foam was laid

over the incision and held in place with the second layer of sutures.

The sternum was approximated with three interrupted wire sutures placed in drilled

holes that had been so staggered that the medial holes were lower than the lateral holes.

When the sutures were pulled tight, the sternal fragment was therefore drawn downward

and inward, and a precise and stable reconstruction of the pectoral girdle was thus obtained.

Great care was taken to accomplish this result because stability had been found to be of

great importance after section of the sternum; the movement of loosely approximated

sternal fragments was painful and could produce shock.

The pectoral muscles were approximated with interrupted sutures of No. 00 chromic

catgut. The superficial fascia was similarly closed, and the skin was sutured with No. 0

black silk. No drains were used.
RETAINED INTRACARDIAC FOREIGN BODIES 385

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386 THORACIC SURGERY

1

FIGURE 179 (case S).—Roentgenograms 3 days after wounding showing clear lung fields. A. Posteroanterior view. B.

Lateral view.

Immediately after operation, the pulse in the right arm was barely perceptible. The

first postoperative day, the blood pressure was 122/80 mm. Hg in the left arm but remained

unobtainable in the right arm. The second postoperative day, the right stellate ganglion

was infiltrated with procaine hydrochloride. The right arm immediately became warm,

and a systolic blood pressure of 68 mm. Hg could be obtained. On 17 November, the blood

pressure was 132/60 mm. Hg in the left arm and 98/70 in the right arm. On November 25,

the respective pressures were 124/S6 and 108/04 mm. Hg. On 15 January 1945, the blood

pressures were the same in both arms.

The patient was heparinized for 3 days after operation. The clotting time usually

averaged from 9 to 15 minutes but on a single occasion was 45 minutes. The hemothorax

still present after operation was evacuated by aspiration and required no further treatment.

Hoarseness, the result of manipulation of the right recurrent laryngeal nerve, was present

for 4 weeks after operation; then it disappeared completely. Union of the sternum was

firm. When the patient was returned to the Zone of Interior on 1 March 1945 for rehabilitation, he was in excellent condition and had no evidence of any circulatory disturbance.

Case 8.—A 22-year-old soldier was struck by a machinegun bullet on 15 July 1944,

while in action in France. The point of entrance was in the right axilla, at the level of

the fifth rib. When he was evacuated to the 159th General Hospital, Teovil, England, on

17 July, routine roentgenograms showed no abnormalities (fig. 179), and the lateral film

established the absence of metallic objects in the retrocardiac zone.

The patient was symptom-free when he was sent to the rehabilitation barracks, and

for about 3 weeks he participated in a vigorous athletic program, with no difficulties. Then,

early in the morning of 13 August, he was wakened by agonizing pain in the lower left chest,

accompanied by dyspnea, orthopnea, cough, and hemoptysis. Rales and diminished breath

sounds were heard over the left axilla. On 15 August, roentgenograms of the chest (tig. 180)

revealed a .30-caliber bullet in the hilus of the left lung. On 19 August, bronchoscopy revealed edema of the left main bronchus with an injected bleeding point on the posterolateral

wall. The continued hemoptysis and the bronchoscopic findings suggested that the bullet

had eroded from the pulmonary artery into the left main or descending bronchus. The

patient was therefore transferred to the chest unit at the 160th General Hospital on

22 August.
RETAINED INTRACARDIAC FOREIGN BODIES 387

FIGURE ISO (case S).—Roentgenograms 1 month later, 2 clays after

sudden onset of pain in left lower hemithorax. A .30-caliber bullet is

now visualized in the hilar region of the left lung. At operation, it

was found in the left inferior branch of the pulmonary artery. A. Posteroanterior view. B. Lateral view.

Since the possibility of erosion of the bullet from the pulmonary artery into the

bronchus seemed an urgent indication for surgical intervention, operation was undertaken

on 28 August 1944. Thoracotomy was performed through a posterolateral approach, with

resection of a lG-cm. segment of the left seventh rib. Exploration revealed discoloration

of the lingular portion of the left upper lobe and, to a lesser degree, of the anterior basic

segment of the left lower lobe. The missile could be palpated through the interlobar fissure

in the lower lobe and hilus; it seemed intimately associated with the artery. A fluctuant

area, about 1 cm. in diameter, was noted over the base of the bullet.

The hilus was exposed, so that the pulmonary artery could be compressed by grasping

the hilar structures from above downward between the index and middle fingers of the left

hand. The digital compression not only was hcmostatic but also served to stabilize the

missile. With the situation thus under control, the fluctuant area was incised. The butt

of the bullet was found lying in an abscess cavity anterior to, and including the anterior

surface of, the lower branch of the left pulmonary artery. The body and point of the

missile, however, lay within the arterial lumen, and as soon as the bullet had been extracted,

the full arterial stream issued from the defect. The hemorrhage was at all times completely under control, as could be proved by voluntary release of the artery and immediate

cessation of the bleeding when compression was resumed.

The abscess cavity was thoroughly dcbrided, and mattress sutures were placed through

its wall and through the subjacent artery. Fibrin foam impregnated with penicillin was

placed over the mattress sutures used to close the arterial incision before they were tied.

An excellent closure of the vessel was thus effected. The gangrenous lingular portion of

the left upper lobe was then resected, and the line of resection was closed with mattress

sutures of No. 00 chromic catgut. The anterior basic segment of the left lower lobe,

although somewhat discolored, was considered viable and was not disturbed. The lung

reexpanded readily. Before the chest, was closed, 100,000 units of penicillin in 50 cc. of

2.4-percent sodium citrate solution were instilled into the pleural cavity.

The left hemothorax present after operation was aspirated and did not recur. The

patient was up and about, the ward within 48 hours, and he was in excellent condition when

he was transferred to a rehabilitation center on 1 December 1944.
388 THORACIC SURGERY

FIGURE 1S1 (case 6).—Migration of bullet from left

pulmonary artery into main pulmonary artery and

thence into right pulmonary artery: Original position

of bullet in left pulmonary artery (a), and final position of bullet after migration into right pulmonary

artery (b).

Migration and Clinical Consequences

Pattern of migration.—In the 42 cases of migratory intravascular foreign

bodies reported in the literature up to 1945 (p. 380), migration was about

equally divided between arterial and venous channels, depending upon which

the object happened to enter at the time of wounding.

Apparently, there is considerable latitude in the possible patterns of migration when a foreign object enters the circulation.

In 11 of the 42 recorded cases, the missile entered one of the larger arteries

and passed peripherally as an embolus. In five instances, it entered the left

ventricle and was swept out into the aorta, to lodge within this vessel or within

one of its branches. In one case, it passed through the left ventricle, to become

embolic to the right femoral artery. Two missiles entered the ascending aorta

and passed downward against the arterial stream; one came to rest in the sinus

of Valsalva and the other in the left ventricle. One missile entered the pulmonary artery, migrated downward into the right ventricle, and killed the

patient 7 days later, when it became embolic to the right pulmonary artery (3).
RETAINED INTRACARDIAC FOREIGN BODIES 389

FIGURE 1S2 (case 7).—Frobable course of migratory

missile from left auricle through left ventricle and

aorta into innominate artery: Foreign body enters

right pulmonary vein (a), left atrium (b), left ventricle (c), and innominate artery (d).

In two instances, the missile entered one of the pulmonary veins and passed

into the left ventricle.

The patterns of arterial migration described in two of the three cases of

migratory foreign bodies observed at the chest center at the 160th General

Hospital do not seem to have been reported previously. In one case (case 6,

fig. 181) migration was from the left pulmonary artery into the main pulmonary artery and thence to the right pulmonary artery. The bullet was

evidently in the lumen of the left pulmonary artery at the first operation and

was dislodged by the exploratory palpation.

In one case (case 7, fig. 182), since the wall of the innominate artery and

the adjacent portion of the aorta were found at operation to be intact everywhere, the course of the missile, it seems, must necessarily have been through

the right side of the chest and into the pulmonary vein or the left side of the

heart. The fragment was then carried as an embolus by the bloodstream into

the aorta and thence to the innominate artery, where it lodged. The pericardial

friction rub noted before operation suggested that the pericardium had been

traversed and that the foreign body had entered the left side of the heart,
THORACIC SURGERY

FIGURE 183 (case 8).—Course of migratory bullet from

entry into inferior vena cava through right auricle and ventricle and out into left pulmonary artery: Apparent mechanism of entry into venous circuit (a) and course as

embolus (b).

whence it passed into the arterial circulation. The case thus represents a

penetrating wound of the heart or pulmonary artery with arterial embolism

of the foreign body to the innominate artery.

In one case (case 8, fig. 183), the exact portal of entry of the bullet into

the circulation can only be surmised. Since, however, the wound of entry

was in the lower axilla and the chest was clear in the films taken immediately

after wounding, it seems reasonable to assume that the bullet was originally

in the liver. It probably began its migration in the inferior vena cava, whence

it was carried to the right auricle, then to the left ventricle, and then into the

pulmonary artery. It entered the left branch of the pulmonary artery and

lodged in the branch to the lower lobe and lingula in such a way as to occlude

the arterial supply to the lingula as it arose from the artery of the lower

lobe in this region. Occlusion of the pulmonary circuit was associated with

parenchymal changes.

No instances of intravenous migration of foreign bodies were observed

at the 160th General Hospital thoracic surgery center during the war. In 9

of the 42 cases recorded in the literature, the object entered one of the larger

veins, migrated to the right auricle, and came to rest in the right ventricle.
RETAINED INTRACARDIAC FOREIGN BODIES 391

In three instances, it followed the same course as far as the right auricle, then

traveled down the vena cava before coming to rest in one of its tributaries.

In two instances, it entered one of the pulmonary veins and passed into the

left ventricle. In other cases, the bullet entered the inferior vena cava and

migrated to the junction of the common iliac veins; entered the right ventricle

and passed into the pulmonary artery; entered the long clural sinus and then

mio-rated into the sigmoicl sinus; and entered the venous circulation through

a wound in the thigh and was found at autopsy in the left ventricle, In the

latter case, there was a widely patent foramen ovale. In the case reported by

Straus (2), the bullet entered the right common iliac vein and traveled to the

left pulmonary artery. Death occurred 4 days later but was not caused by

the embolic missile.

In one case, a patient who harbored a missile that had migrated into the

right ventricle complained of pain over the heart. With this single exception,

foreign bodies migrating within the veins caused no symptoms in the recorded

cases.

When a missile is in the arterial circulation, clinical manifestations vary

according to the portion of the arterial tree involved. The embolic character

of the object is supported by the changing symptomatology as well as by

roentgenologic studies and by the findings at operation.

Varying degrees of arterial insufficiency have been reported as the result

of missiles embolic in the arteries. In the case reported by Paltauf (3) and

already mentioned (p. 388), death occurred when the migratory object became

embolic in the right pulmonary artery. In a case reported by O'Neill (4-),

gangrene of the left lower extremity developed after a shell fragment became

embolic from the left ventricle to the left common iliac artery; the patient

survived 5 clays. In one of the cases observed at the 160th General Hospital,

the patient experienced severe pain when, presumably, the missile moved from

the venous to the arterial circulation, and lodgment of the bullet in the branch

of the pulmonary artery supplying the left lower lobe resulted in gangrene of

the lingular portion of the lung on that side.

Infection.—Infection is a theoretical possibility in all cases of migratory

foreign bodies. Lyle (-5) seems to have been the first to call attention to this

fact. In his case, the foreign body, which was found at autopsy in the right

ventricle, had fragments of clothing adherent to it. A fibrinopurulent pericarditis was present, and gas bubbles were noted in the myocardium, but the

wound of entrance in the thigh showed no evidence of infection at any time.

Diagnosis.—The possibility of intravascular migration of missiles, as the

cases observed at the 160th General Hospital indicate, should be borne in mind

in all instances of penetrating wounds, and the surgeon should make every

effort to locate a missile whose position is not immediately obvious. If a patient

who harbors a foreign body develops sudden and unexplained symptoms, as in

one of these cases (case 8, p. 386), fluoroscopic and roentgenologic examinations
9M THORACIC SURGERY

should be resorted to immediately, to determine whether migration of the

missile is responsible for the clinical manifestations.

Management

A review of the 33 cases collected by Straus (2), including his own, does

not encourage an optimistic attitude concerning migratory foreign bodies. He

listed only six survivals, and the pathologist, not the surgeon, was usually the

one to remove the object and establish the course of the migration. In World

War II, in view of the progress which had been made in thoracic and vascular

surgery and in anesthesia between the wars, the thoracic blood vessels and the

heart had come within the province of the surgeon, and there were few intravascular foreign bodies which could not be attacked surgically, and with safety.

As already stated, there were no deaths in the 78 operations for the removal

of intravascular foreign bodies performed at the chest center at the 160th

General Hospital.

The three cases of migratory intravascular foreign bodies observed there

and just described in detail, together with the cases recorded in the literature,

make clear the indications for surgery, which may be stated as follows:

1. Vascular occlusion,—This risk is well demonstrated in the gangrene

which ensued in the lingular portion of the left upper lobe in case 8. The

pathologic process is interesting; theoretically, gangrene should not have occurred with a normal bronchial circulation.

2. Erosion and hemorrJiage.—These did not occur in this series.

3. Infection.—This did not occur in any of the three cases described, but,

as Lyle's (5) report indicates, it is always a possibility.

4. Emholhm.—This is the overriding reason for surgical removal of the

object, for a fatality is always possible, as a majority of the reported cases

indicate, whenever a foreign body enters the blood vessels.

Four technical points proved useful in the management of the cases of

migratory intravascular foreign bodies observed at the 160th General Hospital,

as well as in a number of other operations on the mediastinum:

1. Splitting of the sternum (case 7) provided good surgical exposure.

The bone was carefully approximated with wire at the end of the operation,

and the patient did not suffer postoperative pain or shock.

2. Manipulation of the missile from the main right pulmonary artery to

the periphery (case 6) permitted surgical manipulations in the relatively safe

peripheral zone rather than in the more hazardous hilar region of the pulmonary artery. This technique, which apparently had not previously been

described, was certainly less formidable than opening the right horn of the

pulmonary artery, removing the missile, and then attempting local reconstitution of the main branch.

3. The digital method of hemostasis, which amounted to using the fingers

as a tourniquet (case 8), proved both simple and functional.
RETAINED INTRACARDIAC FOREIGN BODIES 393

4. As soon as the missile was encountered, it was fixed in position, so that

migration could not occur during the operative procedure. The patient was

also so positioned as to make circumstances unfavorable for migration. The

importance of this precaution is evident from the experience in one of these

cases (case 6).

One other technical point might be made concerning the case (case 7) in

which incision of the innominate artery was necessary. This sort of intervention is always undertaken with some misgivings, since circulatory disturbances

in the homolateral arm, as well as contralateral hemiplegia, are possible complications. These accidents, of course, were less to be feared in the age group

with which military surgeons had to deal. Nonetheless, their possible occurrence points to the wisdom of restoration of vascular continuity of the innominate artery, rather than ligation, when it must be attacked surgically as in

this case.

EXPERIENCES AT THE 155TH GENERAL HOSPITAL THORACIC

SURGERY CENTER

Analysis of Data

To complete the picture, the World War II experience of another chest

center, at the 155th General Hospital, near Malvern Wells, England, European

theater, is briefly summarized. It included the removal of 172 objects from the

lungs; 27 from the mediastinum; 37 from the pleura; and 19 from various

internal structures, in addition to 63 removed from the deep structures of the

thoracic wall. The 172 cases classified as pulmonary included foreign bodies

situated in the paramediastinal surface of the lung, either abutting on the

mediastinum or partly embedded in the mediastinal pleura.

In four other operations, the foreign body was not removed. In two

instances, it lay within the substance of the lung at the hilus but escaped

detection because of hematoma formation and pulmonary infiltration. In both

of these cases, the object was later removed without difficulty. In the two

remaining cases, the object was displaced at operation. In one instance, it lay

within the pulmonary artery on one side and slipped into the artery on the

opposite side during manipulations. In the other case, it lay in the right

ventricle and was displaced into the right auricle and inferior vena cava.

About 93 percent of the retained foreign bodies were high explosive shell

fragments. The remaining injuries were caused by small arms fire.

Of the 172 foreign bodies in the lung, 119 were removed by transpleural

pneumonotomy. In 48 cases, the free pleura was not entered; the operative

procedure could be carried out entirely within a zone of adhesions between

the lung and the thoracic parietes. In the remaining five cases, in which a

collection of pus was encountered unexpectedly around the object at operation,

removal was transpleural, and local marsupialization of the lung was per-
IM Tiioiunc minim

formed in order to minimize the danger of pleural infection. This policy,

as already intimated, was successful.

The incision, whenever practical, was placed directly over the foreign body

and was always as small as was consistent with satisfactory surgical exposure.

A. rib resection was never performed when intercostal incision and division of

the rib were adequate. When the object could be removed through adhesions

which existed between the lung and the pleura, postoperative pleural effusion

did not occur, and convalescence was appreciably shortened. The technique

employed in such cases was similar to that used in one-stage drainage of an

abscess of the lung. Particularly small incisions were required when it was

employed.

Of the 27 foreign bodies in the mediastinum, 7 lay in direct relationship

with the esophagus; 7 with the pericardium; 6 with the aorta; 2 each with the

azygos vein and the innominate artery; and 3 with the vena cava. Seventeen

of the objects were removed transpleurally and ten by extrapleural mediastinotomy, the latter procedure being used exclusively when the foreign body lay

in the anterior or posterior mediastinum.

The 37 foreign bodies classified as pleural either lay free in the pleural

cavity or were embedded superficially in the pulmonary diaphragmatic or

parietal pleura and projected into the cavity. In many of these cases, removal

was possible through an intercostal incision, without the necessity for rib

resection or rib division.

The foreign bodies removed from the deep structures of the thoracic

wall involved the peripleural region, the ribs, the intercostal muscles, and the

root of the neck immediately adjacent to the dome of the pleura. Except for

four cases in which the free pleura was inadvertently entered, all of these

objects were approached through small, accurately placed incisions, for which

careful preoperative roentgenologic studies had served as guide.

In the remaining 19 cases, 4 foreign bodies were removed from the diaphragm, in which they were completely embedded; 3 each from the liver and

the pericardium; 2 each from the pulmonary artery and the heart; 1 from the

subphrenic space; and 4 from the vertebral column.

Postoperative management followed standard practices. At first, penicillin was used intrapleurally as well as parenterally. Later, only the parenteral

route was employed, since the intrapleural route was thought to increase the

frequency and size of postoperative effusion.

There were no pleural infections in the 318 operations in this series, 255 of

which were for the removal of mtrathoracic foreign bodies. The single death

was difficult to explain: A large foreign body, situated posteriorly and superficially in the lung, was removed through a zone of visceroparietal adhesions,

without entry into the free pleura. Eight hours after operation, while the

patient was lying in bed watching a moving picture being shown in the ward,

he suddenly lost consciousness and developed jacksonian seizures involving the

right arm and right leg. Death occurred 16 hours later. At autopsy, a cere-
RETAINED INTRACARDIAC FOREIGN BODIES 395

bral hemorrhage was found, the precise etiology of which could not be

determined.

Comment

In general, indications for the removal of retained foreign bodies at the

155th General Hospital were conservative, a combination of size (not less than

1 cm. in diameter) and symptoms, of which pain was most prominent. Objects

less than 1 cm. in diameter were removed only if they were jagged or irregular

or if they were located close to some vital structure and there appeared to be

danger of erosion because of mechanical factors or infection.

As the war progressed and the maximum permissible period of hospitalization was progressively reduced, certain patients who would previously have

been operated on overseas were returned to the Zone of Interior for surgery.

Such cases included those in which the foreign bodies were in, or adjacent to,

the heart and great vessels, as well as those in the upper abdomen and in, or

adjacent to, the liver. Since most patients with intrapulmonary and intrapleural foreign bodies could be returned to duty overseas within a relatively

short time, the proportion of operations in these groups remained fairly stationary throughout the war. Otherwise, operation was not done overseas unless

the existence of suppuration or some other complication made the procedure

urgent.

References

1. Turner, G. Grey: A Bullet in the Heart for Twenty-three Years. Surgery 9 :832-S52,

1941.

2. Straus, R.: Pulmonary Embolism Caused by a Lead Bullet Following a Gunshot

Wound of the Abdomen. Arch. Path. 33:63-6S, January 1942.

3. Paltauf, R.: Geschossembolie der Arteria pulmonalis. Wien. klin. Wchnschr. 40:

002-603, 1933.

4. O'Neill, C. S.: Fragment of Shell in the Arterial Circulation. Brit. M..T. 2:719-720,

1 Dec. 1917.

5. Lyle, H. H. M.: Migration of Shell Fragment From Right Femoral Vein to Right

Ventricle of Heart. Generalized Gas Bacillus Infection. J.A.M.A. 68:539, 17 Feb. 1917.
Part III

OBSERVATIONS ON WOUNDS AND

DISEASES OF THE CHEST

IN THE ZONE OF INTERIOR
CHAPTER IX

Management of the Sequelae of CombatIncurred Wounds, Zone of Interior

Brian B. Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.

STATUS OF RETURNING CASUALTIES

The mission of thoracic surgeons in Zone of Interior hospitals as it related

to combat-incurred wounds was twofold, (1) reconstructive surgery and (2)

rehabilitation of the casualty. From the time the casualty was wounded, the

goal of management was the achievement of a completely healed wound and a

fully functioning and expanded lung. When these objectives had been accomplished, the casualty was restored to the physical state in which he could perform the duties expected of a soldier returned to duty or could carry on as a

civilian discharged from the Army.

Generally speaking, in all theaters, the status of returning casualties depended upon a number of factors, including the character of their wounds and

the evacuation policy existing in the particular theater at the particular time,

as well as upon the treatment they had received. During the last year of the

war, patients received in Zone of Interior hospitals from the Mediterranean and

European Theaters of Operations, U.S. Army, had usually been treated definitively at thoracic centers in Italy or the United Kingdom Base. Most of them

had also had some form of reconditioning. By January 1945, from 70 to 75

percent were surgically well when they reached the Zone of Interior. They

were well nourished and in excellent general condition. This had not been true

of thoracic casualties received in the first months of the war from the North

African Theater of Operations, U.S. Army, or for the first month or two of

the campaign in Western Europe.

With few exceptions, casualties received from the Pacific Ocean areas were

never in as good condition as those received from other theaters. Their state

of nutrition and their general physical status were usually considerably below

the level of similar casualties received from the Mediterranean and European

theaters, and until the end of the war they presented a relatively high incidence

of hemothoracic empyema and other complications. For this state of affairs,

there were three obvious explanations:

1. The environmental differences between the theaters (terrain, heat, disease, insects, fungous infections, and so forth.

399
400 THORACIC SURGERY

2. The longer timelag before initial wound surgery, which was frequently

inevitable in the Pacific for logistic reasons.

3. The almost complete lack of experienced thoracic surgeons in all Pacific

Ocean areas.

Casualties who required further treatment on their arrival in the Zone of

Interior included those with chronic hemothorax or hemothoracic empyema;

retained foreign bodies; bronchopleural fistulas; and various defects of the

chest wall, including chronic draining sinuses. Those who required no further

treatment either were ready for duty after evaluation of their general physical

and thoracic status or were at the stage of recovery at which disposition would

be possible after 2 or 3 months of reconditioning. Some returned casualties

had recovered from their chest injuries but had associated injuries, chiefly peripheral nerve or bone injuries, which prevented their return to duty.

Disposition.—Many casualties who were returned to the Zone of Interior

could have been sent back to duty overseas except for the time limits imposed

on their convalescence by theater holding policies. Had the Avar lasted longer,

there is no doubt that many others who were evacuated to the United States

would have been kept in combat zones and returned to full duty. An attitude

of extreme caution concerning these casualties was adopted early in the war for

several reasons: The initial severity of many wounds; the recollection of the

poor physical and thoracic status of so many thoracic casualties in World War

I; and lack of experience with casualties managed under new policies, which

made medical officers uncertain about their ability to resume full military duty.

This attitude was apparent in the Zone of Interior as well as in oversea

hospitals. In October 1943, Maj. (later Col.) Brian Blades, MC, head of

the thoracic surgery service at Walter Beed General Hospital, Washington,

D.C., wrote to Lt. Col. (later Col.) B. Noland Carter, MC, Chief, Surgery

Branch, Surgical Consultants Division, Office of The Surgeon General, that

the disposition of soldiers who had undergone lobectomy was creating some

difficulty. More than 50 such operations had been performed at Walter Beed

General Hospital during the past year, and about half of the patients had already been returned to duty. It was anticipated that many of the others would

soon be ready for disposition. Yet, in spite of the excellent results secured, disposition boards seemed to have a great deal of hesitancy in returning to duty

men who had had any sort of chest wound or disease, and line officers had a

corresponding hesitancy in accepting them for service. The attitude grew

more liberal as the war progressed, but the original hesitancy concerning these

patients never entirely disappeared.

CLINICAL CONSIDERATIONS

The management of the sequelae and residua of chest injuries observed

in Zone of Interior hospitals was conducted on the same general principles

and practices as in oversea hospitals. For that reason, and to maintain con-
SEQUELAE OF COMBAT-INCURRED WOUNDS 401

tinuity, most complications have been discussed in detail under special headings, including:

Hemothorax (p. 237).

Hemothoracic empyema (p. 272).

Retained foreign bodies (pp. 325 and 353).

Bronchopleural fistulas (p. 169).

Chest wall defects (p. 181).

Draining sinuses of the chest wall (p. 180).

Lung abscess (p. 175).

Hernia of the lung (p. 197).

Diaphragmatic hernia (p. 186).

Traumatic osteomyelitis (p. 179).

Only a few of these conditions need any further discussion from the standpoint of their management in Zone of Interior hospitals.

ORGANIZING HEMOTHORAX

As a rule, more than 8 weeks had elapsed between their wounding and

the reception of thoracic casualties in Zone of Interior hospitals. Most hemothoraces that had been correctly treated originally therefore needed little or

no attention on their arrival. Figures from the chest center at the Walter

Reed General Hospital are typical: Of the first 107 casualties with hemothorax

received, 77 were in satisfactory condition, and in 24 of the remaining 30

patients, the lung reexpanded satisfactorily after continued aspiration. This

is an unusually high percentage of good results from conservative treatment

after such a timelag.

In the six remaining cases, however, an extensive organizing process had

occurred, and four of them furnish interesting lessons concerning the proper

management of hemothorax. All four wounds had been caused by rifle or

machinegun bullets. All wounds were relatively minor as compared with most

of the wounds in the other 103 cases in the series, in all of which recovery

was without complications. None of the four wounds had originally been

of the sucking type. In no instance was the lung damage extensive. No

patient had a history of hemoptysis. In every instance, however, aspiration

of the chest had been delayed, apparently because the primary wound was not

severe and because respirations were not immediately embarrassed. A single

case history will serve as an illustration for them all:

Case 1.—This patient, who had sustained a machinegun wound, had his first aspiration 10 days after injury. The procedure was repeated several times, but the largest

amount of blood obtained at any aspiration was ISO centimeters. About 30 cc. of air was

injected into the chest each time blood was removed.

When this patient was received at Walter Reed General Hospital several weeks after

wounding, he was having daily low-grade temperature elevations. He was extremely

emaciated. The left chest was flattened, and the expiratory excursion on this side was
THORACIC SURGERY

greatly limited. Tlioracentesis yielded only a few cubic centimeters of dark, bloody fluid.

It was necessary to open the chest, evacuate the organized clot, and decorticate the lung.

Comment.—If this man had been treated originally by simple aspiration of the chest

soon after wounding, he would probably have been saved weeks of invalidism and a

second operation.

Policies of Management

Organizing hemothorax encountered in Zone of Interior hospitals was

treated by exploratory thoracotomy. An overlying rib was resected, the

cavity was widely opened by means of a rib spreader, and fluid and organized

clots were evacuated. If careful inspection showed no need for further surgery,

the chest was closed at once. If it showed that the lung could not reexpancl

because of the pathologic process present, decortication was performed.

Case 2.1—A commander of a tank company, wounded in action on 12 July 1944, sustained a penetrating shell-fragment wound of the left chest with a fracture of the eighth

rib. Treatment overseas consisted of debridement and closure of the wound on the day

of injury, supplemented by two later thoracenteses. When the patient arrived at Halloran

General Hospital, Staten Island, N.Y., on 1 September 1944, roentgenograms of the chest

(fig. 184A) showed an encapsulated hemothorax on the left side and a shell fragment overlying the seventh intercostal space near the vertebral column. Thoracotomy, performed on

30 October, revealed a cavity containing 150 cc. of old blood clot and a rigid fibrous membrane covering the adjacent portion of the lung. The blood clot was evacuated and the

limiting membrane removed, after which the lung was recxpanded. Closure was effected

without drainage. Removal of the shell fragment was not attempted. The lung was

completely reexpanded on the 15th postoperative day (fig. 184B), and the thoracotomy

wound was completely healed at this time (fig. 1S4C).

Comment.—This ease history illustrates the successful management of a small chronic

hemothorax by decortication. The rigid limiting membrane revealed at thoracotomy

contraindicated any other procedure.

Case 3.—This soldier sustained a perforating wound of the chest on 29 March 1945;

the shell fragment lodged in the soft tissues of the back, at the level of the second lumbar

vertebra. Xo immediate effort was made to aspirate the complicating hemothorax. When

the patient reached Halloran General Hospital almost 3 months later, examination showed

contraction and marked limitation of motion on the right side of the chest. Roentgenograms showed an encapsulated hemopneumothorax in the right axilla.

Because of an attack of malaria, the patient could not he operated on until 21 July

1945. At this time, exploration revealed a cavity of approximately 300-cc. volume, and a

rigid fibrous membrane overlying the lung. The membrane was excised and the wound

closed without drainage after the lung had been inflated. The postoperative course was

complicated by a second hemothorax, which could not be controlled by aspiration because

the blood clotted so rapidly. A second decortication was therefore performed on 13 August,

after the blood clot had been evacuated. The wound was closed temporarily with a silk

and gauze tampon, which was left in place for 7 days. The cavity finally closed on

1 December 1945.

Comment.—The first operation on this casualty was unsuccessful because the blood

that had accumulated in the pleura had clotted and could not be removed by aspiration.

This is a complication that is always a risk after pulmonary decortication. AVhen post1 This history and the subsequent case histories in this chapter concern patients observed by

Maj. Eichmond L. Moore, MC, at Halloran General Hospital.
SEQUELAE OF COMBAT-INCURRED WOUNDS 402

FIGUKE 184 (case 2).—Encapsulated liemotliorax managed by decortication. A. Posteroanterior roentgenogram of chest showing encapsulated liemotliorax on left and metallic fragment in seventh left

intercostal space near vertebral column. B. Same, 15 days after

evacuation of clot and dccortieation of lung. Note that lung is completely reexpanded. C. Photograph of patient on 15th postoperative

day, showing primary healing of wound.

operative oozing was profuse and difficult to control, as it was in this case, it was safer

to establish and maintain some form of closed drainage until the lung had reexpanded and

the pleural space was closed.

Case 4.—A large encapsulated hemothorax on the right, with areas of calcification in

the thickened membrane on the surface of the lung (fig. 185), was an unexpected finding

in a soldier who was evacuated from the Aleutian Islands in the spring of 1914. He had

no history of a combat injury to his chest, but he stated that in August 1941 he had been

knocked down by an automobile. No roentgenograms of the chest were taken at that time.

Operation was recommended and refused.
404 THORACIC SURGERY

r

FIGURE 1S5 (case 4).—Traumatic liemothorax. A. Posteroanterior

roentgenograni of chest showing large encapsulated liemothorax on

right side. Note areas of calcification in thickened membrane on pulmonary surface. B. Lateral roentgenogram showing same findings.

HEMOTHORACIC EMPYEMA

Empyema, most often originating in an earlier liemothorax, was the most

frequent complication of wounds of the chest observed in Zone of Interior

chest centers. It decreased in frequency as the war progressed, and it also

decreased in seriousness, at least in casualties received from the Mediterranean

theater and the European theater. The circumstances of the Pacific Ocean

areas, as already pointed out, were different and much more difficult, No matter

from what theater they were received, however, few patients reflected the

effects of the chronic sepsis and general debilitation so typical of similar

patients in World War I.

Early in the war, there were many errors in the management of patients

with empyema, including the basic error, failure to treat liemothorax by frequent and vigorous aspiration. In a few instances, initial surgery had been

ultraconservative, and revision of the thoracotomy was necessary to provide

adequate drainage. In most instances, simple revision, combined with intensive

physiotherapy, was sufficient, and complete obliteration of the cavity resulted.

If additional surgery was necessary, the patient's general condition was invariably greatly benefited by the preliminary revision.

Also early in the war, an occasional patient was received with closed intercostal drainage in effect, This technique created serious problems during

transportation, and drainage was never satsfactory. Later, practically all

surgeons overseas abandoned this method and treated empyema by dependent

open drainage.
SEQUELAE OF COMBAT-INCURRED WOUNDS 405

Still another error observed early in the war was the placement of the

drainage incision. In October 1943, Maj. (later Lt. Col.) William F. Hoyt,

MC, reported from the chest center at Hammond General Hospital, Modesto,

Calif., that almost all the patients with empyema received there from overseas

had been drained anteriorly and their empyemas had become chronic. Major

Blades, transmitting this information to Colonel Carter, stated that the same

error was being observed in casualties received at the Walter Reed General

Hospital chest center. Eeoperation was necessary in all such cases to establish

adequate drainage.

The following case history illustrates initial errors of management that

led to chronic empyema:

Case 5. This 24-year-old soldier was struck by a machinegun bullet on 22 September

1944. The bullet entered the left chest posteriorly, between the scapula and spine, and

emerged anteriorly in the midclavicular line, about 2 inches below the clavicle. The lung

was lacerated and the posterior portion of the fourth rib and the anterior portions of the

second and third ribs were shattered. Both wounds were sutured about 30 minutes after

injury. The next day, both wounds were reopened and debrided, and the lung was sutured.

Both wounds were then closed. After this procedure, the anterior wound became badly

infected and a left empyema developed.

When the patient was admitted to Halloran General Hospital on 27 December 1944,

he had lost 38 pounds (fig. 1S6). The left chest was contracted and fixed. The anterior

wound was still draining, and the opening in the chest wall was large enough to show a

large defect in the lung with multiple fistulas. A drainage tube entered a residual empyema

at the site of a previous rib resection.

This casualty was transferred to another hospital for definitive treatment, and his

subsequent course is not known.

Decortication

Generally speaking, if a well-drained empyema cavity showed no reduction in volume after a period of 6 weeks, the patient was regarded as a

candidate for surgical intervention. The only reliable way of determining

the volume of the cavity was by its accurate measurement with injected fluid.

This test was omitted only if the patient also had a bronchial fistula.

In the Mediterranean theater, where the operation was introduced in

World War II, the optimum time for decortication for empyema was considered to be within a range of ?> to 6 weeks after wounding (p. 286). When

patients with empyema were received in Zone of Interior hospitals, their infections had practically always become chronic, and the optimum time for decortication had long since passed. As a matter of necessity, the time was extended,

and the results were remarkably good.

In 1945, for instance, 67 delayed decortications were performed for organizino' hemothorax or chronic empyema at the chest center at Fitzsimons General Hospital, Denver, Colo., with complete restoration of a functioning lung

in every instance; in some cases, the preoperative pulmonary function on the

affected side had been as little as 10 percent of the normal. This operation,

however, when it was delayed, was not the universal answer to the problem,
406 THORACIC SURGERY

*

FIGTJEE ISO (case ö).—Hemothoracie empyema managed by anterior

drainage. A. Lateral view of casualty with wound of left chest 4 months

after wounding, showing extreme degree of malnutrition, with contraction of left chest. The anterior wound below the left clavicle is the point

of exit of the bullet. The wound in the axilla is the site of the rib resection performed 3

1

/, months earlier ; it leads into the dependent portion of

the empyema cavity. B. Posterior view showing wound in left scapular

region which is point of entrance of bullet. This wound was completely

healed 3 months after wounding. Note the scolio.sis secondary to the

contraction and fixation of the left chest.

as is shown by the fact that at this center, over the same period, 51 patients

with chronic empyema required some type of thoracophtsty.

When decortication was performed weeks and months after wounding, it

was frequently difficult to separate the greatly thickened fibrous membrane

from the visceral parietes. Some modifications of the standard technique were

therefore introduced. At Brooke General Hospital, San Antonio, Tex., the

practice was to separate the membrane from the parietal surface as the first

step of the operation. The thickened endothoracic fascia was dissected down

to the line of reflection from the parietal to the visceral surface. Once this

line was crossed, the adhesions were filmy and readily separated. The peel

was then freed from the apex to the diaphragm and anteriorly. After this

part of the operation had been completed, the lung was reexpanded under

positive pressure, and separation from the visceral pleura was accomplished

by sharp dissection.

Patients who had undergone decortication overseas were usually in good

condition when they reached the Zone of Interior. If there was any residual,

it was usually no more than a small basal empyema, readily corrected by

open drainage.
SEQUELAE OP COMBAT-INCURRED WOUNDS 407

Other Procedures

If delayed decortication could not be carried out without too great risk

of damage to pulmonary tissue, other procedures had to be employed. Internal

pneumonolysis was frequently used at the chest center at the "Walter Reed

General Hospital. The operation began with resection of a rib, followed by

wide exposure of the entire empyema cavity, as in decortication. If inspection

showed that decortication was not practical, the fibroblastic membrane was

incised around the periphery of the empyema cavity. Then the incision was

carried through the membrane at the juncture of the parietal and visceral

portions. The visceral portion was left adherent to the underlying lung, which

was cautiously freed from the involved portion of the chest, preferably by

blunt dissection with the gloved fingertip or with a dissecting sponge. After

the lung had been freed, it was reexpanded by positive pressure (not more

than 10 cm. H30). As a rule, the empyema cavity was promptly obliterated

by this maneuver. Closure was accomplished as in decortication. This operation, which is not a deforming procedure, frequently obviated the necessity for

thoracoplasty, which is a deforming procedure.

Physical Therapy

A competent physiotherapist, with special training in the problems of

chest conditions, was of great help in the accomplishment of maximum reexpansion of the lung and in overcoming the chest wall deformities commonly

seen in chronic empyema and other chest conditions (vol. I).

RETAINED FOREIGN BODIES

It is unfortunate that the Foreign Body Registry, proposed in the 1944-45

report of the Surgical Consultants Division, Office of The Surgeon General,

was not instituted, so that permanent records could have been kept on casualties

with foreign bodies left in situ. The presumed innocuousness of these objects

could then have been established or disproved. The extremely valuable

followup information secured by the Peripheral Nerve Eegistry illustrates

what a similar project might have accomplished in thoracic injuries.

Indications for Removal

The indications for removal of foreign bodies in Zone of Interior hospitals

were essentially the same as in oversea hospitals. They included their size,

their shape (irregularity), the symptoms and signs referable to them, and

psychosomatic indications.

Hemoptysis was infrequent. It was observed only twice at the Walter

Eeecl General Hospital chest center and was equally uncommon at other chest

centers. Pain, which was the most frequent symptom, was often difficult to

evaluate. If the object was peripheral and lay on either the pleural or the
408 THORACIC SURGERY

diaphragmatic surface, there was little doubt that it was responsible for the

complaint, and its removal was advised. Retained missiles were removed in

a considerable number of instances, however, in which there was genuine doubt

as to the relation between their presence and the patient's complaint of pain,

though there was no doubt at all that until psychosomatic difficulties were

thus ended, these men would not again be useful soldiers.

The attitude in Zone of Interior hospitals toward retained foreign bodies

was, in general, extremely conservative. Of the first 80 casualties in this category received at the Walter Reed General Hospital chest center, 16 were

operated on, 12 because of the size of the objects or because of clear-cut evidence

of their responsibility for signs and symptoms, and 4 for psychosomatic

reasons. The proportion at other centers was about the same. At Fitzsimons

General Hospital, for instance, only 68 foreign bodies were removed from the

lung during the entire period of its operation; these were chiefly high explosive

shell fragments. In 19 other cases, foreign bodies were removed from the

chest wall.

Localization Techniques

In addition to routine techniques of localization (p. 332), certain adjunct

techniques were used at the various chest centers. All of the centers found

the Berman locator of much supplemental value when foreign bodies were

deeply embedded in the parenchyma of the lung or in the mediastinum. It

could be used to explore any cavity that could be entered surgically. A constant vibratory sound was heard when the tip of the probe approached, or came

into contact with, a retained magnetic object, the volume varying directly with

the distance between the object and the probe.

Some surgeons employed a visual-radiopaque technique. A few cubic

centimeters of methylene blue or gentian violet were mixed with Lipiodol and

injected into the chest wall at the point at which the object was nearest to the

surface. Routine roentgenograms were then taken.

The angiocardiographic technique employed at the Walter Reed General

Hospital chest center was devised by Lt, Col. George P. Robb, MC, chief of

the cardiovascular section. This technique, which was used for the accurate

localization of foreign bodies in intimate contact with vessels in the mediastinum, was carried out in three steps :

1. The circulation time from the arm to the tongue was determined by

the injection of a solution of Decholin (dehydrocholic acid) and the accurate

measurement, by a stopwatch, of the lapsed time between the injection and the

patient's report of a bitter taste.

2. The lapsed time was determined between the injection of a solution of

ether into the arm and its detection on the patient's breath.

3. After these time factors had been determined, the patient was positioned

between a stereoscopic cassette, and angiocardiograms were obtained after the

intravenous injection of a concentrated solution of Diodrast (iodopyracet).

This radiopaque agent, instead of disseminating immediately in the vascular
SEQUELAE OF COMBAT-INCURRED WOUNDS 409

FIGURE 1ST (case (i).—Retained foreign body with delayed manifestations due to infection. A. Patient on admission to Halloran General

Hospital 14 months after wounding. Scar shows point of entrance of

bullet. B. Left anterior oblique roentgenogram showing bullet in right

chest opposite tenth intercostal space. C. Lateral roentgenogram showing

bullet situated posteriorly just above dome of diaphragm.

system, forms a bolus which can be followed from the point of injection through

the cardiovascular system until it is broken up in the peripheral vessels. By

evaluation of the previously determined circulation time, the approximate time

of opacification of the intrathoracic cardiovascular system could be determined.

Separate roentgenograms were made showing contrast filling of the right

ventricle and pulmonary arterial tree, the left ventricle and aorta, the right

auricle and superior vena cava, and the left auricle and pulmonary veins. With

this information, which was usually remarkably precise, it was often possible

to determine almost exactly the location of mediastinal foreign bodies in

relation to the cardiovascular system in the mediastinum.

Case Reports

Case 6.—A 21-year-old soldier, struck in the right chest by a machinegun bullet on 28

July 1943, made an uneventful recovery. The wound healed satisfactorily, and a complicating hemothorax cleared without aspiration. He had no symptoms referable to his

chest until June 1944, when he coughed up a small amount of bright red blood. Another

hemoptysis occurred in September. When the patient was admitted to Halloran General

Hospital shortly after the second hemoptysis, he was in good general condition (fig. 187A).

746-941'—65 20
410 THORACIC SURGERY

FIGURE 188 (ease 7).—Retained foreign body without symptoms. A. Posteroanterior roentgenogram of chest 10 weeks after wounding-, showing large metallic fragment in left chest at level of tenth dorsal vertebra. Another smaller

fragment is seen outside the chest cavity in the axillary tissues. B. Lateral

roentgenogram taken at the same time, showing the posterior location of the

larger fragment.

Roentgenograms (fig. 1S7B and C) showed a .25-caliber bullet situated posteriorly on the

right side, at the level of the tenth intercostal space. Roentgenograms made after the

instillation of Lipiodol showed no evidence of bronchiectasis.

The bullet was removed on 13 October 1944. The space which it occupied, which communicated freely with the bronchial tree, contained a small amount of necrotic material,

culture of which revealed hemolytic Staphylococcus aurcus. Convalescence was satisfactory except for a small empyema, which healed rapidly after resection and drainage.

Comment.—As this case demonstrates, a foreign body may be embedded in the lung

for many months before it causes symptoms. The patient's history suggests that the

hemoptyses which finally occurred were secondary to the staphylococcic infection.

Case 7.—This soldier received multiple penetrating wounds of the left chest on 28

July 1944. On 30 .Tuly, all wounds were debrided and several readily accessible foreign

bodies were removed. When he arrived at Halloran General Hospital on 9 October, he was

pale and weak and showed evidence of considerable weight loss. The temperature was

103°I\, the pulse 120, and the respirations 30. The red blood cell count was 2,270,000 per

cu. mm. and the white blood cell count 3,900 per cubic millimeters. The hemoglobin

(Sahli) was 7.5 gm. percent. Roentgenograms of the chest (fig. 18S) showed a metallic

fragment, about 2 by 3 cm., in the posterior portion of the left lung at the level of the

tenth dorsal vertebra.

Treatment consisted of penicillin, repeated blood transfusions, and vitamin therapy. A

subcutaneous abscess in the left scapular region was drained on 19 October 1944, and 3

pieces of woolen shirt were evacuated with 25 cc. of purulent fluid. Culture of the exudate

showed Bacillus coll and nonhemolytic Stapli. aureus. After drainage of the abscess, the

temperature quickly fell to normal, and convalescence was satisfactory except for an attack

of malaria, which responded well to Atabrine (quinacrine hydrochloride). By the middle

of November, the patient had gained 19 pounds, and his red blood cells had risen to 4,S70,000

per cubic millimeters. The time was considered optimum for removal of the fragment from

the left lung, but since he had now become transportable, he had to be reported to the

hospital registrar for transfer to another institution for definitive care.
SEQUELAE OF COMBAT-INCURRED WOUNDS 411

_^^BW%^

\A

B

FIGURE 180 (case 8).—Retained foreign body without clinical manifestations. A. Posteroanterior roentgenogram about 6% months after

wounding, showing metallic shell fragment in right upper lung field. B.

Photograph taken at operation 4 months later. The shell fragment can

be seen deeply embedded in the lung. C. Photograph of patient 10 days

after operation, showing surgical wound over second right interspace.

Comment.—This case is an example of the retention of a metallic foreign body in the

lung for many months without symptoms. It also shows the ineffectiveness of penicillin

in controlling a suppurative process associated with tissue damage and retained foreign

material when the causative organism is not susceptible to it. In this case, it was the

fragments of cloth, and not the metallic foreign body, that were responsible for the infection.

Case 8.—This patient, when struck by a shell fragment on 7 November 1944, sustained a

penetrating wound in the right supraclavicular region. Recovery was rapid, and there were

no complaints referable to the chest. When he reached Halloran General Hospital, in May

1945, he was in excellent condition and had no complaints. Roentgenograms of the chest

(fig. 189A) showed a shell fragment in the right upper lobe of the lung and a healed fracture of the right second rib. The fragment was removed in September 1945 (fig. 189B).

Cultures taken from the cavity which it occupied revealed nonhemolytic Streptococcus and

nonhemolytic Staph. aureus. Penicillin was given postoperatively. Healing was uneventful (fig. 189C) except for a small pleural effusion that cleared without aspiration.
412 THORACIC SURGERY

Comment.—This ease history is another illustration of the retention of a metallic foreign body in the substance of the lung for many months without symptoms. The fact that

this man did not develop a postoperative empyema, in view of the organisms present, is

probably to be explained by the use of penicillin.

CHEST WALL DEFECTS

The incidence of serious defects of the chest wall in casualties received in

Zone of Interior hospitals was remarkably low, especially in comparison with

the much larger proportion of such defects observed in the fewer thoracic casualties of World War I. There were several explanations for the low incidence:

1. The excellent emergency care these casualties received.

2. The low incidence of wound infections, due to the adequacy of debridement at initial wound surgery. The extensive infections and massive sloughing

wounds so frequent in World War I were scarcely ever observed in World War

II, in spite of the greater destructiveness of World War II weapons.

3. The practice of delayed primary wound closure in fixed hospitals overseas.

4. The supplemental use of the sulfonamides and later of penicillin.

It was usually possible to effect satisfactory repair of chest wall defects by

the use of regional tissues; that is, the bones, muscles, fascia, subcutaneous tissue,

and skin of the chest. Split-thickness skin grafts were frequently used, and

pedicle grafts were used as necessary. In the few instances in which tantalum

plates were employed to bridge the defect, the results were disastrous. The

plate acted as a foreign body, and if it did not slough out of itself, it had to be

removed at a secondary operation.

DRAINING SINUSES OF THE CHEST WALL

The draining sinuses of the chest wall encountered in Zone of Interior hospitals were due to the same causes as those observed overseas; that is, injuries

to the costal cartilages (with subsequent infection), retained foreign bodies

and other foreign material, unwisely selected suture material, and unwise suture

techniques. Infections of the cartilages and unwisely selected suture material

were the chief causes; they accounted for most of the 62 draining sinuses treated

at the Fitzsimons General Hospital chest center. Associated empyema was

surprisingly infrequent, probably as the result, of the generally excellent initial

treatment of the chest wound.

The principle of management of draining sinuses was removal of the

offending material, whether it was necrotic bone and cartilage, foreign material, or suture material. Since all of these wounds were infected, primary

closure was seldom successful. On the other hand, there were two objections

to leaving the wounds open to heal by granulation. The first was the long

convalescence inevitable under this plan. The second was the tendency of
SEQUELAE OF COMBAT-INCURRED WOUNDS 413

granulation tissue to contract, with resultant exposure of the cut edges of

previously healthy rib or cartilage.

The most satisfactory technique of repair was as follows: The sinus tracts

were fully exposed, with due care to preserve as much healthy skin as possible.

The affected cartilages were excised clown to healthy tissue, and all foreign

material, including sutures, was removed. The wound was then dressed with

petrolatum-impregnated gauze and left open. As a rule, clean granulations

were observed in 4 to 7 days. As soon as they were evident, the wound surface

was covered with a split-thickness skin graft. This simple technique usually

resulted in prompt healing and greatly reduced the period of hospitalization

required when more complicated techniques were used.

ASSOCIATED WOUNDS

Associated wounds in patients with thoracic injuries referred to chest

centers were most often regional fractures and regional nerve injuries. Many

libs were splintered and many scapulas shattered by missiles, and some surgeons

thought that such injuries accounted for more residual pain than ordinary

fractures. Major Hoyt, at Halloran General Hospital, had the impression that

casualties with such fractures took a considerable time to regain their mental

equilibrium. Many of them referred repeatedly to the difficulty in breathing

they had experienced soon after injury. When hemoptysis was added to the

respiratory embarrassment, the experience seemed particularly frightening.

These patients required a great deal of individual attention, and their physical

recovery progressed more rapidly as their mental status improved.

A number of chest wounds were complicated by nerve injuries, particularly injuries of the brachial plexus. The position at wounding accounted for

these injuries. If the soldier was crawling forward on his hands and knees,

or was advancing in a bent over position, the supraclavicular area was presented as a target. The entering missile fractured the clavicle and emerged

between the scapula and spine or the scapula and ribs. The location of the

wound was such that the brachial plexus was implicated in it, and partial

paralysis of the arm and hand resulted. Many of these patients had to be

transferred to neurosurgical centers for treatment after their thoracic injuries

were completely healed.
CHAPTER X

Surgical Aspects of Diseases of the Chest

Brian Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.

BRONCHIECTASIS

Incidence

Army statistics testify to the importance of bronchiectasis among diseases

of the chest. Admissions during 1942-45 (table 15) numbered 6,207, of which

5,164 were to hospitals in the continental United States. During this same

period, there were 12 deaths in the U.S. Army in which bronchiectasis was the

underlying cause, and, more important from the standpoint of Army manpower, there were 4,487 disability separations for this cause.

TABLE 15.—Admissions for bronchiectasis in the U.S. Army, ~by area and year, 19-'t2-Jf5

[Preliminary data based on sample tabulations of individual medical records]

[Rate expressed as number of admissions per annum per 1,000 average strength]

1942-45 1942 1943 1944 1945

Number Rate Number Rate Number Rate Number Rate Number Rate

Continental United

States 5, 164 0. 35 980 0. 37 2, 185 0. 42 1,214 0. 31 785 0. 27

Overseas:

381

174

18

48

176

159

42

40

0. 09

. 12

. 12

. 11

. 10

. 13

.09

. 10

17

4

1

4

15

18

17

15

0.20

. 17

. 17

.46

. 21

. 12

. 17

. 15

49

75

8

6

24

55

17

21

0. 18

. 16

. 15

. 15

. 13

. 19

. 09

. 17

160

70

9

23

62

56

8

4

0. 10

. 11

. 19

. 14

. 11

. 13

.06

. 05

155

25

0.07

Mediterranean 1

Middle East

China-BurmaIndia _ _

Southwest Pacific^,

Central and South

Pacific

North America2

Latin America

.07

15

75

30

.07

.07

.08

Total overseas 3_ 1,043 0. 10 93 0. 16 255 0. 15 395 0. 10 300 0.06

Total Army 6,207 0. 24 1,073 0. 33 2,440 0. 36 1,609 0. 21 1, 085 0. 14

1

Includes North Africa. 2

Includes Alaska and Iceland. 3

Includes admissions on transports.

415
416 THORACIC SURGERY

Even granting the assumption that not every admission for bronchiectasis

represented an actual instance of this disease, the numbers are sufficiently large

to indicate the extent of the problem. The figures also suggest the possible

incidence of this disease in the general population: These 6.207 patients were

in a selected age group of men, who had passed the physical examination and

roentgenologic examination for induction into the Army. The number of

draftees who were rejected for service because bronchiectasis was detected is

undoubtedly several times greater.

The manifestations of bronchiectasis were essentially the same in military

as in civilian practice and call for no special discussion. They were chiefly

dependent upon the degree of sepsis, which in turn was chiefly dependent upon

the adequacy of bronchial drainage. When the disease was advanced, the destructive changes were always permanent and irreversible and could be managed

only by extirpation of the involved tissue.

The following material, which can be assumed to be typical, is based on

an analysis of 390 consecutive patients with bronchiectasis treated at Percy

Jones General Hospital, Battle Creek, Mich., and the chest center at Kennedy

General Hospital, Memphis, Tenn., during World War II by Maj. Earle B.

Kay, MC; Maj. (later Lt. Col.) Eichard IB Meade, Jr.. MC: and Maj. Felix

A. Hughes, Jr., MC (1).

Diagnosis

Diagnosis was based on:

1. Boentgenologic examination, repeated as necessary.

2. Bronchography, with outlining of all five pulmonary lobes. This measure had to be employed with caution, for it sometimes disclosed minor degrees

of dilatation on which a diagnosis of bronchiectasis was based, in the absence

of clinical symptoms. For this, there was no warrant.

3. Bronchoscopic examination, to determine the source of the exudate. If

the bronchial mucosa seemed unduly inflamed, the possibility of bronchial occlusion secondary to a retained foreign body or a neoplasm had to be considered

and eliminated.

4. Bronchospirometric studies, which were important if the disease was

bilateral, to determine which was the worse side (p. 421). It was also important to determine the pulmonary reserve of the uninvolved lung if dyspnea

was a symptom and to establish the extent of functional tissue in borderline

cases.

Differential diagnosis chiefly concerned the reversible bronchial dilatations

that sometimes followed an acute attack of respiratory infection, particularly

atypical pneumonia. In October 1943, Maj. (later Col.) Brian Blades, MC,

wrote to Lt. Col. (later Col.) B. Noland Carter, MC, that Major Meade had

reported this complication at the Kennedy General Hospital chest center and

that it was also being observed at the chest center at Walter Reed General

Hospital, Washington, D.C. The temporary nature of the bronchial dilatation
SURGICAL ASPECTS, DISEASES OF THE CHEST 417

in these cases could be demonstrated by repeating the bronchogram a few weeks

later; the bronchial configuration then usually showed a complete return to

normal. Bronchoscopic examination was also useful. Differential points

were the marked edema and generalized inflammatory reaction in the postpneumonia patients, lesser friability and vascularity, and absence of the characteristic odor of the purulent sputum of bronchiectasis.

Conservative Management

The high hopes originally entertained for the use of penicillin in bronchiectasis were not fulfilled. It was never likely that they would be. This

is a disease characterized by bronchial and bronchiolar destruction, permanent

bronchial dilatation, chronic infection, and marked sepsis. In advanced stages,

the normal bronchial architecture is replaced by less specialized tissue, a pathologic change that explains the recurrent periods of exacerbation and the chronic

state of sepsis that characterize it. Penicillin was of considerable value in the

treatment of recurrent pneumonic episodes as well as in decreasing the sepsis

and toxicity of the interval stages. Occasionally, it changed the character of

the sputum. It frequently decreased the cough and sputum and increased

the sense of well-being. These improvements lasted, however, only as long as

penicillin was administered. When administration was discontinued, they

were promptly lost.

At the Kennedy General Hospital chest center, 45 patients with advanced

bronchiectasis were treated with intramuscular injections of 25,000 units of penicillin every 3 hours for 1 or 2 months and, in 4 cases, for 3 months. The improvements just listed occurred in about two-thirds of the patients, usually

during the first few weeks of treatment. Regression occurred when penicillin

was discontinued, and no patient with advanced bronchiectasis had any permanent benefit from the treatment.

Intratracheal penicillin was used in another 45 patients with bronchiectasis,

with somewhat better results. The seven patients with minimal disease had

almost complete relief, and definite improvement occurred in two-thirds of the

remaining patients.

Indications for Lobectomy

Neither penicillin nor any other form of conservative therapy was the solution of the problem of advanced bronchiectasis. Only surgery provided the

answer. The decision to resort to it depended upon the extent of destructive

changes, the physical evidences of chronic toxicity, and the amount of disability

and invalidism. Of particular importance was the evaluation of the patient

as a whole, including not only his present symptoms but his past history, with

special reference to the increasing frequency or severity of acute episodes.

Operation was never indicated in patients with minimal disease, who

could be treated conservatively with good results. It was not indicated in

patients who had no clinical evidence of the disease, even though roentgeno740-941'—05 30
418 THORACIC SURGERY

grams showed varying- degrees of apparently permanent bronchial dilatation.

Nor was it indicated in patients with disease of all five lobes; they were beyond

surgical help.

Bilateral bronchiectasis, which was present in about 30 percent of the

patients observed in World War II, was not considered a contraindication to

surgery. Past experience had shown that those with advanced disease on one

side and minimal disease on the other were usually greatly improved by operation on the more severely involved side. If the disease was extensive on both

sides, operation was still considered indicated as long as (1) the right upper

lobe and (2) the upper aspect of the left upper lobe were free from disease and

the cardiorespiratory reserve was adequate.

These indications were followed in the 184 lobectomies in this series, in

36 of which the disease was bilateral and in 6 of which bilateral lobectomy

was performed. In another case, the right middle and lower lobes had been

removed earlier, and the left lower lobe and the lingula of the left upper lobe

were removed later (p. 420).

Preoperative Preparation

Operation was not scheduled until 4 to 6 weeks had elapsed after bronchography, to allow time for the elimination of the injected iodized oil. In

the absence of this precaution, a postoperative pneumonitis was a possibility.

Preoperative preparation was extremely careful and painstaking. It consisted of the following measures:

1. Patients who had been ill over a long period of time had a detailed

medical study, to eliminate possible cardiac, hepatic, and renal complications.

2. An otolaryngologic examination was made, and any infection found

received the proper treatment. Sinusitis was treated by nebulized penicillin.

3. The diet was high in vitamins and calories, and supplementary vitamin

therapy was used as necessary. The vitamin C content of the blood was

brought to normal,

4. The plasma protein components of the blood were also broughtto normal

by supplementary protein components in the diet or by blood transfusions if

they were indicated. A blood transfusion was always begun when operation

was started and was usually continued throughout its course, in the amount of

1,000 to 1,500 cubic centimeters.

5. A physiotherapist explained and demonstrated the breathing exercises

to be used during the entire postoperative period.

6. If postural drainage proved useful, it was employed three or four times

a day.

7. If sputum was copious and bronchitis severe, a course of intratracheal

penicillin, given for 7 to 14 days, was frequently helpful in reducing the amount

of sputum.
SURGICAL ASPECTS, DISEASES OF THE CHEST 419

8. Intramuscular injections of penicillin were begun the day before operation. When penicillin became available in preparations of beeswax and peanut oil, single injections of 300,000 units were given daily before operation,

usually for 3 to 7 days, and were continued after operation until the temperature

was normal.

Technique

The individual ligation technique was used in 182 of the 181 lobectomies

in this series; only the first 2 were performed by the mass ligation technique.

If purulent secretions were excessive, the bronchus was closed as soon as possible, but seldom before the arteries were divided. The inferior pulmonary

vein was always the last vessel ligated. It was thought that the danger of

embolism from involved lobes was less important than the technical disadvantage of permitting the lobe to become engorged.

Pleuritic adhesions between the upper lobe and the chest wall were cut.

If they were allowed to persist, they might prevent the upper lobe from readily

readjusting to the larger sj)ace now available to it.

In all partial pulmonary resections, the pleura was drained by an airtight

catheter connected to water-seal suction. Drainage was usually maintained

for 48 hours. Bronchoscopic aspiration was performed routinely at the end

of the operation.

At the end of the operation, roentgenograms were taken and immediate

corrective measures were instituted if they showed atelectasis or if reexpansion

of the remaining lung tissue was notsatisfactory.

Postoperative Routine

The usual routine of postoperative care was followed after lobectomy,

with special emphasis upon the following measures:

1. Oxygen was administered for the first 12 to 24 hours.

2. If the patient complained of tightness in the chest during the early

postoperative period, temporary phrenic nerve paralysis was performed. This

was a particularly important precaution if an emphysematous lobe had been

removed, to prevent overdistention of the remaining lobe (lobes), as well as

in high lingulectomies or middle lobe lobectomies performed in combination

with lower lobe lobectomies.

3. The patient was usually ambulatory by the fifth day and was permitted

out of bed earlier if he had difficulty in voiding.

4. Daily roentgenograms were taken at the bedside, to keep constant check

on the remaining lobe or lobes.

5. When the hemithorax was satisfactorily filled with the remaining lungtissue and the patient's general condition was good, he was given a convalescent

furlough. His disposition was determined on his return to the hospital.
420 THORACIC SURGERY

Mortality and Complications

The single surgical death in this series occurred in the fourth of the 184

lobectomies. The patient had had bronchiectasis of the right lower lobe for

many months, with repeated hemoptyses. Anesthesia was trying. It was hard

to maintain a clear airway. The operation was technically difficult and time

consuming. It is doubtful that this fatality, which was attributed to cerebral

and pulmonary edema, would have occurred if the patient had been operated

on later in the series.

The complications in these 184 lobectomies were as follows:

Significant shock from blood loss occurred in only one case.

Postoperative atelectasis occurred in five cases. Its infrequency was the

result of the vigorous endeavors to keep the bronchi free of secretions by early

movement, frequent voluntary coughing, and aspiration of retained secretions

as necessary. In one case, however, atelectasis was alarming. This patient

had had the right middle and lower lobes removed at one operation, and the

left lower lobe and lingula at another sitting 6 months later. On the third

day after the last operation, atelectasis of the remaining portion of the left

upper lobe developed and persisted to some degree for the next 3 days. During

this time, the patient was maintained only on the right upper lobe, with repeated intratracheal aspiration and the intermittent use of iiitranasal oxygen.

Eecovery thereafter was uncomplicated.

Hemothorax developed in two cases, probably because of injury of the

intercostal vessels when the thoracotomy tubes were inserted.

Bronchopleural fistula with resulting empyeina occurred in 20 cases, all

early in the series. There were only 5 such complications in the last 100 lobectomies. Postlobectomy empyeina was not a serious problem at any of the

thoracic surgery centers. It was thought that careful surgical technique and

prompt reexpansion of the remaining lung had more to do with this than did the

use of penicillin.

Jaundice developed in six cases, whether secondary to blood transfusion or

as the result of concomitant hepatitis is not clear; a number of other patients

developed hepatitis at about this time.

One patient had a cerebrovascular accident, probably from a septic embolus.

He was treated with penicillin and streptomycin. Six weeks later, a trephine

operation was performed, and a small, sterile cystic cavity was evacuated.

Eecovery followed. Penicillin was given by vein during operation in subsequent

cases, to reduce the likelihood of this complication.

There was no complication from the contralateral lung in any patient with

bilateral bronchiectasis, probably because in these cases, the postoperative

regimen was particularly rigid.
SURGICAL ASPECTS, DISEASES OP THE CHEST 421

Bronchospirometry

Ten patients in this series upon whom bronehospirometric studies were

performed before operation had an average oxygen consumption on the affected

side of only 37 percent of the total and an average ventilation of 44 percent of

the total. These figures show the effects of bronchiectatic destruction of tissue

on the pulmonary function. They also show that the efficiency of oxygen

absorption into the alveolar capillaries or through the alveolar membrane is even

more impaired in this disease than is the ability to ventilate the lung.

In one instance, bronehospirometric studies on a patient with bilateral

disease showed that oxygen consumption was 61.1 percent on the more severely

impaired side and only 38.9 percent on the other side, on which there was thought

to be only minimal disease in the right upper lobe. Evidently, destructive

changes not apparent by roentgenogram or bronchogram were present in the

supposedly good lung. Two patients, not included in this series, were found to

have such copious amounts of sputum and such a degree of bronchial obstruction

that there was no oxygen absorption at all on the affected side.

These studies indicate (1) that, in many instances, the bronchiectatic lobe

contributes very little to the oxygenation and gaseous exchange of the blood

circulating in the pulmonary tissues; (2) that the blood returns to the heart

unoxygenated and with a high carbon dioxide content; and (3) that these

phenomena are responsible in large measure for the cyanosis and dyspnea

observed in bronchiectasis. Only by removal of the bronchiectatic tissue can

blood be circulated through the alveoli, with proper oxygenation and diffusion

of gases.

Postoperative bronehospirometric studies in 26 cases in this series showed

that the pulmonary function of the remaining lung tissue on the affected side

was largely dependent on the presence or absence of postoperative pleural

complications (figs. 190, 191, 192 and 193). In none of these cases was the pulmonary function significantly impaired when recovery was uneventful: in

numerous instances, it was within normal limits 2 or 3 months after operation.

That good results persist is suggested by the fact that function was normal in

two other patients examined, respectively, 1 year and 3 years after lobectomy.

Results

The good results in this series were unquestionably influenced by the fact

that practically all of the patients were excellent risks as compared with candidates for surgery in civilian practice. Their disease was such that it could

be cured only by pulmonary resection, and the risks they underwent were so

small compared to the risks of persisting disease that operation was recommended without hesitation in every case in which it was indicated.
THORACIC SURGERY

LEFT

FIGUEE 190.—Bronchospirometric tracing 1 month after left lower lobe

lobectomy for bronchiectasis. Left side now contributes 53 percent of total

oxygen consumption and 52 percent of total ventilation. Convalescence was

entirely uneventful.

RIGHT

^/vVvVW^yVv

FIGURE 191.—Bronchospirometric tracing- 7 weeks after left lower lobe

lobectomy for bronchiectasis in patient with residual dysfunction of right lung

secondary to pneumonia and empyema. The decreased pulmonary function

secondary to pleural thickening on this side is evident from the fact that the

left side contributes 76.4 percent of the total ventilation.
SURGICAL ASPECTS, DISEASES OF THE CHEST 42S

>*^

RIGHT

FIGUEE 192.—Broncliospirometric tracing S weeks after right middle and

lower lobe lobectomy for bronchiectasis. The phrenic nerve was crushed 8 days

after operation to prevent overdistention and emphysema of upper lobe. The

right side now contributes 47 percent of total oxygen consumption and 43

percent of total ventilation.

FIGURE 103.—Broncliospirometric tracing 7 weeks after resection of left

lower lobe and lingula of the 'upper lobe for bronchiectasis. The phrenic nerve

was crushed 3 clays after operation to prevent overdistention of remaining

segment of upper lobe. Remaining segment of upper left lobe now contributes

33.3 percent of total oxygen consumption and 26.3 percent of total ventilation.
^ THORACIC SURGERY

Administrative Considerations

When bronchiectasis was clearly not "line of duty," as manifested by a

history of previous symptoms pointing to it, disposition could be accomplished

at any hospital at which authorized disposition boards were held.

All patients with bronchiectasis considered to be line of duty were transferred to a thoracic surgery center, where treatment was carried out and

disposition was effected by consultation between the medical and the surgical

services. The policy was to discharge men who did not wish to lie operated on

or in whom operation was contraindicated. Those with extensive bilateral

disease were given medical discharges. Those with advanced disease not

suitable for surgery Avere usually transferred to a Veterans' Administration

hospital.

Although many men were returned to full duty after lobectomy, there was

some hesitancy all through the war about returning to duty, or accepting for

duty, any man who had any type of thoracic disease. This problem first came

up in October 1948, after more than 50 lobectomies had been performed at

the Walter Peed thoracic surgery center, and Major Blades Avrote to Colonel

Carter about it.

PULMONARY TUBERCULOSIS

Surgical Procedures

In World War I, pulmonary tuberculosis was a major problem, as might

have been expected, for both roentgenologic and screening techniques were

crude by modern standards. In World War II, the efficient screening and

case-finding methods that had been developed between the wars were put to

good use, and tuberculosis in the Armed Forces was never a major concern.

The finding of active disease in a soldier, at least in the first years of the

war, was considered almost synonymous with his permanent release from

active duty. As the war progressed, however, this concept began to be altered,

and surgery was employed in occasional, carefully selected cases, with remarkably good results.

A listing of the procedures accomplished at the chest center at Fitzsimons

General Hospital, Denver. Colo., in 1944 and 1945 shows interesting chancres

in the procedure employed, as well as an increasing interest in surgery for

tuberculosis (table 16).

All patients selected for surgery were first carefully considered by the

medical board of the hospital, and the responsibility of the chest center for

them varied according to the operation. Patients who underwent only phrenic

emphraxis were brought to the operating room from the medical ward and

returned to the medical ward immediately after the operation. Patients who

underwent pneumonolysis were transferred to the surgery section the afternoon
SURGICAL ASPECTS, DISEASES OF THE CHEST 425

TABLE 115.—Operations for pulmonary tuberculosis, Fitssimons General Hospital thoracic

surgery center, IO.'/.'I-.'IS

Procedure

Thoracoplasty

Phrenic emphraxis

Intrapleural pneumonolysisOpen pneumonolysis

Lobectomy

Segmental resection

Pneumonectomy

Partial pneumonectomy

Decortication

Total

1944-45

860

1944

213 139

490 226

25 23

7'?

40 12

7

5 2

3

5

402

1945

74

204

2

72

2S

7

3

3

5

45S

before operation. A roentgenogram Mas taken at once to determine the degree

of pneumothorax present.

The patients were held on the surgical Avard after operation only until the

intrapleural pressure Avas well stabilized, which was usually within 72 hours.

Candidates for other operations were transferred to the surgery section before

operation and held on it until their immediate convalescence was complete.

Pulmonary resection for tuberculosis was introduced at this center in 1944.

There was 1 death in the 12 operations, from massive postoperative spread of

the process. The patient was a poor surgical risk, with bilateral cavitary disease, and left upper lobectomy was performed in the desperate hope of controlling it. A mixed empyematous process developed in another case after operation, but the patient made a good recovery, and there was no spread of the

disease in any other case. All other patients recovered smoothly. These results were considered so encouraging that the policy was continued and extended

in 1945. There were no deaths in the 28 lobectomies performed in that year,

and postoperative spread of the disease occurred in only one case. The center

closed before long-term results of lobectomy could be observed, but the immediate results were considered most encouraging.

It Avas not ahvays easy to select patients for lobectomy. In general, the

procedure was limited to chronic disease Avith localized involvement Avhich had

not responded to standard collapse therapy.

The results of pneumonectomy were not encouraging, which was not unexpected, for all operations were clone for advanced disease involving the entire

lung. All the patients were extremely poor surgical risks, and operation was

a last resort. There were t,AVO deaths in the three operations performed in 1944.

Tuberculomas.—The seven segmental pulmonary resections performed at

the Fitzsimons General Hospital chest center in 1945 were all for tuberculomas.

These neoplasms were formerly considered extremely uncommon. Routine
426 THORACIC SURGERY

l'oentgenologic examinations of men in service at induction, at separation, and

sometimes more often, showed that they were by no means as uncommon as

they had originally seemed.

Most tuberculomas were asymptomatic, but careful inquiry into the previous history often revealed positive or suspicious stories of active disease.

The majority of the masses were solitary, but in a number of instances, satellite

hbrocaseous nodules were associated with the larger growths, particularly in

the upper lobes.

When a tuberculoma was diagnosed, its presence was regarded as an indication for surgery. These lesions have dangerous potentialities for breaking

down and spreading. At operation, they are usually found to be more extensive

than roentgenologic examination has suggested. Finally, neither roentgenologic examination nor any other measure is sufficiently accurate to differentiate

them from bronchogenic carcinoma.

If bacieriologic examination revealed acidfast bacilli, medical treatment

was employed before operation. The possibility of endobronchial disease always required investigation before operation; it was unusual, but preoperative

treatment was necessary if it was found.

Excision was usually possible by wedge resection, with conservation of as

much lung tissue as possible. Lobectomy was necessary if the lesions were

large or if there were satellite nodules.

Recovery was usually smooth, and most operations could be considered

successful. The postwar experience has shown that many patients treated by

excision of tuberculomas can be returned to full military duty.

Tuberculosis Complicating Combat-Incurred Wounds

Attention has been called to an unusual case in the Mediterranean theater

in which recovery was complicated by activation of latent tuberculosis (p. 165).

The following similar case was observed at Halloran General Hospital, Staten

Island, X.Y., by Maj. Eichmond L. Moore, MC:

Case 1.—A private in the infantry was struck in the left lower chest on 2 May 1944, in

England, by a fragment from an accidentally exploded 60-mm. mortar shell. When he was

seen in a general hospital 2 hours later, he was in moderate shock and was complaining of

severe upper abdominal pain. The upper abdomen was rigid and tender, and there was

beginning dullness in both flanks. The thoracic wound, which was about 15 cm. long, was

in the left midaxillary line, at the level of the tenth intercostal space. A portion of the

spleen had herniated through it. Roentgenograms of the chest and abdomen showed

neither pneumothorax nor foreign bodies.

Exploration of the abdomen through a T-shaped incision revealed a ruptured spleen, a

7-cm. rent in the left leaf of the diaphragm, perforations on the greater and lesser curvatures of the stomach, and a puncture wound on the inferior surface of the left lobe of

the liver. The peritoneal cavity was full of blood mixed with gastric contents. The

operation consisted of splenectomy and repair of the perforations in the stomach and the

diaphragm. The puncture wound of the liver was not explored. The wound of the chest

wall was debrided before closure, which was complete.
SURGICAL ASPECTS, DISEASES OF THE CHEST 427

Roentgenograms on 12 May showed a left hemopneumothorax, but the chart bore no

record of treatment by aspiration. On 15 May, 100 cc. of purulent exudate was evacuated

from the upper half of the abdominal wound.

Both wounds then healed well, and convalescence was uneventful until the latter part

of June, when the patient began to run an intermittent septic fever, for which no cause

was discovered. He was received at a general hospital in the Zone of Interior on 8 August.

On 22 August, aspiration of the chest yielded 300 cc. of thick pus. The following day, 4 cm.

of the ninth rib was resected, and drainage was established.

"When the patient was received at Halloran General Hospital, on 19 September, there

was a discharging sinus at the site of the rib resection. Roentgenograms of the chest on

the following day, after instillation of 20 cc. of Lipiodol, revealed a triangular cavity at the

left base, measuring 3 by G centimeters. A metallic foreign body 7 by 15 mm. was in the

upper abdomen, in the region of the liver.

Drainage was obviously inadequate, and a second thoracotomy was clone on 25 September, with resection of the eighth and ninth ribs and the intervening intercostal muscle

bundles and pleura. Microscopic examination of the excised sinus tract showed numerous

tubercles with central necrosis and borders of granulomatous tissue. The diagnosis of

tuberculosis was confirmed by examination of a second specimen on 27 October.

Another persistent sinus developed after the second thoracotomy and showed no tendency toward healing in spite of vigorous local treatment. On 3 January 1945, roentgenograms of the chest after instillation of Lipiodol showed an empyema cavity about 7 by 2 cm.

and a bronchopleural fistula.

At a third operation on 2 May 1945, exploration showed that the sinus extended deep

into the substance of the lung. The tissue excised at this operation included the surrounding zone of scar tissue, all of the regenerated bone surrounding the external opening of

the sinus tract, and additional segments from the stumps of the eighth and ninth ribs.

Sections of tissues stained by the Ziehl-Neelsen technique showed acidfast organisms.

The lung apparently healed rapidly, but another persistent sinus appeared. At exploration on 22 June, it was found to extend through the lung to the diaphragm. It was

thoroughly excised by the radical technique used at the operation on 2 May. The resulting

extensive defect in the chest wall was closed by undermining and approximating the

muscles and subcutaneous tissue. A small rubber tube was left in the center of the wound

between the lung, diaphragm, and chest wall.

Healing was rapid and satisfactory. The drainage tube was removed on 25 July, and

4 days later, the sinus was completely closed, as it was when the patient returned on

5 September 1945 from a 30-day convalescent leave. Although he had gained 60 pounds

since the second thoracotomy on 25 September 1944 and was in excellent general condition

(fig. 194). he was considered unfit for further military duty and was separated from service.

The tissues removed at this operation again showed classical tubercles with central

necrosis, rimmed by epithelioid cells and lymphocytes and the typical Langhans type of

giant cell.

Comment.—This man received excellent surgery within 3 hours of his injury, and his

recovery must be attributed to it. It was wise not to attempt to remove the shell fragment

in the liver or to explore the chest, for his condition was poor and his blood pressure fell

to 0 on the operating table. Complete primary closure of the chest wound after debridement

was, however, contrary to military teachings. Furthermore, had the hemothorax evident

6 days after wounding been treated by aspiration, it is highly probable that the empyema

which developed would have been prevented.

The particular point of interest in this case is the diagnosis of tuberculosis in the

tissues at the site of injury. Careful inquiry showed nothing in the previous history to

suggest acidfast infection of any kind. The tuberculous infection supplied an adequate

explanation for the chronicity of the process and the repeated failures to obtain satisfactory
428 THORACIC SURGERY

FIGURE 194 (case 1).—Patient after final

closure of tuberculous sinus complicating

thoracoabclominal wound 16 months earlier. Note complete healing of wound and

excellent cosmetic result.

healing despite the establishment of adequate drainage. A satisfactory result was obtained

only when all of the diseased tissues had been excised and the resulting defect closed by the

approximation of well nourished, healthy tissues.

LUNG ABSCESS

The incidence of lung- abscess was remarkably low in World "War II (table

10) and the incidence of acute fulminating- abscesses far lower than the incidence of chronic indolent abscess. During the entire war. only three acute lungabscesses required drainage at the Walter Eeed General Hospital chest center.

There were several explanations for this situation:

1. One of the chief etiologic factors in lung abscess, dental sepsis, was

almost entirely eliminated in World War II by the excellent dental care provided for all soldiers in the Army.

2. The almost universal use of the sulfonamides, and later of penicillin,

in pneumonia and other severe respiratory infections probably accounted for

the absence of the fulminating infections formerly seen and also explained the

presence of more chronic, less severe types.

3. Because of the effectiveness of penicillin, many patients with small

abscesses, which were treated promptly, were probably cured in smaller hospitals and did not have to be referred to chest centers.

Chronic lung abscesses, nonetheless, furnished numerous problems. As

early as October 1943, Major Blades reported to Colonel Carter thatthe thoracic

surgeons at all centers complained that these patients were not being trans-
SURGICAL ASPECTS, DISEASES OF THE CHEST 429

ferred to the centers early enough; most of them had been ill for 4 to 6 months

when they were first seen.

In War Department Technical Bulletin (TB MED) 69 (0), 22 July 1944,

directions were given to transfer all patients with lung abscesses to thoracic

surgery centers if conservative treatment failed to produce prompt symptomatic improvement, accompanied by roentgenologic evidence of clearing of the

surrounding pneumonia and progressive decrease in the size of the cavity. In

view of the difficulties of management of chronic lung abscess, transfer was to

be effected within 30 days of the patient's admission to the hospital unless the

rate of healing clearly indicated that surgical treatment would not be required.

Management

As in other suppurative diseases, the response to penicillin of a patient with

a lung abscess depended upon the process. A number of small, carefully supervised series showed that the only effect in abscesses of any severity was likely to

be symptomatic improvement and that regression would occur as soon as

therapy was discontinued. It could scarcely be expected that a pathologic

process characterized by tissue destruction, necrosis, and gangrene would be

improved by any antibiotic, even if the organisms present were sensitive to it

and were of low virulence.

Even before the war, drainage of lung abscesses had fallen into disfavor

because of the poor results. This operation decreased the sputum and reduced

the fever, but it wrought no real improvement in a patient in whom an entire

lobe had been destroyed and whose infection involved the interlobar fissures

and had spread to adjacent lobes. It was only in very early cases, when the

abscesses were well circumscribed and drainage was instituted promptly, that

the results of conservative surgery were satisfactory.

Excisional surgery had begun to be popular before the war, as technical

refinements and developments in anesthesia greatly reduced the surgical risks.

It was the preferred method of treatment for chronic lung abscesses in the

thoracic surgery centers in the Zone of Interior. The risk of lobectomy was

somewhat greater than in bronchiectasis, but it was generally regarded as

worth taking in view of the prospect of chronic invalidism which otherwise

faced the patient, and, on the w

Thole, the results were excellent.

EMPYEMA

When the sulfonamide drugs first became available, shortly befoi-e World

War II, accumulated data promptly showed that the almost universal use of

these agents in the treatment of pneumonia was resulting in a marked decrease

in the postpneumonic variety of suppurative pleurisy. The local and systemic

use of the various sulfonamide derivatives also showed, however, that once a

purulent exudate had formed in the pleura, cure by chemotherapy was not possi-
4:50 THORACIC SURGERY

ble: Toxic reactions prevented the use of sufficiently large doses by the systemic

route to effect a cure, while local injections into the pleural cavity were equally

ineffective, since the admixture with purulent fluid inhibited their antibacterial

action.

Management

When penicillin became available, it seemed, at least theoretically, that it

would be ideal for the management of postpneumonic empyema caused by

micro-organisms susceptible to it, It has a strong antibacterial action when

used systemically, and retains its potency in the presence of pus and blood.

Its low toxicity permits the use of very large doses both loealty and systemically

with little risk of toxic or other side effects.

In spite of these favorable circumstances, the original high hopes were not

fulfilled. When acute empyema was treated in the early stages by aspiration

and injection of penicillin, there were numerous good results. This was not

always true, however, even in acute cases, and it was seldom true in chronic

cases, in which its prolonged use was an invitation to chronicity. There was no

reason, for instance, for the 11 thoracenteses and 300 intramuscular injections

of penicillin employed in one of the early cases over a 6-month period of hospitalization. There was never any justification, in fact, for the continuation of

conservative treatment unless there was a progressive decrease in the size of

the cavity accompanied by clearing of the purulent fluid.

In TB Med 69 (2), it was directed that surgical drainage must be employed

when the pus in the empyema cavity was thick, since its presence predisposed to

thickening and fixation of the pleura and the consequent development of chronic

empyema, It was further directed that all patients with chronic empyema be

transferred to a thoracic surgery center for treatment and disposition. An

empyema was considered to be chronic when, at the end of 6 weeks after the

original operation, the cavity measured 30 cc. or more.

The following policies of management finally become routine:

1. An injection of penicillin was given intrapleurally as soon as infected

fluid was demonstrated in the cavity. Additional local therapy was then

withheld until the organisms present were identified and it was determined

that they were penicillin susceptible. Delay in local treatment was particularly

emphasized when penicillin first became available and quantities were so

limited that it could not be wasted.

2. If systemic penicillin had not been employed during the pneumonic

stage of the disease, it was begun at once. The chief advantage of this route

was that it put into the blood a bacteria-inhibiting substance which might

prevent or control a spreading cellulitis or invasive infection. This was

particularly important when the responsible organism was streptococcus or

staphylococcus.

3. Three intrapleural injections of 50,000 units each, on alternate days,

were usually sufficient, Before the injection, as much fluid as possible was

removed by thoracentesis.
SURGICAL ASPECTS, DISEASES OF THE CHEST 431

4. If exuclate continued to form and became thicker, surgical drainage was

established without further delay. Thick pus could not be evacuated satisfactorily by needle, and even sterile fluid was often so thick that thoracotomy was

necessary for adequate drainage. Valuable as penicillin was as an adjunct to

surgery, it did not permit the violation of fundamental surgical principles.

ACTINOMYCOSIS

Official statistics for actinomycosis show 207 admissions for this cause in

the 1942-45 period, with 4 deaths and 24 separations for disability.

Particular interest was aroused in this disease at the Kennedy General

Hospital chest center when the ray fungus was isolated in two patients under

treatment for pulmonary suppuration. Thereafter, this organism was searched

for routinely in all suppurative chest disease and was found with surprising

frequency, as is evident in a report by Major Kay (3).

Between May and November 1945, Actinomyces bovis {Israeli) was found

in 109 of 240 patients under treatment for chronic bronchopulmonary infections. In no instance was it the only organism found. In a number of patients

it appeared to predominate, but usually such other organisms as streptococci,

staphylococci, spirochetes, fusiform bacilli, and other less common microorganisms were also identified. Actinomyces was found in the sputum in all

109 cases by direct examination and by culture, in specimens secured by bronchoscopy in 65 cases, in exuclate aspirated from lung abscesses in 6 cases, and

in drainage from sinus tracts in 2 patients with empyema secondary to pulmonary suppuration. The 65 patients from whom the organisms were cultured

from bronchoscopic specimens included 87 with bronchiectasis and pneumonitis

of varying degrees of severity, 8 with lung abscess, 5 with pulmonary suppuration, 5 with aspiration pneumonia, 2 with suppuration distal to obstructing

carcinoma, and 8 with chronic bronchitis.

These findings at first caused considerable concern among medical officers

whose previous experience with this condition had been limited to isolated

cases. There was debate as to whether these cases should be considered

as instances of bronchopulmonary actinomycosis or as instances of bronchopulmonary suppuration in which the ray fungus was present among other

infecting organisms. As experience accumulated, it was evident that the

clinical significance of Actinomyces was far less than had originally been

feared. The clinical course and the response to surgery and chemotherapeutic

measures did not seem to be influenced by its presence or absence; chronic

pulmonary suppuration is a very chronic condition per se.

The precautions originally taken when Actinomyces was identified included increased dosages of the sulfonamides and penicillin before drainage

operations and, in a number of instances, postponement of the indicated surgery, for fear of development of a chronic draining sinus and empyema after

lobectomy. In no instance did this happen. The fungus was isolated in the
432 THORACIC SURGERY

pleura! fluid of one patient after pneumonectomy, but it promptly disappeared

when intrapleural injections of penicillin and sulfadiazine were used. In other

words, as time passed, it became evident that this fungus was of less significance in the clinical course, chronicity, and prognosis of pulmonary and pleura!

infections than the mechanical factors of bronchial occlusion or drainage, tissue

destruction, fibrosis, and avascularity. Patients who presented these findings

were just as resistant to conservative therapy as were patients who harbored

Actinomyces.

Management

The response to treatment depended upon the chronicity and the severity

of the infection. Penicillin and sulfadiazine, used in combination and in

large doses, gave the best results, but it was important that they be continued

well beyond clinical improvement and roentgenologic clearance; otherwise,

recurrence was certain. The routine of treatment required the injection of

50,000 units of penicillin intramuscularly every 3 hours for 8 to 12 weeks or

longer, and the maintenance of a sulfadiazine blood level of 10 mg. percent.

It was thought that streptomycin might prove even more effective, but the

evidence was inconclusive when the survey ended.

If cavitation was present, the routine just described was considerably less

effective; the patients were improved symptomatically, and there was clearing

of pneumonias about the cavity, but the basic disease was not affected.

Lobectomy was required in two cases in this series in which medical treatment

failed and drainage was also unsatisfactory, and pneumonectomy was necessary

in two similar cases. It was thought that one or the other of these procedures

would also be necessary in other cases.

SPONTANEOUS PNEUMOTHORAX OF NONTUBERCULOUS ORIGIN

Spontaneous pneurnothorax of nontuberculous origin was observed at all

chest centers. Coionel Meade and Colonel Blades (4) analyzed the 18 cases

jointly observed at the chest centers at Kennedy General Hospital and Walter

Eeed General Hospital. Eight of the pneumothoraces were recurrent, eleven

were chronic, and all were cured by surgery. In 3 of the 18 cases, no etiologic

factor could be determined. In the remaining cases, rupture of peripheral

emphysematous blebs and bronchogenic cysts was the most frequent cause.

The policy was to perform open thoracotomy on any patient who did not

respond promptly to simple aspiration of air or induction of a chemical pleuritis. The procedures employed included excision of blebs and cysts; closure

of fistulas; division of isolated adhesions; lobectomy; and pulmonary decortication, which was necessary in five cases before satisfactory reexpansion of

the lung was accomplished. Open operation was employed in all cases, so

that the underlying cause could be dealt with and decortication performed if

reexpansion was not satisfactory.
SURGICAL ASPECTS, DISEASES OF THE CHEST 433

MALIGNANT NEOPLASMS

Incidence

Figures collected by the Medical Statistics Division, Office of The Surgeon

General, for 1944 and 1945 (table 17) show a total of 205 primary admissions

for malignant neoplasms of the thorax, of which 140 were in the lung and the

bronchus. Another 45 admissions were recorded for secondary malignancy

of the thoracic structures. No instances of malignant neoplasm of the trachea

were recorded during this period. Though the total number of cases is small,

a wide variety of histologic patterns is represented (table 18).

There were 141 deaths in the 205 primary malignant neoplasms, 83 of

which occurred in the Zone of Interior (table 19). Men whose disease was

discovered overseas were evacuated to the United States at once.

While the figures represent, only the 1944^5 period, it is possible that both

the 141 deaths and the 53 disability separations recorded for the 2 years include

some patients admitted before 1944. As to the remaining 11 patients not included in the deaths and disability separations, it is highly probable that some

died after separation from service.

Neoplasms of the lymphatic and hematopoietic tissue are not included in

these tables, but some figures (based on 20 percent samples) are available.

During the 1944-45 period, there were:

35 primary and 5 secondary admissions for neoplasms of the mediastinum,

with 3 deaths and 10 disability separations.

5 primary admissions for neoplasms of the larynx, with 1 death and 1

disability separation.

Two deaths and three disability separations for this category of pulmonary

neoplasms were also recorded during 1944-45.

Carcinoma of the Lung and the Esophagus

No special discussion of carcinoma of the lung during the war is called

for. The manifestations were the same as in civilian life, most of the tumors

being inoperable by the time the diagnosis was made. A number of highly

malignant peripheral bronchogenic cancers gave no warning of their presence

until metastases contraindicated even palliative surgery. Eesults were only

slightly better in a smaller group of older patients whose tumors were centrally

located and of the squamous cell type.

How discouraging the results of treatment were in carcinoma of the lungis evident in the 1945 report from Fitzsimons General Hospital: Of 10 bronchogenic carcinomas observed that year, 7 were inoperable when the diagnosis

was made, and irradiation was completely ineffective; all 7 patients died

promptly. Of the three who underwent pneumonectomy, one died of extensive

metastases and one of pneumonia in the remaining lung 3 months after operation. The third patient in this group was still in the hospital undergoing

irradiation when the report was made.
THORACIC SURGERY

TABLE 17.—Incidence of malignant neoplasms1of the respiratory system (by anatomic

site) and of the esophagus, by area of admission, U.S. Army, 19J,Jf-Jfö

[Preliminary data based on 20 percent sample tabulations of individual medical records]

Area Site of malignant neoplasm

Lung Bronchus Pleura Mediastinum Larynx Esophagus

NUMBER OF ADMISSIONS

Continental United States 75 15 25 5

Overseas:

Europe,_ __ _ 25

10

5

10 5 10

Southwest Pacific

Central and South Pacific

Latin America

5 5

5

5

Total overseas- 40 10 5 15 15

Total Armv_ _ . 115 25 5 15 40 5

IS UMBER OF SECONDARY CAS ES2

Continental United States _ _ 10

Overseas:

Europe, _ 10

5

5

5

5 5

Mediterranean 3_

Central and South Pacific

Total overseas 20 5 5 5

Total Army _ 30 5 5 5

1

1 Neoplastic conditions of lymphoid and hematopoietic tissues are excluded.

-' Ten secondary cases of malignant neoplasm of lung were reported among battle admissions—5 each in the European

and the Central and South Pacific theaters; all other secondary cases were reported among disease admissions.

3

Includes North Africa.

The outlook in malignant lesions of the esophagus was equally poor. In

seven carcinomas observed at the Kennedy General Hospital chest center, three

were found to be inoperable in exploration. Three were treated by resection

with anastomosis, and the remaining patient underwent, respectively, total

gastrectomy; transverse colectomy; and esophagojejunostomy, a procedure

which almost implies a fatal outcome.
SURGICAL ASPECTS, DISEASES OF THE CHEST 435

TABLE 18—Morbidity and mortality from malignant neoplasms'1 of the respiratory system

(by anatomic site) and of the esophagus, by histologic type and type of case,

U.S. Army, 19U-.)5

[Preliminary data based on tabulations of individual medical records] 2

Anatomic site and histologic type Admissions Secondary

cases

Deaths 3 Disability

separations -

1

Lung:

100

5

25 77

1

19

5

1

1

10 6

Total 115 30 86 19

Bronchus:

20

5

5 26

1

4

Total 25 5 27 4

Pleura:

5 1 1

1

5

Total 5 5 1 2

Mediastinum:

5

5

5

5

2

9

1

6

Total 15 16 7

Larynx:

30 5 3

1

15

1

5

5

1

Total 40 5 4 17

Esophagus:

5 7 4

Total 5 7 4

205 45 141 53

i Neoplastic conditions of lymphoid and hematopoietic tissues are excluded.

2 Admissions and secondary cases are based on 20-percent samples; deaths and disability separations are based on

complete files of the records.

3 These are all deaths due to the conditions indicated which occurred during 1944-45.

< These are all cases separated from the service during 1944-45 because of disability from the conditions indicated.
43( THORACIC SURGERY

TABLE 19.—Deaths due to malignant neoplasms1of the respiratory system (hy anatomic

site) and of the esophagus, try area of admission, U.S. Army, wPf-JS2

[Preliminary data based on tabulations of individual medical records]

Malignant neoplasms inArea Respiratory system, by anatomic site

Esophagus

Lung ' Bronchus Pleura Mediastinum Larynx

Continental United States 55 14 7 4

Overseas:

Europe 12

S

1

5

1

6

1

1

1

2

1

2

3

1 1

Mediterranean 1

3

Middle East

China-Burma-India

Southwest Pacific

Central and South Pacific

North America 4

1

1

1 1

Latin America 9 1 — .. —.

Total overseas ä

31 13 1 9 1 3

Total Armv 8G 27 1 10 4

1 Neoplastie conditions of lymphoid and hematopoietic tissues are excluded.

= These are all deaths due to the conditions indicated which occurred during 1944-45

3

Includes North Africa.

< Includes Alaska and Iceland.

s Includes one death among admissions on transports.

Tumors of the Mediastinum

During the 3-year period of their activity, 109 patients with mediastinal

tumors were operated on at the five thoracic centers in the Zone of Interior.

The figures collected by Colonel Blades (-5) include only the cases in which

the chest was explored because of symptoms or because of the discovery of a

mediastinal mass on routine roentgenologic examination, which was tlie primary means of diagnosis in 94 of the 109 cases.

Five of the masses proved to be aneurysms, not neoplasms. Of the 104

true tumors, 15 were malignant and 89 were benign.

The malignant group included six teratomas, two thymomas, two lymphoblastomas, and one neurosarcoma. It also included four instances of Hodgkin's

disease, in three of which the diagnosis was not realized until histologic examination of the specimen. In one case, the tumor had invaded the upper lobe

of the lung, and lobectomy was necessary for its removal. Surgical intervention would not have been undertaken deliberately in any of these cases if the

true nature of the tumor had been established before operation. Short-term

observation, however, showed that the patients had not been harmed by removal
SURGICAL ASPECTS, DISEASES OF THE CHEST 437

of the visible tumors, and there was some evidence that they might have been

benefited.

Exclusive of the 4 instances of Hodgkin's disease and the 5 aneurysms just

mentioned, the essential data in the remaining 100 cases were as follows:

Bronchogenic cysts.—There w

Tere 23 bronchogenic cysts in this series, a

surprisingly large number considering the fact that up to 1945, according to

Laipply (6), only 35 had been recorded.

Only 2 of the 23 patients had clinical manifestations. In the remainder,

the mass was found on roentgenologic examination. Even with detailed

studies, the true nature of the masses was difficult to establish. On the frontal

projection, they suggested either teratoid tumors or primary nerve tumors.

On the. lateral view, the shadow was not so distinct as in teratoid tumors, and

the extreme posterior position characteristic of most primary nerve tumors

was not evident. Since most bronchogenic cysts are attached to the trachea

(most often near the tracheal bifurcation in the superior mediastinum), the

mass moved during swallowing, as could be demonstrated by fluoroscopic

examination, which was of some diagnostic assistance. A patent lumen communicating with the trachea or a bronchus was not demonstrable in any case.

There were two sound reasons for advising the surgical removal of bronchogenic cysts even if they were asymptomatic:

1. There was no reliable method, except surgical exploration, for determining the true nature of tire tumor. Many neoplasms of the mediastinum

with grave malignant potentialities resemble bronchogenic cysts on roentgenologic examination. Moreover, since bronchogenic lesions are considered as

cell rests, there is no assurance that malignant changes will not occur in them.

2. Bronchogenic cysts may become infected. If they do, operative interference is necessary, and technical difficulties at this time may be considerable.

Also, cysts which are presently asymptomatic may increase in size and produce

later pressure and other symptoms.

Teratoid tumors.—Twenty of the tumors in this series were teratoid, to

use the inclusive nomenclature suggested by Harrington (7). Fourteen were

benign and were removed without difficulty. Advanced changes were evident

in the six malignant growths. Only surgical extirpation can be considered

for these tumors, because of the risk of malignant degeneration.

Up to 1945, close to 250 teratoid tumors had been reported in the medical

literature (6), and they are the most common lesions of the anterior mediastinum. In the collected cases, only three were in other locations. The number

observed in the chest centers during World War II would undoubtedly have

been larger except that these tumors produce sharp shadows and are so easily

detected by roentgenogram that most men who harbored them were probably

identified at the preinduction examination and were rejected for service.

Neurogenic tumors.—The 29 benign primary nerve tumors of the mediastinum observed in this series included chiefly neurofibromas, ganglioneuromas,

and sympathicoblastomas. Up to 1944, 105 of these tumors had been collected
438 THORACIC SURGERY

by Kent and his associates (<S), all but 2 of which were located posteriorly.

In their series, 37 percent of the tumors had undergone malignant change,

which makes clear why surgical excision is the correct treatment as soon as

the tumor becomes evident.

One patient with a neurogenic sarcoma was explored, but invasion of the

surrounding structures precluded its removal. All the other tumors were

excised.

Pericartlial cysts.—The 10 pericardial cysts in the series were all discovered on routine roentgenologic examination. Except for their characteristically anterior location, there is nothing to differentiate these cysts from other

mediastinal tumors, and surgical excision is the only way to establish their

character.

Thymomas.—Four of the six patients with thymomas, two of which were

malignant, had no symptoms referable to the mass. In one case, in which the

patient had advanced myasthenia gravis, it was impossible to remove the malignant mass completely.

Lipomas.—Only 4 lipomas were encountered, which is not surprising,

since less than 40 mediastinal tumors of this type could be collected by Watson

and Urban (9) in 1944.

Other tumors.—Other mediastinal tumors in this series included one fibroma, which was probably a neurofibroma; one thyroid adenoma; one cyst

arising from the esophagus; one osteochondroma; one Boeck*s sarcoid, diagnosed by biopsy of tissue at the hilus; and two tuberculomas.

Comment.—There was not complete agreement among the surgeons at the

chest centers as to the best exposure for mediastinal tumors. Some routinely

employed a posterolateral exposure; others preferred an anterior approach if

the location of the tumor made it logical. The technique employed usually

reflected the early training which the surgeon had received. On one point there

was general agreement, that if difficulties were anticipated, a lateral or posterolateral incision should be used.

Before World War II, tumors of the mediastinum were frequently treated

by irradiation, surgery being resorted to only if satisfactory results were not

accomplished. This was never a safe or a desirable plan. As has been pointed

out several times in this brief analysis of the 109 mediastinal masses treated

at the chest centers in the Zone of Interior during World War II, it is not

possible, in most instances, to determine the true character of a mediastinal

tumor without direct inspection at operation. If operation is delayed until

symptoms and signs become apparent, the chance for successful extirpation

will frequently have been lost.

The reasoning behind the use of irradiation in preference to exploration

was the risk originally attendant upon exploratory thoracotomy. This risk

ceased to exist when refinements in surgical and anesthetic techniques made

exploration of the chest safe. Risks were negligible in the chest centers during
SURGICAL ASPECTS, DISEASES OF THE CHEST 439

World War II. Errors in diagnosis occasionally occurred, and a few tumors

were operated on which might have responded to irradiation, but the danger

to the patients was slight compared to the harmful potentialities of prolonged

and ineffective irradiation. Irradiation will not reduce the size, or halt the

malignant degeneration, of these tumors unless they are of lymphatic origin,

and surgery is more dangerous and more difficult after prolonged use of X-rays.

The results in this series justify the management of mediastinal tumors by

prompt exploration of the chest. There were no deaths that could be attributed

to the operation and no postoperative complications in the cases in which only

exploration and biopsy were performed. Suppurative pleuritis developed in

three cases in which a tumor was removed, but adequate drainage was followed

by prompt healing. In one of these cases, it had been necessary to remove an

infected right middle lobe that had been eroded by a teratoma.

LESIONS OF THE ESOPHAGUS

In addition to the seven malignant tumors of the esophagus treated at

Kennedy General Hospital, Major Kay's (10) survey of esophageal lesions at

that center included:

2 benign new growths (neurofibroma and leiomyoma).

5 cysts (2 clermoicl, 1 bronchogenic).

9 diverticula (4 traction, 3 pulsion, 1 epiphrenic).

I varix (too extensive for treatment).

9 hiatal hernias (5 treated surgically).

4 paraesophageal hernias (1 treated surgically).

20 cardiospasms (11 treated surgically).

II obstructions clue to extrinsic tumors, cysts, aneurysms and tuberculous

nodes (all treated by measures directed to the extrinsic lesion).

8 congenitally short esophagi (3 associated with stricture and 4 with ulcer).

18 strictures (11 clue to ingestion of "sabotaged alcoholic beverages consumed accidentally overseas," and 3 to attempts at suicide).

24 traumatic injuries and war wounds (fistulas, abscesses, strictures, retained foreign bodies).

Management of all of these lesions followed the policies general in civilian

practice. There was only 1 death in the 42 major operations performed.

References

1. Kay, E. B., Meacle, R. H., Jr., and Hughes, F. A., Jr.: Surgical Treatment of Bronchiectasis. Ann. Int. Mecl. 26: 1-12, January 1947.

2. War Department Technical Bulletin (TB MED) 69, 22 July 1944. Notes on Certain

Diseases of the Chest.

3. Kay, E. B.: Bronchopulmonary Actinomycosis. Ann. Int. Mecl. 26: 581-593, April

1947.
m THORACIC

4. Meade, R. H., Jr., and Blades, B. B.: The Surgical Treatment of Recurrent and

Chronic Spontaneous Pneumothorax of Xontuberculous Origin. Am. Rev. Tuherc. CO: 083-

C9S, December 1949.

."">. Blades. B.: Mediastinal Tumors. Report of Cases Treated at Army Thoracic Surgery Centers in the United Slates. Ann. Surg. 123:749-705, May 1940.

0. Laipply, T. C.: Cysts and Cystic Tumors of the Mediastinum. Arch. rath. 39 : 153-

101. March 1945.

7. Harrington, S. YV. : Surgical Treatment in Eleven Cases of Mediastinal and Intrathoracic Teratomas. J. Thoracic Surg. 3:50-72, October 1933.

s. Kent, K. M., Blades, B., Valle, A. R., and Graham, E. A.: Intrathoracic Neurogenic

Tumors. J. Thoracic Surg. 13:110-101, April 1944.

9. "Watson. W. L., and Urban, J. A.: Mediastinal Eipoma: A Case Report. J. Thoracic

Surg. 13 : 10-29, February 1944.

10. Kay, E. B.: Surgical Lesions of the Esophagus Seen in an Army Thoracic Surgery

Center. J. Thoracic Surg. 10:207-214. June 1947.
CHAPTER XI

Long-Term (1943-61) Followup Studies in Combat-Incurred Thoracic Wounds

Lyman A. Brewer III, M.D.

Followup information is as notably deficient concerning casualties with

combat-incurred wounds of the chest as it is concerning- most other casualties.

There are almost no studies of this kind in the medicomilitary literature,

which is extremely unfortunate, for it makes it impossible to determine the

true end results of any given plan of management.

Up to March 19-14, chest wounds sustained in the Mediterranean (formerly

North African) Theater of Operations, U.S. Army, in World War II were

treated according to the personal policies of the surgeon who handled the particular patient, After this date, thoracic casualties were treated by a specific

regimen that differed, in many respects, from the policies employed earlier.

The investigation reported in this chapter was undertaken in an attempt

to trace the postwar course of a group of casualties who had sustained chest

injuries in the Mediterranean theater and who had all been treated (1) in forward hospitals, (2) under the direction of a single surgeon and his assistants,

(3) by the specific regimen just mentioned. This group of patients was followed into the hospitals of the communications zone and the Zone of Interior,

and some of them were followed up for varying periods of time, up to February 1961, after their separation from service.

BACKGROUND OF STUDY

In the summer of 1943, during the Sicilian campaign, studies at the thoracic

surgery center at Bizerte, North Africa, on casualties returning from forward

areas revealed a high mortality rate and a considerable morbidity among the

group treated by thoracotomy at initial wound surgery. The impression arose

that this operation was being performed on unnecessary indications in forward

hospitals and that its promiscuous use was having an adverse effect on the results

of chest injuries.

On the basis of these impressions, Col. Edward D. Churchill, MC, Consultant in Surgery to the theater surgeon, detached Capt. (later Maj.) Lyman

A. Brewer III, MC, from his duties at the Bizerte chest center and assigned

him to the forward hospitals supporting the landings at Salerno in September

740-941^05—31 441
442 THORACIC SURGERY

1943. His mission was to study the problems of forward surgery in thoracic

injuries and to continue the investigation as the troops advanced into Italy.

Two facts promptly became apparentto Captain Brewer:

1. Thoracotomies were indeed being performed unnecessarily in forward

hospitals as part of initial wound surgery.

2. In spite of this fact, the indications for thoraeotomy in forward hospitals could be very sharply defined.

At a conference of thoracic surgeons called, and presided over, by Colonel

Churchill in March 1944, at Marcianese (vol. I), the results of Captain Brewer's investigations were reported. At this meeting, the indications for primary thoraeotomy in forward hospitals were defined, and the so-called limited

approach to this operation thereafter became the prescribed policy in the

Mediterranean theater.

This followup study had its genesis during the war, when Captain Brewer

took upon himself the task of keeping duplicate individual records for all casualties with thoracic injuries treated by him as head of Thoracic Surgical Team

No. 4, 2d Auxiliary Surgical Group. The team consisted of Captain Brewer;

Capt,' Charles A. Schiff, MC; Capt, Werner F. A. Iloeflich, MC; and 1st Lt.

Catherine V. Elliott, AKC.

Team No. 4 served first with the Fifth U.S. Army in Italy and then with

the Seventh U.S. Army in France, Germany, and Austria. This army originated in the Mediterranean theater and remained under its operational control

for the landings in southern France in August 1944 and during the first part

of the campaign in France. In December 1944, it passed to the logistic control of the European theater.

The team served in forward hospitals during the landings at Salerno in

September 1943 and the campaign in Italy, the landings at Saint-Raphael and

the campaign in southern France, and then during the campaigns in Germany

and Austria until A^-E Day in May 1945. It was variously attached to the

94th Evacuation Hospital (Salerno to Cassino), the 11th Field Hospital (Cassino), the 11th Evacuation Hospital (Anzio to Civitavecchia), the 11th Field

Hospital (from the D-day landings at Saint-Raphael into eastern France),

the 66th Field Hospital (Vosges Mountains), and the 80th Field Hospital (Germany and Austria).

The casualties were thus encountered, and the surgeons worked, under a

wide variety of conditions of climate and terrain, in Italy, France, Germany,

and Austria, at all seasons, and from beachheads to mountains.

MATERIALS AND METHODS

Although Major Brewer and his team had personally treated more than

1,000 casualties with combat-incurred wounds, only 822 had wounds of the chest,

and only 372 of these were treated in forward hospitals. Of the 210 patients
FOLLOWUP STUDIES OF THORACIC WOUNDS 443

whose histories were reviewed when this analysis was undertaken, only 167

had sufficiently detailed records to make followup investigation of any real

value.

There are numerous problems connected with such an investigation. The

tracking down of a large number of former soldiers for varying periods of

time (from 3 to 17 years) after the termination of hostilities and their return

to civilian life was not simple. It was impossible, in fact, to follow the majority

because of the general movement of the population that now seems part of

the way of life in the United States. Had all of these men reported for further

treatment to VA (Veterans' Administration) clinics and hospitals, there would

have been no problem. Most of them did not. As will be pointed out later,

their failure to seek medical advice is probably a reflection of the fact that most

of them did not think thatthey needed it.

The A^eterans' Administration, however, is the most obvious source of help

in an undertaking of this kind, and with few exceptions, the men followed up

in this series after separation from service are those who reported to VA hospitals and clinics, either because they were disturbed over their status or because

they were actually in need of treatment.

Whatever success was achieved in this investigation is attributed to three

agencies:

The project was initiated with the complete cooperation, and had the assistance throughout, of The Historical Unit, U.S. Army Medical Service, a

class II activity of The Surgeon General, Department of the Army, under

whose direction the volumes in this historical series are being prepared.

It also had the complete cooperation of the Veterans' Administration and

of the Federal Records Center, General Services Administration, St. Louis,

Mo. (formerly the Army Records Center). Through the painstaking efforts

of the personnel of these two agencies, records were collected from numerous

sources and were forwarded to the study center in the VA Regional Office in

Los Angeles, Calif.1

In some instances, these records were well over an inch thick. A great

deal of the material included in them consisted of correspondence concerning

disability claims, pensions, and similar matters, but when it was winnowed,

it contained sufficient medical evidence to make good followup studies possible

in 167 patients.

In a number of cases, additional followup material was obtained by

direct correspondence with the veterans themselves. This method made it

possible to obtain firsthand, personal reports of their current status and also

to secure current roentgenograms.

1

It should be added that this truly unique investigation was the concept of Dr. Lyman A. Brewer

III, and that it was through his vigorous personal efforts that it was brought to a successful

conclusion.—F. B. B.
4M THORACIC SURGERY

22 23 24 23 26 27 28 29 30

THORACIC WOUND STUDY. WORLD WAR II. Return to: lyman A. Brewer III MD.

LQ> An gele» 57, Cdil.

Nnmf*

RnrA lln

Serinl Nn rintp w USA n USN USAF Q l.Othe G POW G

FORWARD HOSP. 1 nrntion

Rate Op ? Rtnrk D 5 TSC

6 PI. D

D S Tr. Thor. 11 Hem. Thor

G 9 Med. Thor. Q 12 Other

G Other

D

G

Type 3 Dphrd rain

4 Br. Aspr, 7 Thor Abd. G 10 Card. V. Thor. G

CLASSIFICATION OF WOUND:

13 Chest Wall D 18 F.B.PI. n 23 L. Hem n 28 Diaph. G 33 Spleen G 38 Head G

14 Ribs LI 19 F. B. Lung 24 Tr. Br. n 29 Stm. G 34 Renal D 39 Neck n 15 Pnx. 20 F. B. Med. G 25 Esoph. n 30 Sm. Int. Q 35 Pancr. G 40 Arms n 36 Hemnx. a 21 F. B. Ht. 26 Heart n 31 Lg. Int. G 36 Vascular G 41 Pelvis G

17 F. B. C. W. a 22 Lung Lac. 27 Med. n 32 Liver Q 37 Retpr. Q 42 Legs G

COMPLICATIONS:

43 Blast 46 Wet Lufig D 49 W. Infect. G 52 Lung Abc. Q 55 Med. Abd G

44 Shock 47 Hemothor. G 50 Empy ma 53 Br. Fistula Q 56 Abdom. G

45 Coma 48 Cord. Paral. [j 51 Pneumonitis G 54 Esoph. Fistula Q 57 Other G

DISPOSITION:

58 Died 59 Duty Date: 60 Evac. G

Date: Cause of Death Date:

7S 78 77 76 75 74 73 72 69 68 67 66 65 58 57 Si 55 54 53 52 51 SO

30 29 28 27 26 25 24 23 22 21

FOMOW.MP. NAMF

mMFrnM nn.<;p

Further Surgery:

61 C. W. Drain G 63 F. B. Rem.

62 Emp. Drain Q 64 Decort. G

Complications:

67 W. Infection G 69 Lung Inf.

68 Empyema G 70 Clot Hemx. G

Disposition:

73 nierl n Cause nf rips*

Site fifi Other rj Typp

65 Ahd Op G T»pe

71 Ahrl G Type

7? Other G

T

yPp

74 nntv n 75 7 I n nat»-

70NFINT HOSP

Further Surgery: 76 C. W. Drain G

77 Emp. Drain G 79 Lung Resec. G

78 Decort Q 80 Thorpl. Q

Complications: 84 W. Inf. 86 Lung Inf. G

85 Empyema G 87 Lung Abc. G

Disposition: 93 Died G Date:

94 Duty G

na,r

RFMARKS- Rate

92 Other Q

81 F R Rem G TyP"

82 Ahd. Op Q Type

83 Other G

88 Br. Fist. G 30 Med. Abs. G

89 Esoph Fist. G 91 Abd. G

Causp nf Death95 Disability 96 Chest Cause..

97 Other Q Rating % G

49 SO 51 S2 53 54 55 56 57 58 59 60 61 SI 67 68 69 70 72 73 74 75 76 77

FIGTJKE 195.—Punchcard designed to secure data in long-term followup of veterans with

combat-incurred wounds of chest. Top, front. Bottom, back.
FOLLOWUP STUDIES OF THORACIC WOUNDS 445

BASIC DATA

The data were collected on punchcards especially made up for the project

(fig. 195).

The age range of the 167 casualties was from 18 to 39 years. Of this

number, IG were in the 18- to 19-year group, 118 in the 20- to 29-year group,

and the remainder (33) in the 30- to 39-year group.

In 131 instances, the wounding agents were shell fragments and in 36,

gunshot.

Both in age distribution and in wounding agents, therefore, the patients

in this series are representative of all types of combat casualties in World War

II.

THERAPEUTIC CLASSIFICATION

The 167 patients were studied in two groups, according to their management in forward hospitals, as follows:

1. In 86 cases, wound debridement was carried out in forward hospitals,

but thoracotomy was not performed.

2. In the remaining 81 cases, in 25 of which the wound was thoracoabdominal, either thoracotomy or a combined thoracic and abdominal operation was

carried out.

This classification is based on the point, already emphasized, that careful

definition of the indications for, and contraindications to, thoracotomy in forward hospitals was one of the major contributions made by thoracic surgeons

who treated chest wounds in the Mediterranean theater in World War II.

One of the most important objectives of this study was to determine whether

any casualty in the group in which thoracotomy was omitted had died later

from complications or had suffered delayed morbidity referable to his wound.

Only a long-term followup could settle this point.

The components of both resuscitation and initial wound surgery have been

described in detail in the first volume of this thoracic surgery) subseries.

INITIAL WOUND SURGERY

In the group of patients in whom thoracotomy was not considered necessary at initial wound surgery, the penetrating wound produced by the missile

was of such limited dimensions that the wound did not suck (blow) originally

or after adequate debridement. In this type of wound, as in all others, important considerations, in addition to the size of the missile, included its angle of

penetration, its velocity, the damage to the bony cage, and the thickness of the

original protecting musculature. The location of the wound was obviously a

matter of great importance, A wound up to 2 cm. in diameter, if it was located

in the interior thoracic cage, might result in a traumatic thoracotomy, while a

wound up to 14 cm. in diameter, if it was located in the scapular region pos-
446 THORACIC SURGERY

teriorly, might not result in traumatic thoracotomy, even after extensive debriclemeiit. It was also generally true that smaller external wounds were likely

to produce less damage within the chest than would larger wounds. In 3 of the

86 cases in which primary thoracotomy was omitted, blast injuries were associated with powder and dirt burns of the chest, but neither the injury nor the

possibility of internal damage was considered an indication for immediate

thoracotomy.

In the remaining 81 cases, the initial wound was so extensive that it constituted, in itself, a traumatic thoracotomy; or the necessary debridement was so

extensive as to produce a traumatic thoracotomy; or iiitrathoracic or intraabdominal damage required entrance into these cavities to control hemorrhage

or repair damaged organs.

The indication for thoracotomy in 56 of these 81 cases was serious damage to

the chest wall or the iiitrathoracic contents. In six cases in this group, the

diaphragm was lacerated, but the abdomen was not penetrated. In three other

cases, the diaphragm was lacerated and the liver was penetrated by small

foreign bodies, 2 mm. in diameter in each instance. In none of the three cases

was the injury sufficient to cause either hemorrhage or extravasation of bile,

and thoracolaparotomy did not prove necessary at the base section later. Small

foreign bodies in the liver are usually well tolerated. Had the injuries been

more serious, exploration of the abdomen would have been necessary.

In the remaining 25 cases, the wounds were thoracoabdominal, and intraabdominal procedures were necessary. The number of casualties in this group

would have been larger except for the fact that patients with abdominal injuries

associated with chest injuries were considered within the province of general

surgeons. These casualties were always classified as nontransportable at triage,

and they were treated in forward installations, very often by general rather

than thoracic surgeons.

Since thoracotomy was done in over half of the 167 cases in this series, the

emphasis on limited thoracotomy may seem somewhat misplaced. There are at

least two valid reasons for the high proportion:

1. All the patients who were treated by primary thoracotomy were firstpriority, nontransportable casualties. The data (tables 20-23) show that both

iiitrathoracic and extrathoracic damage were frequently extremely severe.

2. The concentration of so many serious injuries in such a small series is

explained by the fact that frequently in forward areas in which there were few

or no thoracic surgeons, thoracic casualties were referred to Thoracic Surgical

Team r>To. 4, which served as a sort of unofficial forward thoracic surgery center.

Another index of the severity of the injuries in this series is the length

of hospitalization in forward hospitals. The 86 patients in whom primary

thoracotomy was not clone were held from 7 to 14 days, on the average, while

the 81 who required thoracotomy were held, on the average, from 4 to 7 clays

longer. An occasional patient in both groups had to be evacuated before the

optimum time because of the tactical situation.
FOLLOWUP STUDIES OF THORACIC WOUNDS 447

TABLE 20.—Thoracic damage in 161 followed-up thoracic casualties according to surgical

procedures in forward hospitals

Thoracic damage

Chest wall:

Soft tissue

Bony cage

Persistent pncumotliorax

Persistent hemothorax_ _.

Foreign bodies:

Chest wall

Pleura

Lung

Mediastinum

Pulmonary laceration

Pulmonary hematoma__.

Mediastinal injury

Diaphragmatic injury—

Surgical procedure

Tlioracotomy

Tlioracoabdominal suraery

Total

Yes No

56 86 25 167

69 23 19 111

10 13 5 28

45 29 17 91

8 18 9 35

14 4 3 21

18 15 3 36

6 1 3 10

38 12 11 61

27 53 9 89

7 4 2 13

9 1 25 35

TABLE 21.—Associated injuries in 161 folhnccd-up thoracic casualties according to surgical

procedure

Head

Neck

Pelvis

Extremities:

Upper.

Lower-.

Spine

Blast

Surgical procedure

Tlioracotomy

Yes

23

12

1

9

Thoracoabdominal

surgery

9

6

22

21

Total

1 11

1 15

3 16

7 52

5 38

1 2

6 21
m THORACIC SURGERY

TABLE 22.—Intra-abdominal damage in 81 followed-up thoracic casualties according to surgical

procedure

Surgical procedure

\ iscera and structures injured

Tlioracotoiny Thoracoabdoininal surgery

Total

Diaphragm 10

3

21

4

5

5

11

6

5

1

3

4

31

7

5

5

13

6

5

1

6

4

Stomach

Small intestine

Large intestine

Liver o

Spleen

Kidnev

Pancreas

Vessels 3

Retroperitoneum

TABLE 23.—Complications in forward and fixed hospitals in 167 followed-up thoracic casualties

according to surgical procedures in forward hospitals

Surgical procedures in forward

hospitals

Surgical procedures in

hospitals

fixed

Complications

Tlioracotoiny Thoracoabdonn'nal

surgery

Total

Tlioracotoiny Thoracoalxloininul

surgery

Total

Grand

total

Yes No Yes Xo

Shock 1

8

1

37

18

22

5

4

1

6

o

12

2

65

26

12

Coma 2

Wet lung 65

Hemothorax 26

Wound infection 5

4

2

3

3

2

10

9

10

12

5

Empvema

Pneumonitis

1

1

2

2

2

2

2

2

o

5

2

11

2

1

16

Luna; abscess 2

Chronic hemothorax 4 5 11

Bronchial fistula 2

Abdominal 2

1

4

4

1 o

6

3

10

7

11

Other 23

3

5 7

1 Severe only. 2 Subplirenic and peritoneal abscesses, et cetera.

s Hepatitis, amputations, toxic psychoses, et cetera.
FOLLOWl'P STl'DIES OF THORACIC AYOl.'XOS 449

SUBSEQUENT SURGERY

In oversea hospitals.—By the time the Italian campaign began, excellent

facilities had been provided in the thoracic surgery centers in base sections of

the North African theater for handling thoracic and thoracoabdominal casualties. The principles of treatment were becoming standardized. Well-trained

and experienced personnel were available. Also, it was possible to keep the

patients in these hospitals, when necessary, for periods up to 150 days.

Delayed primary wound closure, with or without redebridement, accounted

for the largest number of operations (59) necessary in base section hospitals

(table 24). No undue morbidity followed the removal of retained foreign

bodies in 13 cases; in fact, the patients were then in much better condition to

withstand the procedure than they were immediately after wounding.

Most of the drainage operations for infections of the chest wall and for

empyema (seven each) were required because of the extent of the original

wound and the serious contamination that had occurred.

Seven decortications were carried out for empyema and two for organizing hemothorax. Most of the patients in the empyema group had been treated

only by debridement and thoracentesis in forward hospitals.

Colostomies were closed twice, both in patients in particularly good condition. It was always desirable to perform this operation overseas if it could

be clone.

As these data show, most surgery in base section hospitals, aside from

delayed primary wound closure, was necessary for infections of the chest wall

and pleural cavity. Persistent pneumonitis was not seen in any of these

patients.

TABLE 24.—Surgery required in fixed hospitals according to surgery performed in forward

hospitals

Surgery in fixed hospitals

Drainage of chest wall

Drainage for empyema

Removal of foreign body

Decortieation

Abdominal surgery

Delayed primary wound closure

Other

Previous surgery in forward hospitals

Thoraeotomy

2

5

5

4

2

26

8

Xo

31

12

Thoracolaparotomy

I

7

13

9

6

59

2G

74G-941T
450 THORACIC SURGERY

In Zone of Interior hospitals.—Only a small amount of surgery was necessary in these casualties in Zone of Interior chest centers :

Two patients required drainage for empyema 5 and G months, respectively,

after wounding. One had had a traumatic thoracotomy and the other a

thoracoabdominal wound.

In three instances, removal of foreign bodies Avas necessary. In the first

case, the missile was removed from the lung of a patient who had had debridement without thoracotomy in a field hospital. In the second, the missile was

removed from the abdomen when a colostoiny was closed. In the third case,

the object was removed from the liver.

The only other thoracic surgery required was excision of an arteriovenous

fistula involving the internal mammary artery.

Chest pain and dyspnea were the principal complaints of casualties who

were not returned to duty from Zone of Interior chest centers. In practically

all of these cases, as will be pointed out later (p. 523), physical and roentgenologic examinations showed excellent lung expansion and minimal pleura!

reaction.

MORTALITY AND DISPOSITION

Deaths.—Four deaths occurred in base section hospitals, all in casualties

with multiple wounds, all of whom had been serious problems from the

moment they were carried into the shock tent of the field hospital until they

died in a fixed hospital in the base. Three had thoracoabdominal wounds;

hepatic infection and jaundice were factors in each fatality, and one patient

also had peritonitis. The remaining casualty had a traumatic thoracotomy

and a spinal cord injury with paraplegia. He died of pulmonary complications and secondary hemorrhage soon after evacuation from the field hospital.

Disposition.—Two casualties, both of whom had small wounds limited to

the chest, were discharged from forward hospitals directly to their units.

In view of the multiplicity and severity of the wounds sustained by most

of the remaining patients in this series, it is surprising to learn that about

half of them could bo returned to duty in the theater, most to limited duty

but a few to active frontline combat. The larger number of casualties returned

to duty, 50, were in the group in which primary thoracotomy was not necessary, but 38 patients who required thoracotomy and 5 who required thoracoabdominal surgery were also returned to duty. This was, of course, a sound

policy in an oversea theater, in that it conserved manpower in the theater

and reduced the need for replacement from the Zone of Interior. One reason

that it was possible was that the holding time in base section hospitals, sometimes up to 5 months, was sufficient for small wounds to close by secondary

intention,2for wounds closed by delayed primary suture to heal solidly, for

pleura! effusions to be absorbed, and for hematomas of the lung to resolve.

2 Two kinds of wounds were allowed to heal by secondary intention : (1) those in which infection

was just enough of a possibility to make surgeons in the base hospitals hesitant to perform delayed

primary closure, and (2) large clean wounds which for one reason or another were not suitable for

delayed primary closure.
FOLLOWUP STUDIES OF THORACIC WOUNDS 451

In the Zone of Interior, only 17 patients were returned to duty, most of

them to limited duty. The group was about equally divided between those

who had undergone primary thoracotomy and those who had not. The number

was necessarily small, in view of the policy in the Mediterranean theater of

not evacuating casualties to the Zone of Interior, unless there was a shortage

of beds, until it was reasonably clear that they could not return to duty in

the oversea theater.

"When the group of patients returned to duty overseas is added to the

group returned to duty in the Zone of Interior, it is seen that more than twothirds (112) of the 168 patients who survived surgery in forward and base

hospitals could be returned to some form of useful army service. Had the

war continued and this same trend continued, there would have been an

enormous saving in manpower. As it was, it is impossible to estimate the

morale factor inherent in the return to duty of such a large number of seriously

wounded men.

The postwar status of these casualties will be discussed later.

The case histories which follow have been selected from the histories of the

167 patients followed up after forward surgery to illustrate special conditions

and complications and the methods of treatment employed for them. They

are deliberately presented in some detail.

WOUNDS OF THE CHEST WALL

Although the chest wall was, of course, involved in all penetrating wounds

of the chest, in 22 cases in this series, these wounds were small. They were

sometimes associated with serious iihrathoracic problems, but in all cases, the

wounds themselves were readily managed by simple debridement.

In the remaining 145 cases, trauma to muscle masses and the bony cage

was extensive enough to create challenging clinical problems. Foreign bodies

were present in 35 cases, and there were 88 sucking wounds and 4 thoracoabdominal wounds in the series. The bony case was involved 101 times, the

ribs 77 times, the scapula 18 times, the sternum 6 times, and the spine 5 times.

Wound infection was not a serious problem, in any held hospital, but m 10

of these 145 cases, drainage of the wound was necessary for this reason in base

section hospitals. In all 10 cases, the relation between the development of infection and the time at which debridement was performed seemed clear cut; in

a few cases, initial wound surgery had been delayed up to 72 hours. Empyema

developed in 9 cases at the base section and in 2 others in the Zone of Interior,

but in only 2 of these 11 cases did a severe wound infection exist.

Case 1

Management overseas.—This 31-year-old infantryman was wounded in

the chest at 1130 hours on 14 October 1944, near Hupelmont, France. Three

hours later, he received a plasma transfusion of 1,000 cc, in a battalion aid

station, where the sucking wound of the anterior chest wall was closed by skin
m THORACIC SURGEHY

a

ä| **-? *-

Ä

"Ä

;«!

B--J

FIGTTP.E 19G. (See opposite page for legend.)
FOLLOWUP STUDIES OF THORACIC WOUNDS 453

C

FIGURE 196 (case 1).—Schematic shoving of large defects of

chest wall. A. Wound: Large sucking wound of exit in right

anterior chest wall, with destruction of portions of fourth, fifth,

and sixth ribs and the corresponding costal cartilages (a), wound

of entrance in left chest (h), and through-and-through wound of

left upper arm (c). B. Closure of large chest wall defect by

suture of mobilized pectoralis major (a) and rectus abdominis (b).

C. Closure of central portion of wound with wounds of entrance

(a) and exit (b) left open down to fascia, and closed drainage

tube in situ (c).

sutures and a sulfonamide powder was placed in it, lie was given morphine

J/j. and, because of wet breathing, atropine gr. y50.

When he was received at the 11th Field Hospital at Eloyes, France, at 1545

hours, he was dyspneic and cyanotic, and his breathing was still wet. A large

wound in the anterior chest Avail (fig. 196A) extended from the anterior

axillary line on the right at the sixth interspace across to the fourth rib in

the anterior axillary line on the left, Breath sounds Avere heard bilaterally

distant on the right, and there Avere numerous rales and rhonchi throughout

both lung fields.

The resuscitative regimen included oxygen by nasal catheter; penicillin

intramuscularly; thoraceiitesis, Avith removal of 300 cc. of bloody serous mucus

from the right chest; intercostal nerve block, including the fifth through the

eighth nerves; and catheter aspiration, Avhich produced bloody serous mucus.
4M THORACIC SURGERY Ml

I

FIGURE 107 (case 1).—Serial roentgonograms in largo defect of chest

wall. A. Posteroanterior roentgenogram, 14 October 1044, immediately

after wounding, showing fluid in lower half of right chest, with mottled

infiltration above and on the left. Note air in anterior mediastinum outlining left mediastinal pleura. 15. Lateral roentgenogram showing hazy

lung fields and displacement of heart posteriorly by air in anterior

mediastinum. C. Posteroanterior roentgenogram, 21 October 1044, showing closed drainage tube in right chest (reinserted to control pulmonary

air leak), right hydropneumothorax, and subcutaneous and mediastinal

emphysema. 1). Posteroanterior roentgenogram, 25 October 1044, showing clearing of both lungs.
FOELOWUP STUDIES OF THORACIC WOUNDS 455

FIGURE 197.—Continued. E. Posteroanterior roentgenogram, 19 November 19G0, 16 years after wounding, showing irregularity of fifth and

sixth ribs anteriorly, slight blunting of right costophrenic angle, prominent bronchovascular markings, and fibrosis of right paracardiac region

above diaphragm. F. Lateral roentgenogram on same date, showing

pleural shadow anteriorly and fairly flat diaphragms.

Eoentgeiiologic examination (fig. 197A and B) showed fluid occupying

the lower half of the right chest, with a mottled infiltration above and to the

left, and air in the mediastinum displacing the heart posteriorly.

When the patient was first observed, his pulse was intermittently irregular,

and there were dropped beats at the radial pulse. There were also premature

cardiac contractions. After 4 hours of the intensive resuscitation just described,

his condition improved, and his lungs seemed entirely dry.

The sucking wound of the right chest was thoroughly debrided, and

portions of the fourth, fifth, and sixth ribs, with the corresponding costal

cartilages, were resected. The laceration of the right lung was repaired with

interrupted sutures of fine catgut, and a drainage tube was introduced into the

lower right pleural cavity and connected with a closed system.

To effect closure, it was necessary to mobilize a large pectoral flap and a

rectus flap. These were sutured together and attached to the chest wall, to fill

in the huge defect left by resection of the three ribs (fig. 196B). The central

portion of the chest wall was closed (fig. 196C), and the wounds of entrance

and exit were left open and packed with gauze down to the muscle layers.

A wound in the left upper arm was debrided.

The patient's condition was satisfactory throughout the operation, but an

hour after it was concluded, his respirations became very wet. Bronchoscopy,

which was performed at once, yielded a moderate amount of bloody mucus from

both bronchi. At this point, cardiac arrest occurred. The catheter was at once

withdrawn and the bronchoscope was removed. Oxygen was administered by
THORACIC SURGERY

face mask, with intermittent positive pressure on the anesthetic bag. In less

than 2 minutes, the heartbeat returned, the respirations also returned, and

withm 10 minutes, the patient regained consciousness.

Late on the second postoperative day, subcutaneous emphysema in the

neck and the chest wall became quite marked. Pneumothorax, which was

evident on the right, was controlled by a catheter inserted into the pleura]

space and fixed to a closed drainage system (fig. 197C). The inferior drainage

tube ceased to function within 48 hours and was removed at this time.

The temperature was elevated to 101° F. for the first week after operation,

but when the patient was evacuated to the base section on the 12th postoperative

day, the emphysema had disappeared (fig. 197D), the lung was expanded, and

the wound was clean.

Contrary to the usual practice, it was necessary in this case to use a tight

binder during the postoperative period, because of the mobility of the chest

wall. It was discarded as the wound healed and the wall became firm.

Management in the Zone of Interior.—The patient required no active

treatment m the Zone of Interior and was given a disability discharge.

Followup.—This patient has been well since he was finally discharged from

the YA outpatient clinics 5 years ago except for dyspnea on niaimal"exertion

and some pain. He has held a variety of jobs.

Roentgenologic examination on 19 November I960. 16 years after wounding (fig. 197E and F) showed prominent bronchovascular markings, and slight

fibrosis of the right paracardiac region above the diaphragm. ^ The lateral

view was clear except for blunting of the right cardiophrenic angle.

Comment.—This patient presented a number of problems: A large anterior sucking wound of the right chest; fractures of the fourth through the

sixth ribs and their cartilages; some evidence of blast injury to the heart3, with

cardiac irregularity; a moderately severe wet lung syndrome; and media'stinal

emphysema, Satisfactory closure of the large defect in the chest wall was

effected with flaps of pectoral and rectus muscles. Although the patient had

had atropme (gr. i/20(l) 90 minutes earlier, cardiac standstill occurred when

bronchoscopy was performed after operation. Positive pressure oxygen was

effective, and there were no further difficulties in this regard. Accumulation

of air in the affected hemithorax required the insertion of a second closed

thoracostomy tube. The explanation of the cardiac standstill was probably

a combination of hypoxia, so-called cardiac blast, and vagovagal tracheal

stimulation. The use of atropine before operation may have been helpful in

producing the prompt recovery.

Case 2

Management overseas.—This technical sergeant, attached to a tank destroyer battalion, was wounded in the left chest by a high explosive shell fragment at 0815 hours on 3 December 1943, near Cassino, Italy. At the battalion

aid station, a sucking wound of the left chest anteriorly (fig-. 198A) was packed
FOLLOW!"!' STUDIES OF THORACIC WOUNDS 457

'Hi

E

I

¥' '

K

' •

IK»5-/'-S/t'''*.*• 5'*;l"

?. ,**A.'2&;

lb'5'" • J ?

4V> l

)"-*WH1. A'

FIGUHK 108 (ease 2).—Schematic showing of sucking wound with

defect of chest wall. A. Wound in anterior aspect of chest, with sucking wound of second intercostal space packed with petrolatumimpregnated gauze. 13. Schema of pathologic findings, anterior view :

Foreign body in lung and pleura (a), hematoma of left upper lobe (b),

wet lung (c), mucus and blood in trachea (d), and engorged superior

vena cava (e).
458 THORACIC SURGERY

;Wr«*» £&8#

K-W!

FIGURE 19S.—Continued. C. Findings at tlioracotomy, lateral view:

Sucking wound (a), laceration of left upper lobe (b), liematoma of left

upper lobe (c), foreign body in pleura (d), left hemothorax (e), and wet

lung (f).
FOLLOWUP STUDIES OF THORACIC WOUNDS 459

D

if1

FIGUJSK 198.—Continued. D. Anterior aspect of cliest at conclusion

of operation: Debrided pectoralis major muscle sewn together to close

sucking wound (a), with fine-mesh gauze packed into wound (b), and

closed intercostal drainage tube (c).

with a dressing sprinkled with powdered sulfanilamide, and morphine (gr.

y2) was given.

The patient was received at the 94th Evacuation Hospital at 1100 hours

the same day. Here he gave a history of having had a severe respiratory infection for the previous 4 or 5 days. At this time, he was in shock, with blood

pressure of 80/60 mm. Hg, pulse of 130, and wet and labored respirations. He

was extremely dyspneic. Signs of fluid were present over the entire left chest,

and rales were heard over the right chest.

The chest wound was fairly clean. It was cleansed down to the pleural

opening, which was 2 by 3 cm., and a fresh petrolatum-impregnated pack was

inserted. Eesuscitative measures included tracheal aspiration, which yielded

a large amount of bloody fluid; intercostal nerve block, from the second through

the eighth nerves on the left; thoracentesis, which yielded 700 cc. of bloody

fluid; and a transfusion of 500 cubic centimeters.

The patient's condition improved with these measures, but respirations

were wet over both lung fields, and it was obvious that he had been wounded

at a time when he had a severe bronchopulmonary infection. Therefore, since
4G0 THORACIC SURGERY

the wound was fairly clean, it was decided that the risk of immediate surgery

was greater, under the circumstances, than the development of infection of

the chest wall.

Eoentgenograms on the day of wounding, taken after aspiration of the

chest (fig. 199A), showed a large foreign body in the left upper lobe and a hematoma in the same location.

The patient was given 4 gin. of sulfadiazine daily until 7 December 1943.

During this period, he ran a low-grade temperature.

Operation was performed on 7 December 1943, under light nitrous-oxide

anesthesia. The hematoma shown in the roentgenogram 4 days earlier was

still present, but the foreign body Mas not readily accessible, and no search

was made for it (fig. 198B and C). Lateral pleural drainage was instituted.

The pectoralis muscle was closed (fig. 198D) and the rest of the wound was left

wide open and packed.

The postoperative course was satisfactory, and the patient was evacuated

to the 24th General Hospital at Bizerte, 10 days after operation. Here, 3

weeks later, elective thoracotomy was done, and a large foreign body was removed from the left pleural space and left upper lobe. Satisfactory healing

followed delayed primary wound closure.

Four months after wounding, the patient was released for limited duty

in the communications zone. At the end of the war, he was sent to the Zone

of Interior by rotation and discharged there.

Followup.—A communication from this patient on 22 November 19C0

stated that he had done outside construction work since the war. His only

complaints were mild dyspnea when he had chest colds and some pain in the

left shoulder associated with overwork. He was married and had children.

Eoentgenograms made on 21 November 1960 (fig. 199B and C) showed

the left lung completely expanded and no abnormalities of consequence.

Comment.—The interesting feature in this case is the admission of the

patient to a forward hospital with a sucking wound superimposed upon a

severe bronchopulmonary infection. It was decided to repack the wound

daily and allow the respiratory infection to subside before surgical closure of

wound was undertaken. Eemoval of the foreign body in the left pleura and

upper lobe was performed at the base section. Eecovery from this operation,

as from the deferred initial wound surgery, with closure of the pectoralis muscle,

in the forward hospital, was uncomplicated, and there was no residual disability.

This is the only case of the kind in this particular series, though there

were a number of similar instances in the cases in this series not followed up

after the war. The lesson to be learned from it is that, while general principles

must be followed in wartime, they must be flexible enough to permit each case

to be manao-ed on its own merits.
FOLLOWUP STl'DIES OF THORACIC WOT'XDS 461

'W .jtm

JS

A

B

FIGUKE 109 (case 2).—Serial roentgenograms in sucking wound with defect

of chest wall complicated by severe bronehopulmonary infection. A. 1'osteroanterior roentgenogram, 3 December 3043, shortly after wounding, showing large

foreign body and hematoma in left upper lung field, with haziness of both

lung fields. Although the chest has been aspirated, a small amount of pleural

fluid is still present on the left. P. Posteronnterior roentgenogram, 21 November 1900, IT years after wounding, showing clear lung fields, prominent bronchovascular markings, and sharp costophrenic angles. Xote healed fracture of

left sixth rib, apparently the result of elective thoraeotomy performed in base

hospital in 1943. C. Lateral roentgenogram on same date showing clear lungfields and deep, clear costophrenic angles.
462 THORACIC SURGERY

LACERATIONS OF THE LUNG

Lacerations of the lung of sufficient magnitude to present clinical problems

were present in 61 of these 167 cases. Neither blunt trauma nor spontaneous

pneumothoras was an etiologic factor in any case. In each instance, the lung

was torn by a penetrating missile or by fractured ribs.

Intrapleural decompression was required in all 61 cases, but thoracotomy

to repair the rent was employed only selectively. The laceration, per se, was

not regarded as an indication for this procedure.

In 1?> cases, continuing leakage of air was treated conservatively, by aspiration or catheter drainage, and in each instance, the laceration closed spontaneously. In a number of cases not included in the group followed up,

small lacerations of the lung were closed when thoracotomy was done, but

whether all these repairs were necessary is another matter.

In the 48 cases in this series in which thoracotomy was done on the indication of pulmonary lacerations, direct repair of the laceration was necessary in

38 cases, in 6 of which the tear was so extensive that muscle grafting was required to effect closure. This technique proved highly successful; neither

bronchopleural fistula nor empyema developed in any instance.

In only one instance in the series was pulmonary resection carried out in

a forward hospital. In this case, a laceration of the lung and damage to the

blood supply and the bronchus of the posterior basal segment of the right lowerlobe served as a valid indication for segmental resection because the damaged

area of the lung was no longer viable.

Pulmonary resection was not necessary at any hospital in the communications zone, nor was it necessary in a Zone of Interior hospital. One patient

among the 61 with pulmonary lacerations developed a pneumothorax in the

Zone of Interior, ;> months after wounding, and thoracotomy was necessary to

remove the foreign body causing the difficulty. Xo other patient in the series

required surgery in the Zone of Interior, and this was the onlv thoracotomy

performed for this reason in this series in anv Army general hospital in the

United States.

One other point should be emphasized in connection with lacerations of

the lung: Patient s in this group wil h progressive or tension pneumothorax were

not evacuated to the rear until the condition was under control unless tactical

circumstances demanded movement of the installation. In 2 of these 61 cases,

evacuation was necessary for this reason before the air leak was controlled,

but in each instance, a trained medical technician rode in the ambulance with

the patient to insure that the decompression catheter functioned properly en

route. This conservative evacuation policy undoubtedly explains why recurrent pneumothorax was not a problem in base section hospitals in the Mediterranean theater.
FOLFOWUP STUDIES OF THORACIC WOUNDS 465

Case 3

Management overseas.—This 19-year-old infantryman was wounded in

the left chest posteriorly, the left upper arm, and the left hip at 0800 hours

on 28 November 1943, in the mountains near Cassino, by an artillery shell fragment. Emergency treatment consisted of the application of an occlusive

dressing sprinkled with a sulfonamide powder, sulfadiazine by mouth, and

morphine. At the collecting station, a unit of plasma was given. Because

of transportation difficulties, the patient did not reach a clearing station until

the following day.

When he arrived at the 94th Evacuation Hospital at LePezze, he was

found to have a sucking wound (fig. 200A), satisfactorily occluded, of the

left posterior chest in the region of the sixth, seventh, and eighth ribs, and

smaller wounds of the left arm and left chest. lie was extremely short of

breath. The temperature was 101° F., the pulse 90, the respirations 48, and

the blood pressure 130/80. Breath sounds were absent over the left chest;

the right chest was fairly clear. Boentgenograms made on 30 October 1960

(fig. 201A and B) showed almost complete collapse of the left lung; fractures

of the sixth, seventh, and eighth ribs; and a foreign body apparently within

the cardiac shadow. Some fluid was present in the left chest; the right lung

was fairly clear.

The routine of resuscitation included bronchial aspiration per catheter,

after which respirations became more satisfactory.

Operation was performed on 30 November 1943, at 0040 hours. The

posterior sucking wound, which was found to be infected (fig. 200A), was very

carefully debrided down to clean muscle tissue. The instruments, gloves, and

drapes were changed before the remainder of the operation was proceeded

with.

Fractures of the sixth, seventh, and eighth ribs were exposed and the fragments were removed. The pleura! cavity was entered by extending the wound

of the sixth intercostal space (fig. 200B). A metallic foreign body, 2 by 1.5

cm., was removed from the left upper lobe, along with some rib fragments.

A hematoma was present in this lobe, as well as a foreign body which did not

penetrate the heart. Bib fragments were also removed from the left lower

lobe (fig. 200C). Lacerations in both lobes, from which air was bubbling, were

easily repaired with catgut (plain O) mattress sutures. About 500 cc. of

blood was aspirated from the pleural space, after which extremely thoi-ough

pleural lavage was carried out.

The chest Avail was closed (fig. 200D) by suturing the trapezius and latissimus dorsi muscles over the pleural defect in the sixth intercostal space. The

serratus was closed more anteriorly- The fascia and subcutaneous tissues were

left wide open. Closed intercostal drainage was instituted in the eighth intercostal space.
464 THORACIC i-U'RGERY

1

Tv

.A ~fi*%i**t {

FIGURE 200 (case H).—Sucking wound of left posterior chest with

early infection. A. AVonml. Posterior aspect of thorax showing infected sucking wound of sixth intercostal space on left, packed with

gauze. B. Diagram of findings at thoracotomy showing: Collapsed

lung with foreign body (a), pulmonary laceration (b), hemothorax

(c), bone fragments in left lower lobe (d), and hematoma in same

location (e).
FOLLOYVTP STUDIES OF THORACIC WOUNDS 465

FIGUISE 200.—Continued. Appearance of wound after repair of laceration

of left upper lobe with removal of foreign body, leaving hematoma undisturbed

(a). Closed pleural drainage lias been instituted (b).

The immediate postoperative course was stormy, with the temperature

ranging- daily from 100° to 102° F. Koentgenologic examination on 7 December 1948 showed diffuse haziness of the left chest, and thoracentesis yielded

purulent, exudate.

In spite of the fever and the infection, the patient's general condition was

o-ood, and he was therefore evacuated to the base when an inordinate number

of fresh casualties required that, the hospital be emptied.

The left empyema was drained at the 33d General Hospital, at Bizerte,

by resection, of a portion of the ninth rib.

Management in the Zone of Interior.—In February 1944, the patient

was evacuated to the Zone of Interior. By this time, the chest wound was

healed, the empyema had been controlled, and the lung- vras fully expanded,

the only abnormality being some pleural thickening on the left. Neurolysis of

the left median nerve was carried out at Walter Reed General Hospital, Wash-
THORACIC SURGERY

FIGUEE 200.—Continued. D. Airtight closure of deep muscles of chest Avail: Tacking of

superficial wound above closure (a), and closed pleural drainage (b).

ington, D.C. After a period of limited duty, the patient was discharged from

the Army on 14 March 1946.

Followup.—A communication from the patient in November 1960 stated

that he had worked in the post office as a mail clerk since his discharge from

the Army. He was married and had two children. He had no symptoms

referable to the chest. Roentgenograms made on 21 November 1960 (fig. 201C

and D) showed an essentially clear left lung field. The only abnormality was

regeneration and fusion of the sixth, seventh, eighth, and ninth ribs.

Comment.—This casualty was in serious condition when he was first seen,

with an infected sucking wound of the left chest posteriorly, an almost complete collapse of the lung, some fluid in the left chest, and a foreign body at

first thought to lie within the cardiac shadow. A hematoma was present in

the left upper lobe, and there were fragments of fractured ribs in this lobe and

in the left lower lobe. Conservative management included bronchial aspiration

per catheter as part of the resuscitative regimen, debridement, removal of the
FOLLOWUP STUDIES OF THORACIC WOUNDS 467

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FKU'iiK 201 (case 3).—Serial roentgenograms of sucking wound with

early infection. A. Postcroanterior roentgenogram, 30 October 1043, shortly

after wounding, showing collapse of left lung and fracture of sixth, seventh,

and eighth ribs. Note that in this view a foreign body appears to be within

the cardiac outline. B. Left lateral roentgenogram, showing foreign body

within lung and not penetrating heart. C. Posteroanterior roentgenogram

of chest, 21 November 10G0, 17 years after wounding, showing regeneration

and bridging of sixth, seventh, eighth, and ninth ribs; slight blunting of

left costophrenic angle; and slight pleural reaction on left. Otherwise,

the lung fields are clear. D. Lateral roentgenogram on same date, showingclear lung fields and sharp posterior costophrenic sulci.
'IIORAOKJ SURGERY

foreign body and the rib fragments, repair of lacerations in the involved pulmonary lobes, closure of the chest wall, and closed intercostal drainage.

Although the patient developed an empyema, it was readily controlled Incorrect rib-resection drainage, and the damaged lung was fully expanded when

he was received in a Zone of Interior hospital. At the present time, 17 years

after wounding, he is leading an active life, with no residua from his chest

injury and no significant roentgenologie abnormalities.

This case is another illustration of the excellent results achieved by strict

adherence to the principles and practices of thoracic surgery developed in the

Mediterranean theater during World War II.

MEDIASTINAL INJURIES

Injuries to the mediastinum were recorded only l:-> times in these IßT cases.

Tliis might be expected. As pointed out several times earlier in this history,

because the heart, great vessels, esophagus, trachea, and bronchi are located

in this area, most casualties with severe penetrating mediastinal wounds do not

survive to reach any hospital.

The casualties in this series who survived mediastinal injuries all had

wounds produced by small foreign bodies, whose driving force was spent.

Bleeding into the mediastinum sufficient to produce a widened mediastinal

shadow was present in five instances, but in all, the blood was absorbed without

sequelae.

Although this is a small group and the mediastinal injury was not always

the most important lesion, six of the casualties had traumatic thoracotomies,

and others had considerable trauma to the thoracic cage and the lungs. Small

foreign bodies were removed in four instances and allowed to remain in the

others.

At the base section, five patients were returned to limited duty. The other

five were evacuated to the Zone of Interior, where all received disability discharges, in one instance on the basis of psychoneurosis.

The problems encountered in the treatment of mediastinal injuries are

illustrated in the following case history:

Case 4

Management overseas.—This 19-year-old Japanese-American infantryman received a high explosive shell-fragment wound of the left chest (fig.

202A) at 1100 hours on 8 November 1914, at Biflontaine, France. He received

two units of plasma at the battalion aid station, where the wound was packed

with a dressing sprinkled with sulfanilamide.

When the casualty was received at the 11th Field Hospital at 1315 hours,

he was in deep shock. The blood pressure was 80/70 mm. Hg, the pulse 128,

and the respirations 40. The massive sucking wound of the left anterior chest

was occluded by an airtight packing.
FOULOWUU STUDIES OF THORACIC WOUNDS 469

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After 200 cc. of plasma had been given, pulmonary edema occurred, and

no more plasma was given. Trachea! suction, repeated several times, produced

quantities of thin, pinkish fluid. When only 20 cc. of fluid could be obtained

by thoracentesis, the pack in the wound was temporarily loosened, whereupon

a large amount of bloody fluid escaped. An attempt at blood transfusion

precipitated pulmonary edema, and endotracheal suction was again applied,

with positive pressure oxygen therapy, the anesthetic bag being squeezed with

each inspiration.

Boentgenologic examination (fig. 203A and B) showed haziness of

the entire left lung field, a shift of the heart to the right, and subcutaneous

emphysema. The right lung was fairly clear.

At the end of 8 hours of the regimen described, the patient's condition

was still precarious. Blood transfusion was again attempted, while at the same

time, measures were carried out to combat wet lung. The blood pressure was

imperceptible at times, but eventually, after intercostal nerve block and the

administration of atropine gr. y150, it rose to 96/60 mm. Hg.

After the patient's condition had improved sufficiently and his lungs had

been dry for several hours, operation was undertaken at 0130 hours on 9

November, on the indications of continued intrathoracic hemorrhage; the necessity of closing the sucking wound; and the possibility of both diaphragmatic

and cardiac injury. The operation began with clebridement of the chest

wall. The pectoralis and serratus muscles were extensively involved (fig.

202A), the defect measuring 5 by 8 inches. The fifth rib was shattered, and

had to be removed down to the cartilage. There was an opening 2.5 by 3

inches in the fourth and fifth intercostal spaces.

Excellent exposure of the pleura! cavity (fig. 202B) was obtained by opening the fifth intercostal space posteriorly. A massive hematoma occupied

the lower lobe of the left lung and the lingula of the upper lobe, but the accessory lobe was not involved. About 90 cc. of bloody fluid was aspirated from

the pericardium, which was extremely tense. After dirt, cloth, and fragments

of rib were removed from the pericardium, it was seen to contain a large hematoma. A window was made in the pericardial sac, to permit drainage into

the pleural cavity, which contained about 3,000 cc. of blood. After the blood

had been removed, the cavity was thoroughly washed out with physiologic salt

solution. A laceration in the upper lobe of the left lung had almost completely

sealed over.

Pleural drainage was effected in the second intercostal space anteriorly and

in the base posteriorly and was connected with a closed-drainage system.

By this time, the lung had expanded satisfactorily and there was no further

evidence of bleeding. The chest wall was closed (fig. 202C and D) by partial

closure of the intercostal bundles of the fifth interspace. The pectoralis major

was mobilized from above and brought down over the pleural defect, and the

serratus magnus was brought up behind. Since the muscles were abnormally

thin, it was necessary to close the skin and subcutaneous tissues with mattress
m TIIOIUCIO SU1WJKKY

C

FIGTJKE 203 (case 4).—Serial roentgenograms in mediastinal injury with

intraporicardial foreign bodies and liematoma. A. I'osteroanterior roentgenogram, 7 November 1944. immediately after wounding, showing massive left

hemothorax, with slight shift of mediastinum to right, and extensive emphysema of left chest wall. Eight lung is fairly clear. V,. Lateral roentgenogram

on same date showing diffuse haziness. No radiopaque foreign body is seen.

C. Posteroanterior roentgenogram, 22 November I960, IG years after wounding, showing clear lung fields and normal heart shadow. Note muscular defect

of left anterior chest wall, with resection of anterior portion of fifth rib, and

tenting of left diaphragm. D. Lateral roentgenogram on same date showing

defect of left anterior chest wall with pleural reaction posterior to it and

high anterior tenting of left diaphragm. Otherwise, the findings are within

the normal range.
FOUUOWUP STUDIES OF THORACIC WOUNDS 473

sutures anteriorly; both posterior ]imbs of the wound were left open (fig.

202E).

The wound in the left arm was then debrided. The ulnar nerve had been

traumatized but not completely lacerated. The brachial artery, however, had

been lacerated. After the clot which occluded it had been milked out and a

free flow of blood had been reestablished, repair was accomplished with No.

00000 silk sutures. The pulse, which had not previously been present in the left

wrist, could now be felt.

The patient made a satisfactory recovery.

Management in the Zone of Interior.—When the patient reached the Zone

of Interior, no further surgery on the chest was necessary. Repair of the

ulnar nerve was carried out at DeWitt General Hospital, Auburn, Calif. He

was discharged from the Army on 17 August 1946.

Followup.—A communication from this patient on 23 November 1960 revealed that he was working 40 hours a week as a building materials salesman.

He had no difficulty in breathing and no other complaints. Eoentgenograms

made on 22 November 1960 (fig. 203C and D) showed the left lung to be

completely expanded and the lung fields clear. The chest wall defect was

apparent on the film, both laterally and anteriorly, and the left diaphragm was

tented, but there were no other abnormalities.

Comment.—This patient was observed at, a field hospital in eastern France

with a large sucking wound of the anterior chest wall, which undoubtedly involved both the lung and the heart. Stabilization was extremely difficult

and occupied some 10 hours. Although surgery was taxing, he withstood it

well; it included removal of foreign bodies from the pericardium, pericardial

drainage, and the structural problem inherent in the reconstruction of the

anterior chest wall. The pectoralis and serratus muscles were used to cover

the defect, and the weakest portion of the repair was reinforced by closure

of the skin over it. The associated wound in the arm, which involved both the

ulnar nerve and the brachial artery, also required a taxing repair.

The fact that this patient is well and working without complaints referable to the chest 16 years after wounding is heartening when one considers the

severity of the original wound and the complex problems involved in both

resuscitation and initial surgery. The presence of clear lung fields, except for

diaphragmatic tenting, at the end of this period of time also speaks well for

the staged management employed in this case.

BLAST INJURIES

Generalized blast injury, caused by a wave of generalized positive pressure followed by a wave of negative pressure, was a factor in 21 cases in this

series. In three instances, there was no external wound except for powder

and dirt burns of the skin. Perforated eardrums were present in four cases,

74R-041V—05 33
474 TlIOKAdIO SUßGKRY

and transient cardiac irregularities and evidences of cerebral anoxia were

characteristic of the early stages in practically all cases.

All 21 patients were evacuated to the base section, where 3 patients died

of wounds not directly due to the blast injury. After periods of up to 5 months,

six patients were returned to limited duty in the communications zone. The

other 12 patients were returned to the Zone of Interior. None of them was

released for active duty, and all of them eventually received disability discharges, two with the diagnosis of psychoneurosis as the principal cause.

Followup studies showed slight pulmonary emphysema, but no instance of

clinical dyspnea was reported.

Localized blast effect, due to the impact force of high explosive shell fragments upon the chest wall and thoracic organs, was a factor in practically

every patient in the series who had a severe injury of the chest wall.

The following case history illustrates the problems of blast injuries and

the typical followup status of those who sustained them :

Case 5

Management overseas,—This 21-year-old infantryman was 20 feet away

from an aerial bomb blast which occurred at 1330 hours on 10 November 1913,

near Venafro, Italy. He was unconscious for a short period of time. When

he regained consciousness, he found that ho had been sprayed with dirt and

had suffered facial burns. He was picked up by a corpsman shortly after the

blast and taken to a battalion aid station, where he was given 250 cc, of plasma

and morphine gr. 1/,.

When he was admitted to the 91th Evacuation Hospital at LePezze at

1530 hours, he complained of severe dyspnea, orthopnea, wheezing, choking,

slight dysphagia, and severe chest pains. Coughing produced bloody sputum.

Examination showed a second degree burn of the face, involving the left

cornea and conjunctiva, but no other external wounds. The veins in the neck

were full. The patient was cyanotic, and his breathing was extremely difficult.

Breath sounds were decreased, and in some areas almost absent, over the right

chest, and scattered rales were also heard on the left. The heart sounds were

distant and slightly irregular.

The left tympanic membrane was ruptured. Hearing was impaired on

this side, and later there was slight drainage from the ear.

Roentgenologic examination on 11 November 1913, the day after injury

(fig. 201-A), showed diffuse bilateral haziness and infiltration, which were taken

to indicate petechial pulmonary hemorrhage and edema.

Treatment consisted of oxygen administration by nasal catheter, repeated

catheter bronchial aspiration, restriction of fluids by mouth, and control of

the chest, pain by small doses of morphine. The patient was not digitalizecl,

and he was not given intravenous fluids.

The lungs gradually cleared (fig. 20413), and 14 days after wounding,

he was evacuated to a base hospital.
FOLLOWUP STUDIES OF THORACIC WOUNDS 475

A B

FIGUEE 204 (case 5).—Serial roentgenograms in blast injury. A. Posteroanterior roentgenogram, 11 November 1943, 24 hours after injury, showing

diffuse bilateral haziness and infiltration indicative of petechial pulmonary

hemorrhage and edema. 15. Posteroanterior roentgenograin, 17 November

1943, showing clearing of lung field. C. Posteroanterior roentgenogram, 7

January 1900, 16 years after severe blast injury. The only abnormality is

slight emphysema of upper lobes. The diaphragms are at level of the

eleventh ribs; their contours are rounded. Heart is also normal.

Management in the Zone of Interior.—In the Zone of Interior, the patient required no treatment for the blast injury. The considerable facial

scarring left by the powder burns was treated by plastic surgery at Valley

Forge General Hospital, Phoenixville, Pa., in March 1944. On 28 November,

he was returned to limited duty and served without difficulty until his discharge

on 1 September 1945.

Followup.—Since his discharge from the Army, the patient has been followed up in the Veterans' Administration. His only complaint is brief, mild

headaches, about three times a week, relieved by simple medication. They are
476 THORACIC SURGERY

thought, by the neurologist to be evidence of an early, mild, chronic brain syndrome as a result of the blast injury.

Roentgenologic examination on T January I960, 16 years after the blast

injury (fig. 204C), showed no abnormality except mild pulmonary emphysema

of the upper lobes.

Comment.—This case history illustrates a typical blast injury, produced

by a powerful wave of positive, followed by a wave of negative, air pressure,

from a bomb apparently of considerable size. The infantryman was about 20

feet from the bomb, his nearness to it being shown by the superficial burns and

dirt wounds of the skin of the face. The symptoms and signs were those usually

observed in serious blast injuries. They included unconsciousness, severe

dyspnea, hypoxia, severe chest pain, and rupture of an eardrum. The dilatation of the veins of the neck indicated increased venous pressure, and the wet

lung syndrome was characterized by the presence of persistent rales and

rhonchi.

Treatment included maintenance of a clear airway by repeated catheter

aspirations; the administration of oxygen, to provide adequate oxygenation of

the blood while the lung was healing: restriction of fluids by mouth; and avoidance of administration of fluids by vein. With these measures, digitalization

was not necessary.

This casualty could be returned to active duty, and 16 years after the blast

injury, he is in good health and is leading an active life. lie has no pulmonary

symptoms and there are no significant roentgenologic findings. The only

(minimal) evidence of the injury takes the form of occasional mild headaches.

THORACOABDOMINAL WOUNDS

Thoracoabdominal wounds, which occurred 25 times in these 167 thoracic

wounds, represented the combined problems encountered when two major

serous cavities were involved. The seriousness of these problems is evident

in certain facts:

1. Three casualties, as already mentioned (p. 450), died of late complications in base hospitals.

2. Xo patient in this group was returned to duty from the forward area,

although four performed limited duty in base sections of the Mediterranean

or European theaters within 2 months after wounding.

o. Secondary surgery was required in six cases, three times for drainage or

empyema, twice for drainage of subphrenic infections, and once for removal of

a foreign body which was left in situ in the forward area because of the

urgency of the abdominal wounds.

4. All patients who returned to the Zone of Interior eventually received

disability discharges, in one instance almost 10 years after wounding.

The following case histories illustrate the course of, and the problems

involved in, thoracoabdominal wounds:
FOLLOWUP STUDIES OF THORACIC WOUNDS 477

Case 6

Management overseas.-—This 22-year-old infantryman was wounded in

the left lower chest anteriorly (fig. 205A) at 1200 hours on 28 September 1944,

at Faucompierre, France. He was standing about 100 feet from an 88-mm.

shell explosion. He was knocked down but did not lose consciousness. Within

15 minutes, he was taken to a battalion aid station, where he was given eight

sulfonamide tablets by mouth and a unit of plasma intravenously. The wound

was sprinkled with, a sulfonamide powder and dressed.

When he was admitted to the 11th Field Hospital at Eloyes, France, the

wound was bleeding moderately. He complained of moderate pain in the chest

and severe pain in the left upper quadrant of the abdomen. The blood pressure

was 120/78 mm. IIsc, the pulse 80, and the respirations 20.

The wound in the lower left chest was close to the costal margin in the

eighth intercostal space. It was packed because movement of the chest wall

caused sucking. Breath sounds on the left were decreased, but the right lungshowed no abnormalities.

The patient complained of increased pain in the abdomen immediately

after admission to the field hospital. Examination revealed tenderness in the

left upper quad rant; pressure on any portion of the abdomen produced pain

in this area.

Koentgenologic examination (fig. 206A) showed a large metallic foreign

body below the left diaphragm, at the level of the eleventh rib. The lung fields

were hazy.

The patient had eaten a K-ration 5 hours before wounding, and gastric

lavage produced undigested food along with bloody fluid.

Obviously, peritoneal contamination had occurred from a wound of the

gastrointestinal tract, and operation was urgent. At 15-50 hours, when the

anesthesiologist began induction, the blood pressure fell to 40/0 mm. Hg.

After a transfusion of 500 cc. was given, the systolic pressure rose to 90 mm.

Ilg, and operation was restarted at 1630 hours.

The wound at the eighth intercostal space was debrided and the incision

was extended along this hiterpace (fig. 205A), to expose the pleural cavity.

The diaphragm was found widely torn. The omentum had herniated into the

left pleural cavity, which also contained gastric contents. When the diaphragm

was opened posteriorly, providing excellent exposure of the upper abdomen

(fig. 205B and C), an 8-cm. tear was found in the stomach. Both the spleen

and the pancreas were lacerated. The foreign body responsible for these

wounds, which was 4 by 1 by 2 cm., had dropped back into the stomach. It

was removed, after which the gastric laceration was repaired and the spleen

was removed. Blood in the amount of 1,000 cc. was aspirated from the peritoneal cavity, which also contained a small amount of gastric contents. The

rent in the gastrocolic omentum was repaired. The diaphragm was closed with

a double layer of interrupted silk sutures. The chest wall was closed in layers

with similar suture material. Closed intrapleural drainage was instituted.
4^8 THORACIC SURGERY

A

B

FICURE 205 (ease (>).—Schematic showing- of thoraeoabdominal

wound. A. "Wound of entrance: Shell fragment wound in anterior

eighth intercostal space (a), metallic foreign liody (b), and incision in eighth intercostal space (c). 15. Diagram of course of missile: Wound of chest wall (a), laceration of diaphragm and stomach

(b), foreign body (c), and laceration of spleen and pancreas (d).
FOLLOWUP STUDIES OP THORACIC WOUNDS 479

1

---2. ,

FIGUKE 20.">.—Continued. C. Excellent exposure of left upper abdomen at operation, with diaphragm opened and rib

spreaders in place : Anterior wound in stomach (a), posterior

wound in stomach (b), foreign body (c) responsible for lacerations of pancreas (d), spleen (e), and left lower lobe of

lung (f).

The immediate postoperative recovery was satisfactory, but on the following morning, the patient was dyspneic and cyanotic, and diffuse rales were

heard over both lungs. Thoracentesis produced 500 cc. of bloody fluid. Because the hematocrit showed henioconcentration, an intravenous infusion of

glucose and physiologic salt solution was given, together with 250 cc. of plasma.

Bilateral intercostal nerve block was carried out from the sixth through the

twelfth nerves. The penicillin therapy begun before operation was continued.

Thereafter, the patient coughed and raised sputum, and the lungs cleared.

On the eighth postoperative day, peristalsis was active, and fluids were

permitted by mouth. On the 10th postoperative day, signs of consolidation

were demonstrable in the right lower lobe, and some fluid was present.

Bronchoscopy produced thick mucus from the right lower, middle, and upper

lobes, and a small amount from the left side. The temperature ranged from

100° to 101° F.

Eoentgenologic examination on the loth day (fig. 20(>B) revealed fluid

and infiltration in the lower two-fifths of the right lung field and fluid in the

left costophrenic angle. Because of the pneumonitis and fluid on the right

side, subphrenic abscess was considered a paramount diagnostic possibility.

On the 19th postoperative day, thoracentesis produced 700 cc. of clear fluid

from the right pleural cavity. Eoentgenologic examination (fig. 206C)

after this procedure still showed pleural fluid bilaterally, especially on the

rieht.
THORACIC SURGERY

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FIGUHE 200 (case G).—Serial roentgenograms in thoracoabdominal wound.

A. Posteroanterior roentgenogram, 23 September 1944, immediately after

wounding, showing large metallic foreign body below left diaphragm, at

level of eleventh rib, with haziness of both lung fields. B. Posteroanterior

l'oentgenogram. 11 October 11)44. showing fluid in left costophrenic angle

and fluid and infiltrative process in lower two-(ifths of right lung field.

C. Posteroanterior roentgenogram, 19 October 1944, showing fluid in both

pleural cavities, more marked on right.

On the following clay, the patient was evacuated to the 36th General

Hospital at Dijon, France. Here the plem-al effusion on the right gradually

resolved. On the left side, the fluid became purulent and rib-resection drainage was required. A subphrenic infection did not develop.

Management in the Zone of Interior.—At Fitzsimons General Hospital,

Denver, Colo., to which, the patient AY as evacuated, the empyema pocket on the

left side gradually became obliterated without further surgery. The patient

Avas considered for limited duty, but with the end of the Avar in Europe and

the reduced necessity for manpoAver, he was given a disability discharge on

28 May 1045.
rOLLOWUP STUDIES OF THORACIC WOUNDS 481

ID

KiGViiE 200.—Continued. D. Posteroaiiterior roentgenogram. 19 November 10G0, 10 years after wounding, showing lung fields clear except for

pleural shadow above diaphragm and defoi'inity of rib in lower left

costophrenic angle as result of rib resection for empyema. E. Lateral

roentgenogram on same date, showing blunting of anterior cardiophronic

sulcus. Posterior sulci are sharp, and lungs are clear.

Followup.—Following his discharge, the patient returned to an active

civilian life. At this time (November 1960), he is still working hard as a

maintenance worker in a large city. The work at times involves manual labor,

but he wrote that he had "no ill effects from his injury" and considered himself

perfectly well.

Eoentgenologic examination on 19 November 19G0, 16 years after wounding (fig. 206T) and E), showed clear lung fields except for blunting of the

lower left costophrenic angle as a result of rib resection for empyema, with

some blunting of the anterior cardiophrenic sulcus.

Comment.—This casualty bad serious injuries, including a sucking wound

of the chest; a tear of the diaphragm; and lacerations of the stomach, spleen,

and pancreas. Severe blood loss and early contamination of the pleura and

peritoneal cavities with gastric contents made resuscitation difficult. The

spleen was removed, and the stomach, pancreas, and diaphragm were repaired.

The course after operation was storm}', as a result of bilateral pleural effusion

and pneumonitis. The right side cleared under penicillin and sulfonamide

therapy, combined with aspiration of the chest. Empyema developed on the

left side, as a result of early soiling of the pleura with gastriet contents. Recovery followed drainage of the left empyema, with a complete return to health.

At the end of 16 years, this man has no residual symptoms and is hard at work.

^ase 7

Management overseas.—This 23-year-old sergeant in a chemical warfare

battalion sustained bilateral shell-fragment wounds of the posterior chest at

2130 hours on 10 December 1914, at Enchenberg, France, He was given four

74fl-941v—G5 34
THORACIC SURGERY

WSw

Mt

A f. *

FIGUKE 207 (case 7).—Schematic showing of thoraeoabdominal wouml. A. "Wounds: Sucking wound over left eleventh

rib posteriorly (a), fracture of eleventh rib (b), and nonsucking wound in right chest posteriorly (c).

units of plasma and two injections of morphine at a battalion aid station. The

sucking wound in the left chest was packed.

When he was admitted to the 54th Field Hospital at 0200 hours on 11

December, he was comatose, apparently from shock and from the two injections

of morphine. The blood pressure was 90/GO mm. Hg, the pulse 130, and the

respirations 36. His respirations were wet and labored.

Examination revealed shell-fragment wounds of the right and left chest

posteriorly. The wound on the left side was sucking (fig. 207A). Roengenologic examination (fig. 208A) revealed massive opacity of the left chest, haziness of the right lung, and a large amount of gas in the stomach. After gastric

decompression, another examination (fig. 208B) showed a foreign body in the

upper part of the left upper lobe.

Eesuscitation was begun immediately and continued for 14 hours. It

included, in addition to gastric decompression, catheter suction of the tracheobronchial tree, intratracheal oxygen administration under positive pressure,

and the slow transfusion of 1,000 cc. of blood.

At the end of this period, the lungs were clear and the blood pressure had

stabilized at 112/72 mg. Hg. The patient was therefore taken to the operatingroom and, under endotracheal anesthesia, the pack was removed from the

sucking wound of the left lower posterior chest. The wound was debrided

down to the pleura, after which it was extended upward and laterally along

the eleventh intercostal space. The eleventh rib was divided to improve exposure (fig. 207B). The kidney capsule was torn, and there was a rent 3 by
FOLOAVUP STUDIES OF THORACIC WOUNDS 483

«&•

FIGTU:K 207.—Continued. B. Diagram of course

of shell fragment in abdomen and thorax: Sucking

wound of entrance (a), laceration of upper pole of

kidney (1>), severe laceration of spleen (c), laceration of diaphragm (d), laceration and hematoma

of left lower lobe (e), laceration of left upper lobe

(f), shell fragment in lung (g), and massive liemotliorax (h).
48-1 THORACIC SURGERY

4 '• }

FICUISK 207.—Continued. C. Posterior view of chest: Central portion of wound packed down to sutured muscle layers

(a), closure of skin at both ends of incision (b), wound in

right posterior chest wall after debridement and packing with

fine-mesh gauze (<•), Penrose drain to left kidney (d), and

closed thoraeostomy drainage tube (e).

1 cm. in the posterior lateral portion of the upper pole. A eatheterized specimen had shown blood. Bleeding was controlled with catgut sutures, so that

it was not necessary to remove the kidney. The spleen, which was badly torn

and bleeding, was removed: the artery and vein were controlled with mattress

sutures of No. 00 silk. The diaphragm, which was torn near the dome, was

opened anteriorly, to provide adequate exposure of the inferior pleural cavity.

The lower left pulmonary lobe, which was lacerated and the site of a hematoma,

was oozing moderately: it was repaired with fine catgut sutures. About 800 cc.

of blood was aspirated from the pleural cavity.

Since the upper pulmonary lobe expanded fairly well at this point, it was

decided to remove the foreign body. It was left in situ, however, when exposure

proved inadequate and there was no evidence of leakage of air or bleeding

from the affected area. Closed catheter drainage was instituted in the eighth

intercostal space.

The diaphragm was debrided and closed with interrupted sutures of No. 00

silk. Sulfanilamide (?> gm.) and penicillin (100,000 units) were left in the

upper abdominal cavity. The kidney was drained with a Penrose sheath drain

through a stab wound in the flank.

The latissimus dorsi was closed over the defect in the eleventh intercostal

space in the central portion of the wound, which had been debrided, and this

area was packed with gauze clown to the muscle layer (fig. 207C). The anterior

and posterior extensions of the wound were closed in layers.
FOLLOWUP STUDIES OF THORACIC WOUNDS 485

L

FIGT-EE 20S (case 7).—Serial roentgenograms in thoracoabdominal

wound. A. Posteroanterior roeutgenogram, 11 December 1944, immediately after wounding, showing massive opacity of left chest, haziness

of right lung, and large amount of gas in stomach. B. Oblique roeutgenogram after gastric decompression, with Levin tube still in stomach.

A foreign body is now visible in left upper lung. Left chest is hazy.

C. Posteroanterior roeutgenogram on sixth postoperative day, showingexpansion of left lung but somewhat hazy lung field. Retained shell

fragment is clearly seen in left mid lung field.
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FIGURE 20S.—Continued. D. Posteroanterior roentgenogram, 19 November 10(i0, almost IG years after wounding, showing few adhesions

along left diaphragm, healed fracture of eighth rib, and clear lung field.

E. Lateral roentgenogram, on same date, showing clear lung fields and

sharp costophrenic angles.

The right posterior wound did not extend through the muscle layers and

did not involve the pleura, so it required only debridemenfc. It was packed

with fine-mesh gauze.

The patient received 1,000 cc. of blood during the operation, which he

tolerated wed. His temperature was elevated for the first 6 days, but otherwise

his recovery was satisfactory. Eoentgenologic examination (fig. 208C) on the

sixth postoperative day showed the left lung to be well expanded.

The patient was evacuated to the 23d General Hospital at Vittel, France,

on the seventh day after operation. Here an elective thoracotomy was performed, with removal of the foreign body in the left upper lobe.

Management in the Zone of Interior.—After satisfactory recovery from

this operation, the patient was evacuated to the Zone of Interior. After

hospitalizati on at Kennedy General Hospital, Memphis, Tenn., where he was

found to require no further active treatment, he was sent to a reconditioning

center on 28 July 1045. He was discharged shortly after V-J Day.

Followup.—A communication from the patient on 26 November 1960

stated that he was working as a carpenter's helper, was married, and had two

children. He suffered from occasional attacks of nausea and vomiting, which

responded to simple medication. He had no breathing difficulties except on

strenuous exertion, when he became somewhat dyspneic,

Eoentgenologic examination (fig. 208D and E) on 19 November 1960

showed the left lung to be well expanded. Two pleural streaks were seen at

the left base in the posteroanterior view, but the costophrenic angles were sharp

in the lateral film. The lung fields were normal except for prominence of the

bronchovascular markings.
FOLLOWUP STUDIES OF THORACIC WOUNDS 487

Comment.—This patient was admitted to a field hospital in serious condition, with a severe thoracoabdominal wound. He was in shock, which was

complicated by both the wet lung syndrome and morphine poisoning, and

resuscitation required 14 hours. At operation, it was found possible to save

the damaged kidney. Since the foreign body in the left upper lobe could not

be reached through the low thoracoabdominal incision being used, it was left

in situ at the original operation and removed later at the base. The hematoma

of the left lowerlobe resolved spontaneously. Only reconditioning was needed

in a Zone of Interior hospital.

At the present time, the patient is living an essentially normal life, with

only occasional minor gastrointestinal symptoms and some dyspnea on strenuous exertion. His condition immediately after wounding was so precarious

that the additional surgery necessary to remove the foreign body at the original

operation might well have been fatal. Vigorous resuscitation, staging of

surgery, and limitation of initial wound surgery were important factors in the

successful result and in the patient's excellent state of health 16 years after

woundino-.

Case

Management overseas.—This 21-year-old infantryman sustained shellfragment wounds of the left chest (fig. 209A), shoulder, upper arm, and the

scalp at 1400 hours on 22 September 1944. He was given sulfonamide tablets

and two units of plasma at the battalion aid station.

When he was admitted to the 11th Field Hospital at Plombieres, France,

shortly afterward, he was not in shock. The blood pressure was 130/80 mm. Hg,

the pulse 80, and the respirations 36. He complained of severe pain in the chest

and the abdomen.

Breath sounds were depressed on the left, apparently chiefly from pain;

there was improvement when intercostal nerve block was done. Tenderness and

rebound tenderness in the left upper quadrant, however, persisted, and peritoneal contamination had evidently occurred.

Eoentgenologic examination of the chest (fig. 210A and B) showed the

luno-s to be comparatively clear. There was a small amount of fluid at the left

base and a small fragment in the left upper quadrant of the abdomen was seen

on both posteroanterior and lateral films.

Kesuscitation consisted, in addition to intercostal nerve block, of the slow

administration of 500 cc, of blood and evacuation of the stomach through a

Levin tube. No food had been taken that clay, and there was little gastric

content.

Wien the patient was taken to the operating tent at 1815 hours, the blood

pressure was 90/50 mm. Hg and the pulse 114. Chest involvement was found to

be minimal. The small 2-cm. wound of the eighth intercostal space (fig. 209A)
THORACIC SURGERY

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FIGUHE 200 (case 8).—Schematic showing- of thoracoabdominal wound. A. Small penetrating wo'und in left

eighth intercostal space in midaxillary line. P.. Pathologic findings : Laceration of lung (a), omentum plugging

laceration of diaphragm (b), intact stomach (c), laceration of splenic flexure of colon (d), and foreign body (e).
FOLLOWrr STUDIES OF THORACIC WOUNDS 489

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FIGTJHK 200.—Continued. C. Anterolatcral chest wall at

conclusion of operation : Closed thoracotomy incision (a),

closed pleural drainage tube (b), and exteriorized loop of

colon over glass rod (c).

could have been handled through either the chest or the abdomen, but the

location of the foreign body indicated an approach through the thorax. After

debridemeiit of the chest wall, the incision was extended along the eighth intercostal space and the pleural cavity was opened. A moderate amount of bloody

fluid was aspirated. The lower lobe of the left lung was lacerated (fig. 209B).

A plug of omentum had herniated through a perforation in the diaphragm and

sealed off the pleural cavity.

Excellent exposure of the upper abdomen (fig. 209B) was secured through

an anterolateral incision in the diaphragm. The spleen and the stomach were

intact. A 1-cm. laceration in the antimesenteric border of the transverse colon

was repaired with fine silk sutures. Localized peritonitis was present in this

area only. The foreign body seen on the roentgenograms (fig. 2fOA and B)

was about 1 cm. in diameter and was adjacent to the colon. It was removed.

The colon was exteriorized through a counterincision in the left upper quadrant

and brought out over a glass rod. Exploration revealed no other injured organs.

The diaphragm was closed with interrupted silk sutures. Closed drainage

was instituted in the ninth intercostal space posteriorly. The chest wall was

closed tightly in layers (fig. 209C), primary closure being considered safe

because of the small size of the wound.

The wounds of the shoulder, upper arm, and scalp were debrided.

The postoperative course was benign. The highest temperature was 100.8°

F. The exteriorized loop of colon healed well, and gas was passed after the

o-lass rod had been removed. The lungs remained clear throughout (fig. 210C).
THORACIC SURGERY

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FICTI;KK 210 (case S).—Serial roentgenograms in thoracoabdominal wound.

A. Posteroanterior roentgeuogram of chest. 22 September 1944, shortly after

wounding, showing relatively clear lung fields, small amount of fluid in left

pleural cavity, and small metallic foreign body in left upper quadrant of

abdomen. Levin tube in esophagus is shown by arrow. B. Lateral roentgenogram on same date, showing small metallic foreign body in left upper

quadrant of abdomen and haziness of lungs. Note that an artifact present

in posteroanterior view is not seen in lateral view. C. Posteroanterior

roentgenogram showing expansion of left lung on sixth postoperative day.
FOLLOWUr STUDIES OF THORACIC WOUNDS 491

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FIGUHE 210.—Continued. D. Posteroanterior roentgenogram of chest, 14 February 1961, 16 years and 5 months after wounding, showing clear lung fields.

Left diaphragm is flat and costophrenie sinus is blunted laterally. B. Lateral

roentgenogram on same date, showing prominent bronehovascular markings,

tenting of diaphragm anteriorly, and sharp posterior diaphragmatic sulcus.

The patient was evacuated to the 46th General Hospital on the 10th postoperative day. Here the loop colostomy was opened when some distention

developed. It was closed shortly afterward.

Management in the Zone of Interior.—When the patient was evacuated

to Battey General Hospital, Rome, Ga., on 29 December 1944, he required only

rehabilitation. After a period of service on limited duty, he was discharged

in August 1945.

Followup.—A communication from this patient on 14 February 1961

stated that he had worked as a truck driver since the war. He was married

and had children. He had no digestive symptoms and no dyspnea and considered himself well except for occasional pain in the left chest. Koentgenograms at this time (fig. 210D and E) showed no abnormalities of consequence.

Comment.—This patient had a satisfactory recovery after severe thoracoabdominal wounds and multiple other injuries. Several reasons may be given :

He was admitted to a field hospital 75 minutes after wounding. The gastrointestinal tract was almost empty, since he had taken no food that day. Minimal

contamination occurred because of the prompt handling of the lacerations of

the lung, diaphragm, and colon. The pleura was spared serious contamination

because the omentum partly blocked off the wound of the colon and also plugged

the diaphragmatic wound. Had the war continued, this man could have gone

back to full duty. He is well at this time, more than 16 years after wounding,

and is leading an active civilian life.
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Case 9

Management overseas.—This 21-year-old infantryman sustained a high

explosive shell-fragment wound of the left chest at 1025 hours on 30 October

1944 in the mountains of northern France. At the battalion aid station, the

sucking wound was packed (fig. 211A), and he was given morphine gr. %.

When he was admitted to the 11th Field Hospital at Floyes at 1825 hours,

he was in shock, with a blood pressure of 80/50 mm. ITg. He complained of

severe chest and abdominal pain and was spitting up blood. Breath sounds

were absent on the left. The right chest was clear. Tenderness, spasm, and

rebound tenderness were present in the left upper quadrant of the abdomen.

Koentgenograms are shown in figure 212. The right chest was fairly clear,

and the cardiac shadow was not enlarged. A small foreign body was discerned in the- region of the left upper quadrant of the abdomen. On further

examination (fig. 212A and B), it was seen that two foreign bodies were present, one deep in the left upper quadrant and the other apparently in the abdominal wall. Roentgenogram (fig. 212C) showed haziness over the left

chest.

Two units of plasma were given as soon as the patient was admitted, and

transfusions of 1,500 cc. of blood were given over the next 3 hours. By the

end of this time, the blood pressure was stabilized. Since there was no improvement in the abdominal symptoms and signs, the patient was taken to the

operating room at 2125 hours.

The sucking wound in the sixth intercostal space was debrided, and the

incision was extended in this interspace, down to the costal margin. The left

lower lobe, of the lung was lacerated (fig. 211B) and was the site of a small

hematoma. The diaphragm, which was torn, was opened at the dome anterolaterally. This provided excellent exposure of the upper abdomen. The spleen,

which was badly torn, was bleeding and was removed. Two perforations in the

stomach were repaired easily, as was a through-and-through wound of the

splenic flexure of the left colon. A. small foreign body was found in this

region, and a larger object, palpated in the anterior abdominal wall, was removed through a counterincision. The splenic flexure of the colon was mobilized, the perforations in it closed, and the involved area brought out through

a stab wound in the left upper quadrant of the abdomen, over a glass rod.

The diaphragm was repaired with interrupted No. 00 silk sutures. Closed

pleural drainage was instituted in the eighth intercostal space: the catheter

was connected to a closed system. After the pleural cavity had been thoroughly

lavaged with physiologic salt solution, the chest wall was closed in layers. The

central portion of the wound was left open (fig. 211C) and was packed with

fine-mesh gauze down to the muscle layer.

For the first week after operation, the temperature rose daily to 101° F.

Peristalsis was observed on the second day. The colostonry was opened, and

fluids by mouth were permitted. The lung expanded well and there was only a

moderate pleural reaction when the patient was evacuated to the 23d General
m THORACIC SURGERY

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FIGURE 212 (ease 0).—Serial roentgonograins in Ihoraeoabdominal wound.

A. Anteroposterior roentgenogram of abdomen showing- two intra-abdominal

foreign bodies. B. Lateral roentgenogram of chest and abdomen on same

date, showing two metallic foreign bodies in left upper quadrant. C. Posteroantorior roentgenogram of chest, 30 October 1944, immediately after

wounding, showing haziness of left hemothorax, diffuse pleural fluid, and

small metallic foreign body in left upper quadrant. Right lung is fairly

clear.
FOLLOWUF STUDIES OF THORACIC WOUNDS 495

D

FIGI'KK 212.—Continued. D. i'ostoronnterior roentgenogram, 20 December

10G0, 10 years after wounding, showing flat left diaphragm and relatively clear

lung fields. E. Lateral roentgenogram on same date, showing sharp costophrenic angles.

Hospital, Vittel, France, on the 10th day. He had, however, complained of

some pain and distention in the left upper quadrant. Later, swelling, tenderness in the left costal margin, and fever indicated the development of a subphrenic abscess, which was drained successfully on 30 November 1944.

Management in the Zone of Interior.—The patient was evacuated to

Barnes General Hospital, Vancouver, Wash., on 29 December 1944. The

colostomy, which functioned well, was closed in April 1945. Pie received a

disability discharge on 11 August 1945.

Followup.—On 28 December 1960, the patient reported that he had worked

as a printer since his discharge from the army. He was married and had six

children. He had no digestive or other complaints and considered himself

well. Roentgenograms made on 29 December 1960 (fig. 212D and E) revealed

clear lung fields, with prominent bronchovascular markings.

Comment.—This was a patient with an extremely severe thoracoabdominal

wound, which was treated promptly, though before his admission to the field

hospital, spillage of contents into the upper abdomen from wounds of the

stomach and colon had produced severe shock. Prompt surgery was lifesaving

in this case. Colostomy prevented further contamination of the upper abdomen.

The subphrenic abscess which developed was promptly drained at the base

section hospital, and healing was satisfactory. The colostomy was closed

without difficulty in a Zone of Interior hospital. Although the chest trauma

in this case was moderately severe, the wound could perhaps have been handled

from below. Exposure, however, would have been more difficult, and it was
i% THORACIC SURGERY

thought better to handle the sucking wound of the chest and the wound of the

diaphragm in a single operation. The excellent health of the patient 16 years

after operation points up the value of the staged treatment that he received.

HEMATOMA

The diagnosis of intrapulmonary hemorrhage or hematoma was made in

forward hospitals in 89 cases in this series. "When the chest was not opened and

only a debridement of the chest wall was done, the diagnosis was made on

clinical grounds. When pneumonitis and atelectasis could be ruled out, the

presence of hemoptysis and a pulmonary parenchyma! shadow, with slow resolution of the shadow, was regarded as continuation of the diagnosis.

Hematoma of the lung is a pathologic process in which there is extravasation of blood into the alveoli and interalveolar tissue of the pulmonary parenchyma. Observations at base section hospitals in the communications zone

showed that these lesions resolved slowly within 4 to 6 weeks, according to their

severity. No mention is made of their persistence in any of the roentgenologic

reports in this series at Zone of Interior hospitals from 2 to 5 months or longer

after wounding.

In other words, all 89 hematomas resolved spontaneously and without

morbidity. Xo resection of any type was performed for them, nor did lung

abscess or other secondary infection develop in any instance, even when a

massive hematoma of an entire lobe might liquefy to produce a cystlike shadow

on the roentgenogram.

The evidence from these 89 cases thus clearly indicates that there is no

reason to perform lobectomy or segmental resection of a lung that at initial

wound surgery is tense and boggy and contains large amounts of extravasated

blood. As alarming as such a lung may appear to a surgeon who is viewing

his first pulmonary hematoma, there should be no surgical interference. The

lung has tremendous recuperative, power because of its dual blood supply from

the bronchial and pulmonary arteries, and recovery can be expected without

complications when this natural power is supplemented by vigorous measures

to keep the bronchial tree clear of blood and mucus and the pleura! cavity

dry.

The concept of noninterference in pulmonary hematoma formation is

one. of the important advances in thoracic surgery developed in World War II.

Case 10

Management overseas.—This 31-year-old infantryman was wounded by a

fragment, of a 20-mm. missile from a German airplane at 1500 hours on 24 April

1945, at Amerbach, Germany. After a delay of 25 minutes, the ensuing sucking

wound was packed with petrolatum-impregnated gauze at a battalion aid

station, and sulfonamide crystals were placed in the wound.
FOLLOWUP STUDIES OF THORACIC WOUNDS 491

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FIGURE 213 (case 10).—Schematic showing of thoracic wound with

massive heniatoma of the right lung. A. Course of missile : Anterolateral wound of entrance in eighth right intercostal space, with resulting

sucking wound (a), passage of missile through lung to lodge close to

mediastinum posteriorly (h), and high explosive shell fragment (c).

Location of the wound introduced the possibility of diaphragmatic

laceration.

When he was admitted to the 60th Field Hospital at Gunzenhausen, Germany, at 1855 hours, he was eyanotic and dyspneic, and his respirations were

wet and labored and were 40 to the minute. The blood pressure was 150/72

mm. Tig and the pulse 120.

Examination revealed a large anterolateral sucking wound of the eighth

intercostal space (fig. 213A), packed with an airtight dressing. There were

sio-ns of fluid and air in the right chest (fig. 214A and B). and numerous wet

rules over both lung fields, but no cardiac shift.

Eesuscitation occupied 10 hours. It consisted of the administration of

oxygen; the immediate slow administration of 500 cc. of blood and the deferred, very slow, administration of 1,000 cc, of blood; evacuation of the pleura!

cavity by loosening the gauze packing and tipping the patient so that the wound

drained about 500 cc. of blood; intercostal nerve block (T.i-Ts) ; and bronchial
THORACIC SURGERY

IBBS

Fiona-: 213.—Continued. B. Findings at tlioraeofoiny : Laceration of right lower lobe of lnng (a), with massive hematoma of

entire lobe (b), wet lnng of adjacent lobes (c), clots (Ö00 cc.) and

blood (300 cc.) in right iilenral cavity (([). and foreign body resting

in right lower lobe and iilenral cavity (e).
FOLLOWUP STUDIES OF THORACIC WOUNDS 499

aspiration per catheter. The patient, coughed voluntarily after the nerve block

and the catheter aspiration, and the lung gradually cleared of rales.

The wound in the right thoracic wall was thoroughly debrided under

endotracheal anesthesia. Fragments of the fractured eighth rib were resected

and the incision was extended in the intercostal space to make a formal thoracotomy (fig. 213B). The diaphragm was found intact. The right lower

lobe, of the right lung was lacerated and was the site of a massive hematoma

which resembled the liver in appearance. A foreign body free in the posterior

pleural cavity (fig. 214B) was removed, and 500 cc. of blood clot and 300 cc.

of fluid blood were evacuated.

Although the lung was lacerated, it was not blowing air, and no attempt

was made to place sutures in the boggy, engorged right lower lobe.

At this point, it is typical of conditions under which much war surgery

was clone in the Mediterranean theater that a small bug flew into the pleural

space, It was not seen again, but the cavity was thoroughly lavaged with

1,500 cc. of physiologic salt solution.

The muscles were closed in layers with interrupted sutures of fine silk.

The posterior wound of entry was left open and was packed with fine-mesh

gauze down to the muscle layer. Closed intrapleural drainage was instituted in

the eighth intercostal space posteriorly. Penicillin (500,000 units) was injected

into the tube, which was clamped off for 3 hours.

Bronchoscopy immediately after operation produced a large amount of

blood and mucus from the right main bronchus and the right lower lobe

bronchus.

The patient ran a febrile course (101°-102° F.) for the first 5 days, after

which his temperature gradually dropped to 99° F. Intercostal nerve block was

repeated twice, with relief of pain and effective cough. Eoentgenograms on

the third postoperative day (fig. 214C) showed a small cyst, with a fluid level,

the result of liquefaction of the hematoma in the right lower lobe of the lung.

The patient was evacuated to a base hospital on the eighth postoperative

day and thence to the Zone of Interior.

Management in the Zone of Interior.—When the patient was received at

Walter Seed General Hospital 2 months after wounding, his only complaint

was pain in the right chest, with intercostal neuritis. Eoentgenograms were

essentially negative. He was returned to duty in the Zone of Interior but

eventually was discharged for disability.

Followup.—The patient now works as a manager of a store, with no apparent disability.

Ivoentgenogranis 15 years and 10 months after wounding (fig. 2111) and E)

showed clear lung fields and no evidence of the massive hematoma or the cyst

with fluid level seen shortly after wounding.

Comment.—The problems in this case were (1) a sucking wound, (2) a

massive hematoma. of the, right lower lobe of the lung, (3) a foreign body in the

pleura, and (4) the wet lung syndrome. Significant factors in the history are
500 THORACIC SURGERY

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FIGVEE 214 (case 10).—Serial roentgonograms of henmtoma of right lower

lobe of lung. A. 1'osteroanterior roenrgenogram, 24 April 1045, immediately

after wounding, showing fracture of eighth rib at diaphragm and foreign

body in right lower lung close to hilus. Xote haziness of right lung field

and shift of heart to left. P>. Lateral roentgenogram on same date, showing

foreign body lying posteriorly in pleura! cavity. C. I'osteroanterior roentgenogram on 27 April 104."» (third postoperative day) showing cyst with

fluid level, result of liquefaction of hematoma of right lower lobe.
FOLLOWUP STUDIES OF THORACIC WOUNDS 501

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FIGURE 214.—Continued. 1). l'osteroanterior roentgenogram of chest, 2 February 1061, 15 years and 10 months after wounding, .showing complete absorption of massive hematoma of right lower pulmonary lobe. There is no evidence

of cyst with fluid level seen in April 1945. The diaphragmatic shadows are

flattened laterally. E. Lateral roentgenogram on same date, showing flattened

diaphragms anteriorly and fairly deep sulci posteriorly. Lung fields are clear.

the 16-hour preoperativc preparation, the delay being- caused by the wet lungsyndrome; the necessity for traumatic thoracotomy because of the sucking

wound, with, removal of the readily accessible intrapleural foreign body; and

the conservative management of the massive hematoma of the right lower lobe.

Although the hematoma eventually liquefied and formed a pseudocyst, there

are no apparent residua and the lung fields are essentially clear more than 15

years after injury.

In this case, the performance of lobectomy at initial wound surgery to

correct the hematoma might have been more than this dangerously wounded

casualty could have endured. His course since wounding indicates that the

surgery was not necessary.

WET LUNG

Since the concepts and management of traumatic wet lung were developed

in the Mediterranean theater (p. 208), it is important to assess the results of

the incidence and management of this complication of thoracic injuries. It was

extremely troublesome in forward hospitals, in which initial surgery was performed. It was a major problem in 65 of the 167 cases in this series.

In general, it was the policy to treat these casualties intensively in forward

hospitals (p. 217) and not attempt to exacuate them, rgeardless of the nature

of their wounds, until their lungs were comparatively dry. As a matter of fact,

they withstood transportation very poorly. It was therefore the policy to
THORACIC SURGERY

retain them at the primary installation to which they were admitted unless,

as sometimes happened, the tactical situation required the evacuation of the

whole hospital. At the Battle of the Bulge, at Christmas 1944, the Seventh

U.S. Army was serving- as the southern anchor of the front, and as a precautionary measure, all noncombat personnel were evacuated from the frontlines.

The clearing station which had been supported by a platoon of the 60th Field

Hospital was moved 6 miles to the rear, but the platoon itself could not move

for another week because it was holding nontransporfable casualties who had

undergone thoracotomy or thoracolaparotomy and who could not be moved

because of serious wet lung complications.

"When wet lung was properly managed in forward hospitals, few complications arising from, it were encountered in base hospitals. When the reverse

was true, complications were numerous. In this series, only two patients showed

a late pneumonitis which might have been connected with the original wet lung

syndrome. This low incidence is in sharp contrast to the earlier experience: Bi

three of the four deaths in this series, already described (p. 450), the wet lung

syndrome had been a major problem in the resuscitative regimen, and in the

patient with a spinal cord injury, the problem was never completely solved.

This patient, who had multiple Mounds, was, however, the only one in the group

in whom the wet lung factor was an important cause of death.

By the time casualties reached the Zone of Interior, there was never any

clinical problem traced to the orginal wet lung syndrome if it had been properly

handled in the forward hospital. Chronic pneumonitis, bronchitis, and bronchiectasis were seldom recorded—never in this series—nor was the massive

atelectasis so frequent in World War I casualties seen in the thoracic casualties

of World War II. This, no doubt, reflects the careful attention paid in forward

installations to the correction of the wet lung.

The following case report illustrates various aspects of this condition.

Case 11

Management overseas.—A 32-year-old infantry major was wounded in

the left chest by a shell fragment on 22 January 1944, while he was crossiim

the Bapido River during the assault on Cassino. He took the sulfonamide

tablets in his own first aid kit, and the corpsman applied a pressure dresshm

and gave him a unit of plasma. Thirty minutes later, he was given morphine

gr. J/9 in a battalion aid station, for severe chest pain.

When the casualty arrived at the 11th Field Hospital in Mio-jiano Monte

Lungo, Italy, at 1615 hours, the wound (fig. 215A) was bleeding externally

and he had been coughing up blood. He was extremely dyspneic and was disoriented and in shock, with a blood pressure of 55/35 mm. Hg. The pulse

which was difficult to count, was 130, and the respirations 40. Immediate

resuscitative measures consisted of the administration of nasal oxygen; the

administration of three units of plasma and 500 cc. of blood; repacking of the
FOLLOWI'P STUDIES OF TIIOKACIC WOI'XDS 503

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PiCiDiio 215 (ease 11).—Schematic showing of large sucking wound of chest. A.

Wound after debridement of chest wall: Wound of entrance in left chest (a), large shell

fragment in right pleura and axilla (b), laceration of right upper lobe of lung (c), and

open apical segmental bronchus (d). B. Technique of bronchial closure. Blowing segmental bronchus sutured with fine silk and reinforced with pedicle muscle graft.
504 THORACIC SURGERY

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FioruF. 215.—Continued. 0. Appearance of wound at end of operation: Gauze

pack in ehest wall and lung (a), l'enrose sheath drain in right axilla (h), closed

pleural drainage (c), and closure of muscles to superlicial fascia (d).

wound, which was oozing and sucking, with petrolatum-impregnated gauze,

repeated bronchial suction, with aspiration of blood and mucus, as bubbly rales

continued present over both lungs; and the very slow administration of another

500 cc. of blood.

Eoentgenograms (fig. 216A) showed a large foreign body (4 by 2 cm.)

in the right pleura and axilla and haziness of both lung fields, more marked

on the right. There was no mediastinal shift,

Traumatic thoracotomy was performed 10 hours after resuscitation had

been begun. The wound was debrided across the sternum, after which the

shattered second and third costal cartilages were resected, with portions of the

second and third ribs on the right (fig. 215E). The wound was thoroughly

debrided, and the foreign body in the pleura and right axilla was removed.

The lung was partly adherent near the apex and badly torn below. Lobectomy

would have been necessary to close it completely. The fistula in the apical

segmental bronchus was closed with silk, and the closure was reinforced with

a graft of pectoralis minor.

The wound in the lung, pleura, and chest wall was packed tightly with

fine-mesh gauze (fig. 215C) over an area 4 by 6 centimeters. The remainder

of the wound and the muscles were pulled together with interrupted sutures

but left open from the fascia! layer outward.
FOLLOWFP STUDIES OF THORACIC WOUNDS 505

FjuriiE 210 (case 11).—Serial roentgenograms of sucking' wound of chest with wet

lung syndrome. A. Posteroanterior roentgenogram, 22 January 1944, immediately after

wounding, showing large foreign body in right axilla and pleura, with diffuse haziness of

both lungs, more marked on right. F.. Posteroanterior roentgenogram first postoperative

day. showing severe bilateral pulmonary edema. Note gauze pack in right mid lung field.

0. Fosleroanterior roentgenogram, 7 February 1944, showing clearing of lungs. Dotted

line outlines site and extent of gauze pack; 1-cm. right lateral pleural shadow indicates

loculated pleural fluid. D. Posteroanterior roentgenogram, 3 May 1960, 10 years after

wounding, showing essentially clear lung fields. Note anterior stumps of second and third

right ribs.

740-941v
506 THORACIC SURGERY

A Penrose drain was left in the left axilla, and closed pleural drainage

was instituted. Bronchoscopy immediately after operation produced a large

amount of bloody mucus, chiefly from the right upper lobe.

The postoperative course was extremely stormy because of pulmonary

edema. Eoentgenograms made the day after operation (fig. 216B) showed

massive edema of both lungs, with the pack in the right anterior chest wall

and the lung. Treatment consisted of nasal oxygen, supplemented by brief

periods of positive pressure oxygen, administered with each voluntary inspiration by means of an anesthetic machine and manual pressure on the bag

(fig. 50, p. 162) ; intercostal nerve block; and repeated bronchial suction. Because of some blowing from the wound, which did not end until a week after

operation, it was necessary to repack portions of the chest wall. Thoracentesis

was done twice after closed drainage was terminated; about 1,000 cc, of bloody

fluid was aspirated each time.

When the patient was evacuated on the 14th postoperative day, the cavity

in the lung had decreased to about the size of an egg and was granulating well,

and the right had expanded (fig. 216C).

At the 30th Evacuation Hospital, which was then operating as a forward

thoracic surgery center, Maj. Thomas II. Burford, MC, performed a fat graft

of the pulmonary cavity with delayed primary closure of the large anterior

wound.

Followup.—This patient required no active treatment in the Zone of Interior, where he was eventually given a disability discharge. Since that time,

he has been working as a rural mail carrier and has been followed by a private

physician. Eoentgenograms made on ?, May 1960 (fig. 216D) showed the

resected ends of the second and third ribs on the right. Vascular markino-s

in the lung fields were prominent, but the fields were essentially clear.

Comment.—This patient had a very large sucking wound, complicated by

a wet lung syndrome of such severity that he was delirious from hypoxia for

the first 4 days after wounding. The lacerated upper lobe of the rieht lung

was not sacrificed; a muscle graft closed the major bronchial fistula, and packing of the lung and the chest wall was a successful complementary procedure.

Plight upper lobe lobectomy would never have been feasible in this patient

until he reached the base hospital, and there, a skillfully performed fat jrraft

and delayed primary wound closure made further surgery unnecessary. The

wet lung syndrome and massive bilateral pulmonary edema made his early care

extremely difficult.

HEMOTHORAX

Hemothorax is the most common complication of thoracic wounds, which

might be expected, since in every penetrating wound of the chest in which the

pleural space is involved there is some degree of extravasation of blood into

the cavity. A small amount of blood is of little clinical significance if infection
FOLLOWUP STUDIES OF THORACIC WOUNDS 507

does not occur; it is well tolerated by the pleura, and absorption is the rule.

If larger amounts are present, preoperative aspiration is necessary to expand

the lung and increase the vital capacity, as well as to supply an accurate index

of the amount of hemorrhage which has occurred into the pleural space. After

operation, the cavity must be kept empty by the use of intercostal closed

drainage and repeated thoracenteses.

In World War II, when these principles were employed, the goal was to

evacuate the casualty to the base section with the pleural cavity completely

dry. This was not always possible. In spite of diligent aspiration of blood

from the chest, a lung which lias been traumatized and collapsed temporarily

loses its elastic recoil and its ability to expand. During the period in which it is

regaining its elasticity, a pleural effusion develops and there is a deposit of

fibrin that forms a pleural membrane. This membrane is often quite inelastic,

and in some cases, the process includes massive clotting, which can be handled

only by decortication.

In this series of 167 chest wounds, bleeding into the pleural cavity was

sufficiently persistent and of sufficient magnitude, in 91 instances, to create a

considerable clinical problem. In 77 of these patients, repeated thoracenteses

before operation, repeated after operation and supplemented by closed intercostal drainage, were successful in expanding the lung. Only 11 of the casualties were evacuated to the rear witli persistent or clotted hemothorax and pulmonary collapse. These figures would seem to support the policy of repeated,

prompt aspiration of the pleural cavity in hemothoraces.

At the base, decortication was carried out in nine cases, seven times for

organizing hemothorax and twice for hemothoracic empyema. The other seven

casualties who developed empyema were treated by drainage. This means that

decortication was necessary in only 10 percent of the patients in this series with

severe hemothorax and in only about 5.8 percent of the total series. Xo patient

who underwent decortication on any indication was returned to duty overseas.

In the Zone of Interior, 2 of the 91 patients with persistent hemothorax

developed late empyemas which had to be drained. No additional decortications were necessary. There were no deaths in this group of patients and no

major disabilities clue either to chronic empyema or to major collapse of a

so-called captive lung. No patient had a chronic draining sinus of the chest

wall.

These results are in sharp contrast to the results in "World War I, after

which the thoracic wards in Veterans' Administration hospitals were full of

patients with collapsed lungs, chronic empyemas, and persistent sinuses of the

chest wall following hemothorax and hemothoracic empyema. The excellent

results in the World War II patients, of which the results in this series are

typical, were attributable not only to adherence to the principles established

for forward surgery but also to the proper timing and staging of surgery in

base hospitals before the casualties were transferred to the Zone of Interior.
THORACIC SURGERY

Case 12

Management overseas.—This 23-year-old infantry sergeant received a

shell-fragment wound of the posterior left chest at 14-00 hours on 21 September

1914, at Remiremont, France. He also received a wound of the scalp. Immediate treatment consisted of a pressure dressing, on which sulfanilamide powder

had been sprinkled, and the subcutaneous administration of morphine gr. y2.

A unit of plasma was given later at a clearing station.

When the patient was admitted to the 11th Field Hospital at Plombieres

at 1710 hours, he was comatose and in shock, with wet respirations and pinpoint

pupils. The blood pressure was 90/40 mm. Hg, the pulse very rapid and difficult to count, and the respirations 14. Although the record did not indicate

it, further inquiry produced the information that another half grain of morphine

had been administered at the battalion aid station.

The patient was obviously in morphine poisoning. Shortly after he was

admitted to the hospital, the blood pressure began to drop further, and he was

given a unit of plasma and 500 cc. of blood. An hitratracheal catheter was

introduced, and repeated aspirations were carried out; oxygen was administered through the catheter between the aspirations. When the respirations

fell to 12, three ampules of Coramine (nikethamide) were administered intravenously. When the sucking wound of the left chest (fig. 217A) was inspected, a small amount of blood drained from it.

At 1900 hours, the patient, coughed out the catheter, after which lie coughed

up bloody mucus voluntarily. Oxygen was administered by nasal catheter.

When thoracentesis of the left chest, was done posteriorly, only 5 cc. of blood

and 20 cc. of air were aspirated; there was no evidence of tension pneumothorax.

Penicillin was given intramuscularly.

In spite of the active therapy carried out, the lungs remained wet. Over

the next 18 hours, however, there was gradual improvement, in spite of evidence, by the results of thoracentesis, of continued hemorrhage into the left

chest. Over this period, treatment consisted of two additional blood transfusions, intercostal nerve block, and the administration of oxygen by positive

pressure.

At 1400 hours on 22 September 1943, the patient was considered sufficiently

prepared to withstand surgery, which was performed under endotracheal

anesthesia, in the right posterolateral position. The wound of the scalp was

debrided, together with the extensive wound of the left chest and the back.

The large wound over the left scapula (fig. 217B) was found to connect with

the right, shoulder. On the left side, there were extensive lacerations of the

trapezius, latissimus dorsi, subscapularis, and rhomboid muscles. A laro-e

part of the central portion of the left scapula was destroyed. The involved

area was debrided, which left a portion of the tip in situ, together with the

intact, upper portion.
FOLUOWUU STUDIES OF THORACIC WOUNDS )09

FIGUKE 217 (case 12).—Schematic drawings of chest wound with massive chest wall

and intrapleural trauma. A. Posterior aspect of chest showing: "Wound of entrance in

right shoulder (a), large sucking wound with destruction of inferior portion of scapula

and fifth rib (h), portion of wound bridged by skin (c), and second wound in left shoulder,

with two small foreign bodies (d).

The pleural cavity was opened by resection of the comminuted fifth rib.

Intrapleural bleeding was occurring from the fifth intercostal artery (fig.

217B), which was secured at once; 500 cc. of blood was aspirated from the

pleura 1 cavity. A huge hematoma occupied the left upper pulmonary lobe.

The bone fragments in the lung were removed, and a small laceration was

closed, but no pulmonary tissue was resected.

Closed catheter drainage was instituted posterolaterally in the left eighth

intercostal space. The wound and the pleura! cavity were lavaged with physiologic salt solution. The pleura was closed by suturing the subscapularis and

posterior serratus, and then closing the trapezius and latissimus dorsi over this

suture line, as a reinforcing layer (fig. 21TC). The trapezius on the right

was debrided and closed. The whole wound was left open down to the muscle

layers.

Bronchoscopy was performed at the conclusion of the operation. A small

amount of bloody mucus was aspirated from the trachea, and larger amounts

from both main bronchi.
THORACIC SIMRY

FIGURE 217.—Continued. B. Findings at thoraeotomy: Massive hemoimeumothor

with hemorrhage from fifth intercostal vessels (a), rib fragments in left lung (b), lace

tion of left lower lobe of lung (c), hematoma formation (d). wet lung diagramed on ri.

side (e), and superficial wound of left shoulder (f).

ax,

night

The patient -was given 550 cc. of blood during- the operation. Immediately

after it was concluded, his pulse was irregular, but thereafter the major

postoperative problem was keeping the tracheobronchial tree clear.

Roentgenograms before operation (fig. 218A) had showed massive left

hemothorax and haziness of the right lung. There was some improvement in

expansion of the left lung after thoracentesis (fig. 218B). On the ninth postoperative day, the left lung had almost completely expanded, and both lungs

were dry.

After operation, there was considerable drainage (about 500 cc. daily)

for the first 2 clays; the loss of blood was covered by transfusions.

Delayed primary closure of all wounds was carried out at the 46th General

Hospital in the base.

Management in the Zone of Interior.—When the patient was evacuated

to the United States on 18 October 1944, the lung had completely expanded,

and the hematoma had completely resolved. He was given a disability discharge on 8 May 1945, at Madigan General Hospital, Tacoma, Wash., limitation

of motion of the scapula being the main problem.
FODLOYvXF STUDIES OF THORACIC WOUNDS 511

FIGURE 21T.—Continued. C. Diagram depicting types of muscle closure: Right trapezius closure demonstrating simple interrupted sutures (a), left trapezius closure demonstrating mattress type sutures (b), left latissimus dorsi (erector spinae group not

closed) (c), infraspinatus, skin and superficial fascia left open, wound packed down to

muscle layer (d), closure of superficial left shoulder wound (e), and closed intrapleural

drainage tube (f).

Followup.—A personal communication from this patient on 6 December

I960 stated that he had been employed as a truck driver for the past 11 years.

He complained of soreness and stiffness around the left scapula, of lack of

much grip in the left hand for heavy lifting, and of inability to do work involving raising the hand to the level of the shoulder. Although the chief

complaint was referable to the shoulder, the patient stated that when he jumped

from a truck platform, a distance of 2 or 3 feet, he sometimes spat up blood

the following day. He had trouble sleeping on the left side, because of pain

in the left shoulder, but he had no difficulty in breathing, and the occasional

hemoptysis, the cause of which is not known, was so slight that he had never

bothered to seek medical attention for it.

Comment.—This patient had an extensive sucking wound of the chest

wall, with continued hemorrhage into the left pleura! cavity. The original

trauma was complicated by the wet lung syndrome, with bilateral pulmonary

edema, and was further complicated by morphine poisoning. Resuscitation
512 THORACIC SURGERY

W

'.:M.

w

:~

FIGURE 218 (case 12).—Serial roentgenograms in thoracic wound complicated by

massive hemotliorax. A. rosteroauterior roentgenograim 21 September 1043. immediately

after wounding, showing massive left hemotliorax, with slight shift of mediastinum, and

haziness of right lung, due to wet lung syndrome. A defect in left scapula is faintly seen.

15. 1'osteroanterior roentgenogram, showing some improvement in expansion of left lungafter aspiration of blood in left pleural cavity. Appearance of right lung is not materially

altered. Two small foreign bodies are now visible in left shoulder. C. 1'osteroanterior

roentgenogram, 23 November I'.KiO. 17 years after wounding, showing clear lung fields,

except for prominent hronchovascular markings. Xote bridging of fourth, fifth, and sixth

ribs. Heart and mediastinum are normal, and diaphragmatic angle is clear. 1). Lateral

roentgenogram. 23 November 10(i(), showing sharp costophrenic angles. These findings are

approximately normal and do not explain occasional hemoptyses reported by this patient.
FOUUOWUI- STUDIES OF THORACIC WOUNDS 513

covered 21 hours, but the time occupied in stabilizing him was well spent, for

he tolerated corrective surgery well. It is gratifying that for the past 14 years

he has been able to work as a truck driver, and that his residual disability is

only minor. This is the only patient in the 163 survivors followed up who gave

a history of occasional blood-streaked sputum. Eoentgenograms (fig. 218 C and

D) offer no explanation.

RETAINED FOREIGN BODIES

Retained foreign bodies were observed in 102 of these 167 cases. In 33o

instances, they were in the chest wall, in 21 in the pleura, in 36 in the lung

and in 10 in the mediastinum.

These objects always presented a difficult problem in forward hospitals,

for the decision as to their removal was frequently delicate. Those in the

chest wall were most often removed during debridement at the field hospital.

They were usually accessible without a prolonged search, and if they were not

in the original wound of entry, they could be removed by a simple counterincision.

Foreign bodies in the lung and the pleura were not removed as part of

traumatic thoracotomy at held hospitals unless they were readily accessible or

were believed to lie so close to vital thoracic organs as to constitute a potential

danger to them.

Only 13 operations were done for the removal of foreign bodies in base

section hospitals, in only 1 instance because of pulmonary hemorrhage. One

patient, after an uneventful immediate postoperative course, died 2 months

later of hepatitis and jaundice. He had multiple wounds of the head and trunk,

and the sucking wound of the chest was complicated by the wet lung syndrome.

In this case, a foreign body in the pericardium was removed when the suckingwound was closed. The pulmonary object was not accessible, and its removal

would have meant an additional incision and undue prolongation of the operation. It is possible, though highly unlikely, that the retained object was a

factor in the fatal outcome.

Only two foreign bodies were, removed in this series in Zone of Interior

hospitals. One was removed because of a delayed air leak, and the other was

removed during closure of a colostomy. Of the 41 patients with retained

metallic foreign bodies who were evacuated to the Zone of Interior, only the

patient just mentioned, with the delayed air leak, developed symptoms that

required its removal.

Case 13

Management overseas.—This 29-year-old artilleryman was wounded in

the left shoulder by a high explosive shell fragment at 1146 hours on 29 Xovember 1943 near Ardo, Italy. The wound was dressed with sulfonamide powder at

a. battalion aid station, where the patient was also given morphine (gr. i/o) and

sulfadiazine (15 gr.) by mouth.

74(i-0-Hv—(!ö-
514 THORACIC SURGERY

A

B

FIGURE 210 (case 13).—Schematic showing of chest wound with retained foreign body.

A. Wound : Penetrating shell-fragment wound of left shoulder, with fracture of left lmmerus

(a), passage of missile through chest wall and lung with lodgment in left mid thorax (b),

and incision for elective thoraeotomy (c). B. Findings at thoracotomy : Large hematoma

of left upper lobe (.a), hematoma and laceration, left lower chest wall extending down to

diaphragm (b), and foreign body in lung adjacent to heart (c).
FOLLOWUP STUDIES OF THORACIC WOUNDS 515

c

FIGUEE 210.—Continued. C. Diagram of left lung at conclusion

of operation following removal of shell fragment. Repair of

laceration of left lower lobe with two layers of interrupted sutures of fine silk (a), liematoma of upper portion of left upper

lobe, which was not disturbed (b), and water-seal intrapleural

drainage tube (c).

When he was admitted to the 94th. Evacuation Hospital at LePezze at 1410

hours, examination revealed a 2-cm. penetrating wound of the left deltoid

region (fig. 219A) but no other thoracic injuries. He complained of considerable chest pain and was dyspneic, orthopneic, and coughing up blood. The

blood pressure was 128/60 mm. Hg, the pulse 128, and the respirations 38.

Breath sounds were absent over the left chest, and the heart was shifted slightly

to the right. The right lung was clear. Roentgenogranis (Hg. 220A) showed

a left hydropneumothorax, with a foreign body in the left cardiac shadow,

fractures of the sixth, seventh, and eighth ribs, and haziness of the right lung.

There was also a fracture of the left humerus.
516 THORACIC SURGERY

-"

FIGURE 220 (ease .13).—Serial roentgenograms in wound with intrapulmonary foreign body. A. Posterolateral roentgenogram, 20 November 1943,

immediately after wounding, showing foreign body in left cardiac shadow;

extensive collapse of left lung; fractures of sixth, seventh, and eighth ribs

on left; fracture of left humerus ; and haziness of right lung. B. Posterolateral roentgenogram. 7 December 1913, showing expanding left lung and

resection of segments of sixth, seventh, and eighth ribs. Right lung and

cardiac shadows are normal. C. Posteroanterior roentgenogram, 2 December

1000, 17 years after wounding, showing healed fractures of sixth, seventh,

and eighth ribs on left; tenting of left diaphragm and blunting of left

costophrenic angle. Note prominent bronchovascular markings. D. Lateral

roentgenogram on same date, showing left pleural shadow anteriorly and

deep posterior costophrenic angle. Note clear lung field.
FOLLOWUP STUDIES OF THORACIC WOUNDS 517

After thoraceiitesis, which yielded 800 cc of air and 800 cc. of blood, a

transfusion of 500 cc. was given. A second thoraceiitesis, performed because of

signs indicating a reaccumulation of fluid and air in the left pleura 1 space,

yielded 500 cc. of blood.

Thoracotoiny was carried out through an elective incision 7 hours after

admission, through a left post erolateral incision over the seventh rib, because

of the continued reaccumulatioii of air and blood in the left hemithorax and

also because the foreign body was in the region of the cardiac shadow. Fragments of the sixth, seventh, and eighth ribs were resected, and the pleural

cavity was opened through the bed of the eighth rib. The sixth intercostal

muscles were bleeding and were ligated, and fragments of ribs were removed

from the lung. A huge hematoma (fig. 21.9B) occupied the upper portion of

the left lower lobe. The laceration in the lung extended down to the diaphragm, where the foreign body was felt in the pulmonary substance next to

the pericardium, which was not involved. The foreign body was removed

(fig. 219C) and the lung was repaired with two layers of mattress sutures of

fine silk. The hematoma was not disturbed. The chest wall was closed in

layers from the pleura to the skin, and closed intrapleural catheter drainage

was instituted.

The wound in the deltoid was debrided, and a small sequestrum of the left

humerus was excised. The wound was packed open with fine-mesh gauze.

At the conclusion of the operation, bronchoscopy was performed and a

large amount of bloody mucus was obtained from both bronchial trees.

The postoperative course was uneventful, Eoentgenograms 8 days after

wounding (fig. 220B) showed satisfactory expansion of the left lung. The

patient was evacuated to the base on the 18th postoperative clay. The shoulder

wound healed by second intention.

Management in the Zone of Interior.—The only active therapy which

the patient required in the Zone of Interior was physiotherapy to the left arm.

He received a disability discharge.

Followup.—The patient has worked as a salesman since his discharge from

the Army and lias no complaints referable to the chest wound.

Eoentgenograms (fig. 220C and D) made in December 1960, 17 years after

wounding, showed no abnormality except for some obliteration of the costophrenic angle and the thickening of the axillary pleura,

Comment.—In this case, a wound of the shoulder was associated with extensive damage to the chest wall and the left lung. Thoracotoiny through an

elective incision was performed on the indication of continued bleeding, leakage of air into the left pleural cavity, and the possibility of cardiac damage

from a retained foreign body. At operation, the intercostal vessels were

found to be the source of the intrapleural hemorrhage, The hitrapulmonary

foreign body was removed at operation, but the large hematoma was not

disturbed, and satisfactory healing of the lung followed.
rnOKACIC SURGERY

FIGUP.E 221 (case 14).—Schematic showing of chest wound with retained foreign bodies

(rib fragments) in lung. A. Wound: "Wound of entrance in left lateral chest wall (a),

fracture of left scapula (b), fracture of spine of fourth dorsal vertebra (c), and wound of

exit (cl).

Case 14

Management overseas.—A 20-year-old infantryman received a bullet

wound of the left chest at 0800 hours on 12 January 1943. A sulfonamidepowdered dressing was applied to the wound at a battalion aid station at 0830

hours, and he was given a half grain of morphine and a unit of plasma. Two

additional units of plasma were given at a collecting station because of

persisting shock.

When he was admitted to the 94th Evacuation Hospital at 1130 hours, he

was orthopneic and somewhat comatose and was coughing up blood. He complained of severe pain in the left chest, neck, and abdomen. The blood pressure was 102/70 mm. Hg, the pulse 142, and the respirations 42. There was

considerable external bleeding. There was a 3-cm. sucking wound in the left
FOULOWUP STUDIES OF THORACIC WOUNDS 519

FIGUKK 221.—Continued. B. Findings at thoraeotomy: Laceration of lung (a) and

fragments of fractured rib in liematoina occupying- apex of left lower lobe (b).

lateral chest, wall (fig. 221A) and a 4- by 5-cm. wound at the base of the neck

posteriorly on the right. The sucking wound was immediately packed.

Further examination revealed much crepitus over the posterior chest wall,

absent breath sounds on the left, and dullness and signs of fluid in the lower

half of the left chest (fig. 222A). The right lung was fairly clear except for

occasional rales.

Oxygen was administered and bronchial catheter suction begun. Aspiration of'the left chest produced 500 cc. of air and 800 cc. of blood. A slow

transfusion of 1,000 cc. of blood was given.

At 2020 hours, about 9 hours after the patient's admission, his blood pressure was stable, the pulse had dropped to 110 and the respirations to 28. He

was considered fit for surgery.

The wound of entrance was debrided along the left lateral chest wall, and

the incision was extended upward across the chest to the base of the neck on
THORACIC SURGERY

N_—-*■■

L

i£S3

FIGURE 221.—Continued. C. Appearance of wound at conclusion of operation: Wound

of entrance (a) and wound of exit (b). Wound has been ieft open down to deep muscle

layer and packed with fine-mesh ganze (c). Closed pleural drainage tube is in situ (d).

the right. The muscles were debrided. The spinous process of the fourth

dorsal vertebra, which was fractured, was excised, as was the extensively fractured lower third of the left scapula. Fragments of the fractured fifth rib

were also excised. The pleura was then opened through the bed and interspace

of the fifth rib, and three bony fragments were removed from the apex of the

left lower lobe, which was occupied by a large hematoma (fig. 22115). The

lung was slightly debrided, and all air leaks were closed with interrupted

sutures of hue catgut. The pleural cavity was lavaged with 1,500 cc of

physiologic saline, after which a catheter was placed in the eighth intercostal

space and connected with a closed system. The deep muscle layers were approximated with interrupted sutures of fine cotton. The remainder of the

wound was left open and was packed with fine-mesh gauze (fig. 221C).
FOLLOYVUP STUDIES OF THORACIC WOUNDS 521

*\

5

6

FIGURE 222 (case 14).—Serial roentgenograms of thoracic wound with

retained foreign bodies (rib fragments) in lung. A. Posteroanterior roentgenogram of chest, 1 January 1043, immediately after wounding, showingdiffuse haziness and fluid in left chest; shift of heart to right; and fractures

of fifth and sixth ribs and left scapula. P>. Posteroanterior roentgenogram

of chest, 12 January 1943, after resection of portion of fifth rib and scapula

on left. Note hematoma still evident in lower lobe of expanded left lung.

C. Posteroanterior roentgenogram, IS November I960, more than 17 years

after wounding, showing partial absence of fifth and sixth ribs; slight

blunting of left costophrenic angle ; and increased bronchovascular markings

in lung, which otherwise is clear. I). Lateral roentgenogram on same date,

showing sharp costophrenic angles and prominent, bronchovascular markings.
*l rlTTHORACIC SURGERY

At the conclusion of the operation, considerable blood and mucus were

aspirated from both major bronchi through the bronchoscope.

The postoperative course was satisfactory. When the intercostal tube was

removed on the fourth day, after it had ceased to function, the temperature was

100° F., the pulse 90, and the respirations 22. When the patient was evacuated

to the base section on the 12th day, roentgenograms (fig. 222B) showed good

expansion of the left lung.

Management in the Zone of Interior.—The patient was evacuated to the

Zone of Interior after delayed primär)- wound closure in a base section hospital. He required no active treatment there, and was given a disability

discharge.

Followup.—This patient reported in November 1960 that he was working

as a diese! railroad engineer and was in good health. He was married and had

two children. Roentgenograms made at this time (fig. 222 C and D), IT years

after wounding, showed essentially negative lung findings.

Comment.—In addition to a sucking wound and extensive damage to the

muscles of the posterior chest wall, this patient had extensive fractures of the

ribs, scapula, and a spinous process, which resulted in numerous bony foreign

bodies. Although this is an area in which anaerobic cellulitis is always a

possibility, healing of the lung and the chest wall occurred without pneumonitis, abscess formation, or other infection. Early, careful debridemeiit, with

removal of the bony fragments, undoubtedly was the most important factor in

the good recovery and subsequent absence of serious disability. The. role of sulfanilamide, which was applied locally and given by mouth, is much less certain.

POSTDISCHARGE FOLLOWUP

It has been possible to follow the course in civilian life of 119 of the 163

survivors in this series of combat casualties with chest wounds since their discharge from the Zone of Interior hospitals in which they were kept until their

wounds had healed and their lungs had expanded. When they were released,

their chest roentgenograms usually showed good healing of the bony cage and

clear lung fields except for pleural adhesions and thickening. The followup

periods ranged from 3 to 17 years and averaged 5.6 years.

Roentgenologic Observations

Subsequent roentgenograms usually revealed substantially the same findings as the predischarge films, although there had often been further clearing

of the pleural shadows. The most frequent abnormal findings in the current

roentgenograms consisted of pleural adhesions or tenting of the diaphragm,

which occurred in 57 cases. These roentgenologic findings are exactly what one

would expect to find in civilian patients after thoracotomy for jmlmonary,

mediastinal, or cardiac surgery.
FOLLOWUP STUDIES OF THORACIC WOUNDS 523

Oilier roentgenologic observations included thickening of the pleura in 20

cases, slightly increased or prominent bronchovascular markings in 8 cases,

and pulmonary emphysema in 5 cases. The generally inconsequential abnormalities in the roentgenograms described in the 14 case histories just recorded,

all of which were taken 16 or 17 years after wounding, are typical of almost

all the cases in this series.

Retained Foreign Bodies

Of the 119 patients followed up in civilian life, 41 harbored retained

foreign bodies, 35 times in the lung, 4 times in the chest wall, and once each in

the liver and in the region of the right diaphragm. All these objects were less

than 1 cm. in diameter, and in no instance was a pleura! or pulmonary reaction

noted about them on roentgenograms.

All of these patients had been observed in all echelons of U.S. Army hospitals, from the combat zone to the Zone of Interior, and in every case it had

been predicted that the retained missiles would cause no further difficulties.

The prophecy proved correct in all but 1 of the 41 patients. The exception was

a 32-year-old infantryman, who had sustained multiple wounds of the arms,

legs, and chest at Anzio on 29 May 1944. He was treated at the 11th Field

Hospital, where the wounds of the extremities were debrided. The two penetrating wounds of the left chest were also debrided, and a foreign body was

removed from the chest wall. On 14 July 1944, a drainage operation was

performed for hemothoracic empyema at the 23d General Hospital at Naples,

and on 9 February 1945, a chest abscess was drained at Walter Eeed General

Hospital.

The patient remained well until 3 October 1951, when hemoptysis and a

recurrent infection of the lung and the pleura required wedge resection of the

left lower pulmonary lobe, which was the site of the retained foreign body.

Both operations in the Zone of Interior were performed by Dr. Brian Blades.

This was the only case in this series in which a retained intrathoracic

foreign body gave rise to delayed difficulties. The patient represents about

0.6 percent of the 163 casualties AVIIO survived to be evacuated from hospitals

in the communications zone. From the purely clinical standpoint, therefore,

there seems to be no reason for early removal of small (less than 1-cm.)

asymptomatic missiles. All such objects, of course, should be removed whenever this can be conveniently done in the course of surgery on other indications.

Symptoms Referable to the Chest

Most of the patients followed up in civilian life had no symptoms referable

to the chest. The few who had symptoms complained chiefly of pain and

dyspnea. The evaluation of any post-traumatic pain is notoriously difficult,

particularly Avhen industrial compensation is part of the picture. Since dis-
524 THORACIC SURGERY

ability and pensions were involved in all of these chest injuries, the problem

was much the same as in civilian compensation cases.

Hemoptysis was recorded only twice. In one case, just described, the

bleeding could bo attributed to a retained foreign body. In the other, there was

occasional slight streaking of blood when a driver jumped off his truck (case

12, p. 508). The origin of the bleeding in this case is not apparent; the roentgenogram, taken IG years after wounding, shows no significant findings.

Severe chronic cough, chronic bronchopulmonary infection, bronchiectasis,

and chronic lung abscess, the heritage of so many thoracic casualties of World

War I, did not appear in any of these 119 patients.

Psychoneuroses

There is thus a gratifying paucity of physical complaints in these 119

patients followed up in civilian life. In another area, however, unhappy dividends of battle wounds are apparent. In IS cases, reports in Veterans' Administration files indicated some form of psychoneurosis. These were probably

the most serious posttraumatic sequelae observed. In two instances, the patients

had sustained blast, injuries and had had severe cerebral symptoms immediately

afterward, but all of these symptoms had cleared up before their discharge from

Zone of Interior hospitals.

It seems highly likely that the psychoneuroses in these 18 cases are far

more closely related to the total experience of war and of wounding than to

the chest wound in itself. They are also both a factor in, and an index of, the

casualty's postwar adjustment to civilian life.

Development of Thoracic Disease

Whether the postdischarge development of thoracic disease is related to

thoracic trauma is a matter still to be settled. This is the present situation in

these 117 men:

1. A number were hospitalized at various times for pneumonia and other

acute respiratory infections, but the number was probably no greater proportionately than would be expected in the general population.

2. Two patients developed pulmonary tuberculosis, one after reenlistment

during the Korean War. Both cleared well.

o. One patient, in 1952, developed a bronchogenic carcinoma on the same

side as the penetrating wound of the chest. He died a year after pneumonectoniy.

The incidence of posttraumatic thoracic disease was thus very small in

these 119 patients. Whether the figures can be taken at their face value is

another matter. The number of patients followed up is small, and the series

is not representative in one sense, that it includes only a few patients who were

not cared for in the Veterans' Administration hospitals and clinics. Further-
FOLLOAYUF STUDIES OF THORACIC WOUNDS 525

more, carcinoma of the lung will undoubtedly be seen in other patients, even

in this small group, as they pass into the age range in which this and other

forms of malignancy are more common.

SUMMARY AND CONCLUSIONS

The patients in the series reported in this chapter, like all patients with

chest wounds encountered after March. 1944, Mere treated by policies of management developed, for the first time in medicomilitary history, in the Mediterranean theater. In general, these policies were conservative, and it is fair to

say that no patient in the series who was treated without thoracotomy at initial

wound surgery because he was not considered to need that operation suffered in

any way because his chest was not widely opened.

In summary, these policies and practices were as follows:

1. Careful stabilization of the cardiorespiratory physiology was the first

principle of management and was vital to the success of every procedure from

simple debridement of the chest Avail to extensive intrathoracic surgery. That

is, no matter vvhat the wound, the first attention was directed to its effect on the

lung and the heart. The single possible exception to this generalization was

thoracoabdominal wounds associated with shock caused by peritoneal

contamination.

2. Debridement of the wound was the first procedure in thoracic wounds.

In those limited to the chest wall, nothing else was required.

3. The indications for primary thoracotomy in forward echelons were

strictly limited. They included traumatic thoracotomy (sucking wound),

thoracoabdominal. wounds, continued intrathoracic hemorrhage, leakage of

air from the respiratory tract, and injury to vital mediastinal structures

(esophagus, trachea, heart, great "vessels, and thoracic duct). In retrospect,

there seems to be no valid reason to widen these indications. Their standardization, in fact, represented a major contribution to thoracic surgery in World

War II.

4. Immediate recognition and intensive treatment of the wet lung syndrome not only reduced the intial surgical mortality but prevented the late

sequelae of pulmonary atelectasis and broiichopulmonary suppuration. These

were frequent sequelae of chest wounds in World War I. There were no

complications of this sort in this series.

5. In severe wet lung, in which pain in the chest wall was an important

factor, treatment consisted of intercostal nerve block, tracheobronchial aspiration, and the administration of oxygen under intermittent positive pressure.

All of these techniques have been carried over to civilian thoracic surgery since

the war. In fact, intermittent positive pressure oxygen therapy, which was

used in the Mediterranean theater for the first time in medical history, in the

management of severely wounded thoracic casualties before and after opera-
526 THORACIC SURGERY

tion, is now almost standard in the management of many pulmonary and cardiac

conditions for which thoracic surgery is done,

6. Prompt aspiration of hemothoraces increased the vital capacity of the

lung and permitted the evaluation of the degree of intrapleural hemorrhage.

In some instances, this measure undoubtedly prevented the deposition of fibrin

and the development of the so-called captive hmg. In no instance was there

any evidence that bleeding into the chest was increased by this technique, as

many surgeons, before the war, had predicted.

7. Hematomas, even if they involved an entire pulmonary lobe, responded

well to conservative treatment and furnished no indications for resection of

the involved tissue. These hematomas resolved with almost no pathologic

pulmonary residua.

8. Pulmonary lacerations usually responded to intercostal decompression

by the closed technique. If they did not, thoracotomy, with simple suture, Avas

the indicated treatment. Neither lobectomy nor resection Avas required. In

fact, these folloAvup studies, as Avell as other studies, shoAV that such operations

had no place in the initial surgery of Avar casualties. Even localized (segmental or less) resections Avere almost never indicated; only one Avas performed

in this series. The explanation is the tremendous recuperative poAvers of the

lung together with its dual blood supply and elaborate lymph drainage.

9. Sucking Avounds of the chest required immediate occlusion of the chest

Avail defect, After resuscitation of the patient from the cardiorespiratory

point of view-, traumatic thoracotomy could be performed with a low mortality

and generally excellent results.

10. Patients with blast injuries Avho survived their stay in forward hospital could be returned to civilian life with feAv cardiorespiratory symptoms

and only moderate residua caused by damage to the cerebrum or tympanum.

11. Eetained foreign bodies, if they Avere not producing hemorrhage, persistent air leaks, or esophageal trauma, Avere best handled at the base section,

where the patient Avas in better condition to tolerate the necessary procedures.

Asymptomatic foreign bodies in the lung, pleura, and mediastinum Avhich

were less than 1 cm. in diameter Avere usually Avell tolerated, if the evidence of

this series is to be believed.

12. Patients Avith thoracoabdominal Avounds handled by the principles

employed for thoracic and abdominal surgery in the Mediterranean theater

Avere returned to civilian life Avith fW or no cardiorespiratory or gastrointestinal symptoms.

13. Patients Avith mediastinal injuries seldom surviA-ed to reach forward

hospitals. When they did, gratifying long-term results Avere achieved if they

were managed by the principles and practices just described.

The postwar followup of the patients in this series furnishes every cause

for encouragement as to the general results of these principles and practices.

The series is small, it is true, but it is entirely unselective except in the sense

that the patients Avere included in it because the original information concern-
FOLLOWUP STUDIES OF THORACIC WOUNDS 52 i

ing their wounds was available and their subsequent records were complete

enough to be useful.

Only 4 of the 167 severely wounded casualties in this series who survived

initial wound surgery in forward hospitals died in base hospitals, and no deaths

attributable to thoracic wounds occurred in casualties followed up in Zone of

Interior hospitals or in those traced in civilian life.

From the records, and from personal correspondence with a number of

men in the group, it was evident that practically all of them were gainfully

employed, usually full time; that they were married and had families: that

they were leading useful civilian lives; and that, with few exceptions, they

considered themselves well from the standpoint of their chest wounds.

The assumption also seems warranted, as already intimated, that the majority of patients in the original panel of casualties (822) do not appear in this

followup because they regarded themselves well. Those who reported to the

Veterans' Administration are a group with more persistent ill effects from

their wounds—frequently not their thoracic wounds—or a group of psychoneurotic patients whose attention was focused on their old chest injuries.

One emerges, therefore, from an analysis of these records with the impression that if the patients in the series may be assumed to be representative, the

great majority of casualties who survived chest wounds were really rehabilitated and restored to normal, useful lives. If this impression is correct (and

there are no data to the contrary), it furnishes strong evidence of the validity

of the principles and practices of thoracic surgery developed in the Mediterranean theater in World War II and recorded in detail in these volumes.
APPENDIX

Special Reports and Statistical Data

B. Noland Carter, M.D., and Michael E. DeBakey, M.D.

Throughout this volume, statistical and other material has been cited from the clinical

experiences in World War II of various organizations and individuals. This appendix summarizes the clinical-statistical data on thoracic surgery of the activities of :

1. The 2d Auxiliary Surgical Group in the Mediterranean (formerly North African)

Theater of Operations, U.S. Army, from the final report made by Maj. (later Lt. Col.)

Reeve II. Betts, MC; Maj. (later Lt. Col.) Caul C. Samson, MC; Maj. Lyman A. Brewer

III, MC ; Maj. (later Lt. Col.) Lawrence M. Shefts, MC ; and Maj. Thomas II. Burford, MC.

2. The 51 h Auxiliary Surgical Group in the European Theater of Operations, U.S.

Army, from the final reports on 1,008 war wounds of (he thorax and abdomen, made by Maj.

William H. Ealor, MC; Maj. Charles B. Burbank, MC; and Maj. (later Lt. Col.) Elmer

I>. Gay, MC.

3. The Kennedy General Hospital thoracic surgery center, Memphis, Tenn. The material used is an analysis of the first 500 thoracic casualties received in the center after it

became fully operational. The report was prepared by Maj. Earle B. Kay, MC, and Lt. Col.

Richard II. Meade, MC.

The original detailed reports are on file in The Historical Unit, U.S. Army Medical

Service.

2D AUXILIARY SURGICAL GROUP

Basic Data

Between the Tunisian landings in November 1042 and the end of the war in Italy in

May 1045. the 27 general surgical and 5 thoracic surgical teams of the 2d Auxiliary Surgical

Group1cared for approximately 22,000 battle casualties in North Africa, Sicily, Italy,

southern France, and Germany. The 3,154 abdominal injuries included in this material

are analyzed in another volume of this series.2

During the specified period, surgeons of the 2d Auxiliary Surgical Group cared for

1,364 casualties with thoracic wounds, 135 of whom (9.89 percent) died, and 903 casualties

with thoracoabdominal wounds, 247 of whom (27.35 percent) died. This is a total of 2.267

casualties with thoracic and thoracoabdominal wounds and 382 deaths (16.85 percent).

Among the casualties with only chest wounds were 115 civilians and prisoners of war,

of whom 19 (16.52 percent) died. This leaves 110 deaths in 1,249 U.S. Army personnel with

thoracic wounds (9.29 percent). The following discussion includes only these 1,249 casualties unless otherwise specified.

The figures include all penetrating and perforating wounds encountered by the group

surgeons during this period. They do not include injuries limited to the thoracic cage,

1 The extensive experience of the teams of the 2d Auxiliary Surgical Group with thoracoabdominal

injuries is summarized under that heading (p. 130).

= Medical Department, United States Army, Surgery in World War II. General Surgery. Volume

II. Washington : U.S. Government Printing Office, 1955, pp. 79-333.

0 29
530 THORACIC SURGERY

without pleural penetration, even though pleural damage sometimes occurred under these

circumstances.

In the early days of the Tunisian campaign, a small number of these casualties were

operated on in clearing stations. A few were also operated on in beach installations, during the first few days of amphibious landings. With these exceptions, all the casualties

received their initial wound surgery in field and evacuation hospitals.

All the deaths occurred in these forward hospitals, for which the figures can be

assumed to be complete. On the other hand, casualties were held in forward hospitals only

for limited periods, seldom more than 14 days. It must therefore he assumed that a certain

number of deaths occurred later, in fixed hospitals and thoracic surgery centers in the base.

There is no information on this point, for the attempts at followup that were occasionally

made were not successful.

Deficiencies of records.—Many errors and imponderables enter into any records prepared by medical officers under field conditions. There are errors and omissions in these.

Yet they are surprisingly complete when one considers the circumstances in which the

material was compiled. It was necessary for each team to prepare from four to seven

official records on each patient, all in longhand, all without secretarial or stenographic

help, and all containing much duplicated material. All post mortem examinations were

made by members of the teams, and all protocols were written by them in longhand. During

rush periods, when surgeons were working long hours under extremely adverse conditions,

their zeal in the preparation of additional records for some future study was naturally

limited. The most amazing thing about the records is that they were kept at all.

These statistics and conclusions are based on the overall experience of the surgeons

of the 2d Auxiliary Surgical Group. They represent not only individual experiences but

the aggregate experiences of all the surgeons. The number of injuries is large enough to

warrant conclusions. The casualties were treated over a sufficiently long time, in sufficiently varied climates and terrains, under sufficiently varied conditions, to compensate for

some of the variables and to cancel out some of the inevitable errors. The chief justification for the presentation of this clinical-statistical material in detail is that, so far as

is known, this is the most extensive study of combat-incurred thoracic and thoracoabdominal

wounds that has ever been made.

Chronologic division of cases.—There are a number of reasons for analyzing certain

of these data according to whether the casualties were treated before or after 1 May 1044.

The date, which is arbitrarily selected, represents a turning point in clinical policies, to

which the improved results (a drop in the case fatality rate from 11.27 percent to 8.3

percent) bear witness. Among the factors responsible for this improvement were :

1. Better triage, based on a clarified definition of transportability (vol. I).

2. More rapid evacuation of casualties from the battlefield to the division clearingstation.

3. A more correct appreciation of the physiologic components of resuscitation, including the importance of wet lung (p. 207).

4. A clarification of the indications for thoracotomy in forward hospitals and of the

limitations of this operation.

j. Improvements in postoperative care.

6. The provision of liberal amounts of blood by a theater blood bank, so that every

casualty could be given all he needed.

7. Improvements in anesthesia, as a result of both more adequate equipment and the

increased experience of anesthesiologists.

5. The universal availability of penicillin, which after 1 May 1944 could be used in

adequate amounts whenever it was indicated.

0. The increased experience of both thoracic surgeons and general surgeons who were

called upon to care for thoracic casualties, which is discussed elsewhere as the so-called

learning curve (p. 139).
AITEXDIX 531

It was the opinion of many surgeons of the 2cl Auxiliary Surgical Group that casualties

cared for after 1 May 1944 were, generally speaking, more severely wounded than those

treated before that date. This is not a matter which lends itself to statistical proof. If

the opinion were correct, and if other factors had remained equal, a higher case fatality

rate might have been anticipated after that date. Instead, as just pointed out, the rate

fell, probably for the reasons just specified.

Wounding Agents and Location of Injuries

In the 1,203 injuries in which this information is available, the wounding agent was a

shell fragment in 830 cases, a gunshot wound in 371 cases, and a stab wound in 2 cases.

In 1.240 stated injuries, the right side was involved G02 times (48.55 percent) and the

left side 003 times (48.63 percent) ; both sides were involved 35 times (2.82 percent).

In 1,238 injuries, 719 of the wounds were penetrating (58.08 percent). 478 perforating

(3S.G1 percent), and 41 lacerating (3.31 percent).

Shock and Resuscitation

Shock.—Of the 400 thoracic casualties treated before 1 May 1944 (hereafter referred

to as Group I) for whom this information was recorded, 149 were not in shock, 07 were

in mild shock, 83 were in moderate shock, and 44 were in severe shock. The corresponding

data for the 849 casualties treated after 1 May 1944 (hereafter referred to as Group II)

indicate that 314 were not in shock, 102 were in mild shock, 190 were in moderate shock

and 110 were in severe shock.

Blood and plasma.—During the early fighting in North Africa, plasma was used liberally and blood infrequently. Blood was used in increasing amounts and on broadening

indications in the fighting in Sicily and in the first months of fighting in Italy, but the

supply was limited, and it was often difficult to obtain until a theater blood bank was

established in Naples in February 1944. That circumstance is part of the explanation

for the more limited use of blood and the more liberal use of plasma in Group I injuries

in this series. On the other hand, there must also be taken into consideration that in the

early months of the war, it was believed that plasma was an acceptable substitute for whole

blood and that in some quarters, at least, this belief died slowly. The amount of blood

and plasma administered to these two groups of casualties therefore depended not only

upon their special necessities but upon the availability of whole blood and the original

impression of the value of plasma.

It is not thought that the statistics that follow are complete, though they are based

on all the specific information recorded on the emergency medical tag and on the records

of the hospital in which initial wound surgery was performed. Entries on some additional

charts suggested that replacement therapy might have been employed, but the data were

not specific and were discarded.

The composite recorded figures for replacement therapy are as follows :

In Group I, 190 or 400 patients (49.00 percent) received plasma in the total amount

of 138.200 cc, the average amount per patient being 705 cc. The largest amount given

was 2.500 cc.

In Group II. 509 of the 849 casualties (07.02 percent) received a total amount of

351.200 cc. of plasma, the average amount per patient being 017 cc. The largest amount

given was 2.750 cc. The drop in Group II of almost 100 cc. in the average per case probably

reflected the increased availability of blood at this time and the restriction of plasma

to its proper uses.

In Group I, 172 of the 400 patients (43.00 percent) received a total of 179,900 cc. of

blood, the average per patient being 1,046 cc. The largest amount given was 3,600 cc.
532 THORACIC SURGERY

In Group II, G33 of the 849 casualties (71.56 percent) received a total amount of

753,850 cc, the average amount per patient being 1,189 ec. Tlie largest amount given to

a single patient was 7,500 cc.

Autotransfusion was used in 29 patients in Group I, in (lie total amount of 23,100. The

average per patient was 807 cc, and the largest amount thus given was 2,700 cc

In Group II, 42 patients were treated by autotransfusion, in the total amount of 28,950

cc. The average per patient was «89 cc, and Hie largest amount given was 2,000 cc. The

figures for Group II probably reflect the increased availability of blood: autotransfusion

is not a desirable technique if blood can be secured elsewhere.

Other resuscitative measures.—In Group I, 8 of the 400 palients were treated by intercostal nerve block. 53 by thoracentesis (in 1 case via intercostal catheter), and 4 by

trachea] aspiration per catheter. Preoporative bronchoscopy to clear the airway was not

used in any instance in Group I.

In Group II, 09 of the 849 casualties were treated by intercostal nerve block, 21S by

thoracentesis (in 9 cases by intercostal catheter), 25 by tracheal aspiration per catheter,

and 8 by bronchoscopy. One must be impressed by the more active measures used in

Group II to facilitate deep breathing and coughing and to keep the airway clear. In spite

of the time consumed by these additional measures, the average timelag fell from 15.7

hours in Group I to 11.0 hours in Group II.

Measures to control pressure pneumothorax were seldom necessary. This complication

was encountered only once in Group I and only 10 times in Group II.

Surgical Procedures

In Group I, 231 of the 400 patients (58.50 percent) were treated only by debridement.

In Group II. 531 of the 819 patients (02.90 percent) were thus treated.

In Group I, 07 thoracotomies were performed by general surgical teams in the 213

cases which they handled (27.57 percent). There were 11 deaths (10.42 percent). In this

same group, over the same period, 72 thoracotomies were performed in 157 cases (45,80

percent) by thoracic surgical teams, with 10 deaths (13.89 percent).

In Group II, 224 thoracotomies were performed in 023 cases by general surgical teams

(35.95 percent), with 27 deaths (12.05 percent). In this same group. 72 thoracotomies were

performed in 220 cases by thoracic surgical teams (31.80 percent), with 0 deaths (8.33

percent). The casualties in this group were all cared for after strict limitations had been

put upon the use of thoraeotomy. This fact is reflected in the much smaller proportion of

cases in which (he operation was used, as well as in the reduced case fatality rates.

Thoraeotomy was performed through the wound in 308 cases, in 150 of which it was

necessary to enlarge the traumatic thoraeotomy, and by a separate elective incision in «7

eases.

The indications for the operation, according to the 144 charts on which this information

was available, were as follows :

Combined thoracic and abdominal wounds (as contrasted to thoracoabdominal wounds)

in «3 cases, with 13 deaths.

Bleeding in 30 cases, with « deaths.

Injuries to the mediastinum, heart or both in 20 cases, with 2 deaths.

Retained foreign bodies in 11 cases.

Retained bone fragments in 3 eases, with 1 death.

Pulmonary lacerations in 2 cases, with 1 death.

Bronchial injuries in 3 eases, with 1 death.

Injuries of the esophagus in 3 cases, with 3 deaths.

Possible injury of a hilar vessel, pressure pneumothorax, and failure of the lung to

expand in 1 case each. The casualty with the vascular injury did not survive.
APPENDIX

Analysis of Fatalities

The breakdown of the 11G deaths in 1,249 wounds of the chest in U.S. Army personnel

(9.29 percent )was as follows:

53 deaths in 70S debridemcnts (0.90 percent).

19 deaths in 23-1 debridements in Group I (8.12 percent).

34 deaths in 531 debridements in Group II (6.37 percent).

51 deaths in 135 thoracotomies (12.11 percent).

21 deaths in 139 thoracotomies in Group I (15.11 percent).

33 deaths in 290 thoracotomies in Group II (11.15 percent).

9 deaths before, or in the course of, operation.

There were 19 deaths in the 115 wounds in civilians and prisoners of war not included

in this analysis (10.52 percent).

Among the 1,249 casualties with chest injuries were 200 who also had associated

wounds of major importance, including 03 wounds of the abdomen, 42 severe compound

fractures. 39 spinal cord injuries, 15 severe soft tissue wounds, 7 traumatic amputations,

and 4 contralateral thoracoabdominal wounds.

There were 40 deaths in these 200 cases (23.0 percent), as compared to 70 deaths in

the 1.019 U.S. Army casualties (0.07 percent) whose wounds were limited to the chest

or who had associated wounds not of major importance. In all combat injuries, the risk

was always greater when the wounds were multiple, and it increased in proportion to the

severity of the principal and associated injuries. In many of the cases just listed, the

chest wound was obviously of lesser importance than the associated injury.

Causes of Death

In 10 of the 110 deaths in U.S. Army personnel, the cause was not recorded and it was

impossible to gather from the scanty notes to what they should be attributed. The 41

separate causes listed for the remaining 100 deaths can be conveniently grouped as follows :

Pulmonary and respiratory causes.—Of the 100 deaths, 28 were due to pulmonary or

respiratory conditions. This was the largest single group of deaths, and, from the clinical

standpoint, the group most amenable to treatment. In the opinion of the surgeons who

eared for these casualties, some of these deaths, at least, must be regarded as preventable.

Seven deaths from pulmonary edema occurred between the first and fourth postoperative (lays. In every instance, the pulmonary damage was severe. It is not known

whether positive pressure oxygen therapy was employed in any of these patients, but in

several cases, it was thought that injudicious replacement therapy played a part in the

fatality.

In 15 cases, the cause of death was listed as pneumonia. In some instances, exposure

on the battlefield, preexisting upper respiratory infection, and the virulence of the organism

in relation to the resistance of the host explained both the complication and the fatal

outcome.

Four patients died of atelectasis. One died of tracheal obstruction caused by an excessive production of mucus, and another died of wet lung, on the fifth postoperative day.

Attempts to improve drainage of the traeheobronchial tree were always vigorous, once the

importance of the wet lung of trauma had been realized (p. 207), but occasionally they were

not successful. Sometimes there was a recurrence of the traeheobronchial obstruction

after it had been relieved, and the stage was then set for the development of atelectasis and

pneumonia if prompt, zealous efforts were not made to overcome it.

Shock. Ten patients died of shock, eight on the day of operation, one on the following

dav, and one on the second postoperative day.
534 THORACIC SURGERY

Nine patients died of renal failure, which in most instances seemed related to their

previous state of shock. All these deaths occurred in Group II; earlier in the war. lower

nephron nephrosis was not recognized and, as a matter of fact, much about it remained

to he clarified when the war ended.

Hemorrhage.—Nine patients died of hemorrhage, as follows:

3 from lacerations of the aorta.

2 from massive intrapleural hemorrhage.

2 from massive intrapulmonary hemorrhage.

1 from media stinal hemorrhage.

1 from laceration of the vena cava.

The small number of deaths from intrapleural and intrapulmonary hemorrhage (only

five when the lacerations of the great vessels are excluded) is striking in view of the emphasis put upon intrathoracic bleeding as a possible cause of death in the prewar discussion

of chest injuries.

Cardiac deaths.—There were five deaths from cardiac injuries, three of which had been

overlooked, and another death from cardiac tamponade. One of these injuries was complicated by atelectasis. Two other deaths were caused by cardiac fibrillation.

Miscellaneous causes of death.—Other causes of death, which cannot be conveniently

grouped, were as follows :

0 deaths from blast injuries, which affected the pulmonary tissues in 4 cases, the

mediastinal tissues in 1 case, and the cerebral tissues in 1 case.

4 deaths from clostridial myositis, in 1 instance complicated by pneumonia.

4 deaths from pulmonary embolism.

3 deaths from mediastinitis, in all of which injuries to the esophagus or the esophagus

and trachea had been overlooked.

3 deaths from cerebral anoxia.

2 deaths from aspiration pneumonia, both caused by aspiration of vomitus during

anesthesia.

1 death from each of the following causes: cerebral malaria, cerebral embolism,

cerebral abscess, phosphorous burns, splenomegaly and jaundice, severe lacerations of the

lung, the vagovagal reflex, peritonitis, thrombosis of the pulmonary artery, empyema, right

heart failure, massive emphysema, pressure Pneumothorax, and multiplicity of wounds.

Post mortem observations.—Post mortem examination was carried out in 78 of the

11C fatalities, the most impressive findings being 12 overlooked injuries, including 3 perforations of the aorta ; 3 cardiac injuries, 1 associated with massive pulmonary collapse; 3

injuries of the esophagus, 1 associated with an injury of the trachea; 1 injury of the

trachea ; and 1 injury of the vena cava. Thoracic surgical teams cared for only 3 of these

12 cases.

Chronology of deaths.—Of the 116 deaths, 9 (7.76 percent) occurred before surgery

could be undertaken or on the operating table. Of the remainder, 26 occurred the day

of operation, 19 on the first postoperative day, and 9 on the second postoperative day. In

other words, something over half (54.3 percent) of the 116 fatalities had occurred by the

end of the second postoperative day. All but 10 of the 116 fatalities (91.4 percent) had

occurred by the seventh postoperative day.

5TH AUXILIARY SURGICAL GROUP

In the 1,068 combat-incurred wounds of the chest and abdomen treated by surgical

teams of the 5th Auxiliary Surgical Group in the European theater in 1944 and 1945 were

374 penetrating and perforating wounds of the chest, with 31 deaths (S.29 percent) and 165

thoraeoabdominal wounds, with 39 deaths (23.70 percent). A few of these wounds occurred

in civilian casualties, but the analysis does not distinguish them from the injuries in

military personnel.
APPENDIX

Thoracic Wounds

Basic data.—Of the 374 patients with perforating or penetrating wounds of the chest,

283 were treated in field hospitals and 01 in evacuation hospitals. Field hospitals received

twice as many casualties within the first 12 hours after wounding as in the second 12-hour

period. Evacuation hospitals received ahout the same number in each 12-hour period.

The timelag for field hospitals averaged 7 hours and for evacuation hospitals, 10 hours.

Of these wounds of the chest, 180 were on the left and 189 on the right; 5 were

bilateral. Gunshot caused 193 wounds and shell fragments 181. Penetrating wounds

caused by shell fragments were twice as frequent as perforating wounds, and sucking

wounds were caused by shell fragments twice as frequently as by gunshot. Sucking wounds

were also twice as common in penetrating as in perforating wounds.

Policies of management.—In the European theater, as in the Mediterranean theater,

the management of chest wounds progressed through a definite cycle. In the beginning,

before surgeons had had much experience with combat-incurred wounds, the general

tendency was to be somewhat radical, and there were few patients with chest wounds

who did not undergo thoracotomy. When casualties became heavy, however, and there

was a large backlog of patients with abdominal and thoracoabdominal wounds, experience

showed, as it had in the Mediterranean theater, that casualties with thoracic injuries could

be treated satisfactorily by delayed surgery and by less radical procedures.

The following indications for thoracotomy then became regulation :

1. Ilemothorax due to active bleeding, with rapid refilling of the pleural cavity after

aspiration. The source of bleeding was usually an intercostal artery or the internal mammary artery; the lung itself; or, less often, the heart or some other mediastinal structure.

Patients in this group were usually in severe shock on admission and did not respond well

to resuscitation.

2. Massive clotted hemothorax that did not lend itself to aspiration. These patients

often presented dyspnea, cyanosis, and mediastinal shift. Evacuation of clotted blood

and control of bleeding were readily effected through an open thoracotomy, and this method

of management became the procedure of choice.

3. Retained foreign bodies 2 cm. or larger in the pulmonary parenchyma or the pleural

cavity. The principal indication for removal of these objects was risk of an infected hemothorax or lung abscess. Possible future damage to the lung or to a blood vessel was also

considered an acceptable indication.

4. Shattered rib fragments in the lung or pleural cavity or large fragments that had

not perforated the pleura. Many surgeons came to believe that bone fragments in the

lung were of much more serious consequence than metallic foreign bodies. They were

apt to be long and spiky, with irregular edges, and they tended to penetrate the tissues

and to forge ahead in them. After a time, bone fragments often became necrotic, and an

abscess or an infected hemothorax was a possible consequence. Laceration of a blood vessel

was also far more likely from contact with bone fragments than from contact 'with metallic

foreign bodies. The preferable technique of removal was thoracotomy or extrapleural rib

resection.

5. Sucking wounds. If intrathoracic damage of any consequence was suspected,

thoracotomy was performed. Otherwise, simple dehridement and closure was usually

all that was necessary.

6. Tension pneumothorax due to an air leak, as in bronchopleural fistula.

After these indications had been set up, the treatment of thoracic casualties became

considerably more conservative. Toward the end of the war, however, reports from general

hospitals were to the effect that the incidence of infected hemothorax, empyema, and

lung abscess was higher when foreign bodies were left in situ, and as a result, more

thoracotomies began to he performed. In the 374 wounds of the chest cared for by the
586 THORACIC SURGERY

5th Auxiliary Surgical Group, 142 thoracotomies were performed (38.00 percent), with

12 deaths (S.45 percent).

Hemothorax.—Hemothorax was recorded as present in 206 of the 374 perforating or

penetrating wounds (79.14 percent) and was stated to be absent in 24 cases. It was

probably present in all the cases in which no statements were made about it. Hemothoraces varied in volume from 200 cc. to 2,500 cc. In the absence of other indications

for interference, collections up to 300 cc. were left in situ. Larger collections were treated

by aspiration, which was repeated as necessary. Air replacement was not employed, and

no fluid was used except for a small amount of distilled water necessary to dissolve the

penicillin (usually 40,000 units) used intrapleurally. If the chest continued to refill

with blood after adequate aspiration, operation was considered to be indicated.

Active intrathoracic bleeding was found at thoracotomy in 50 wounds, 32 of which

were caused by shell fragments. In 32 instances, the bleeding was from the lung (in

1 case from an intercostal vessel also), in 10 from an intercostal vessel, and in 2 from the

internal mammary artery.

The case fatality rate was apparently related to the volume of the hemothorax. There

were 2 deaths in the 49 cases in which the volume ranged up to 500 cc. and 12 in the 78

cases in which it ranged from 2,000 to 2,500 cc.

Tension pneumothorax.—Tension pneumofborax occurred only 32 limes, usually in

valvelike sucking wounds. Treatment consisted of sealing the wound and emptying the

pleural cavity by aspirations. If the collection of air was caused by an actual air leak

from the lung, a large needle or stiff catheter was introduced into the pleural cavity via the

second anterior interspace, and water-seal drainage was instituted.

Injuries of the lung.—It was the practice to leave small lacerations of the lung unsutured unless they were bleeding. Larger lacerations were repaired.

In one instance, pneumonectomy had to be done for severe lacerations of both the

upper and lower lobes. Recovery was uneventful. In another instance, massive intrabronehial hemorrhage occurred after suture of a large laceration and reexpansion of the

lung by positive pressure. The patient died before the bleeding could be controlled. Autopsy showed that it came from the laceration and made it clear that a lobectomy should

have been done. Both these injuries, however, are exceptions; valid indications for

radical surgery for damage to the pulmonary parenchyma were extremely uncommon.

Cardiac wounds.—Cardiac injuries were encountered 4 times in the 374 wounds. Two

patients recovered uneventfully, one after suture of a laceration of the left ventricle and

one after suture of a laceration of the right atrium and repair of a perforating wound of

the lower lobe of the left lung. In the third case, autopsy revealed a shell fragment in

the wall of the left ventricle, which had lacerated the descending ramus of the left coronary

artery. Roentgenograms had indicated that the object was in the mediastinum. In the

fourth case, autopsy revealed a shell fragment 25 by 15 by 10 mm. in the right ventricle.

It had entered the superior vena cava and been swept down into the ventricle, lacerating

the tricuspid valve in its passage.

Analysis of deaths.—Of the 31 deaths in these 374 injuries, (i occurred in gunshot

wounds and 25 in shell-fragment wounds. Of the fatal wounds, 14 were on the right side

and 14 on the left; 3 were bilateral. In one of the bilateral injuries, death occurred suddenly, 7 days after initial wound surgery, from a secondary hemorrhage from a lacerated

azygos vein. Another patient developed bilateral pneumothorax and died of anoxia on

the third postoperative day.

In 16 cases, death occurred on the operating table or during the first 12 hours after

operation, chiefly from shock. In these 16 deaths were 4 caused by blast injuries and 1

caused by a skull fracture.

One fatality represented a serious but quite understandable error in diagnosis. The

patient had sustained a penetrating, sucking wound of the left chest. According to the

roentgenograms, the stomach seemed to be in the thorax. When, however, the patient
APPENDIX

stated that, as a boy he had had a left phrenieectomy for tuberculosis, the surgeon's assumption was that the diaphragm was elevated because of the previous operation and that the

stomach was below the diaphragm, not above it. Surgery was therefore limited to debridement and closure of the chest wall, without intrathoracic exploration. The patient did not

react well from operation and died on the third postoperative day. Autopsy revealed a

congenital diaphragmatic hernia of the stomach, which had sustained a perforating wound.

Thoracoabdominal Wounds

Of the 105 casualties with thoracoabdominal wounds treated by the surgeons of the 5th

Auxiliary Surgical Group. 4 died before operation could be started or were so obviously

moribund that surgery was considered futile. On the other hand, the high case fatality

rate from shock in the first 12-hour period after operation shows that surgery was not withheld merely because casualties were poor risks.

Basic data.—Of the 105 thoracoabdominal wounds. !),S were on the left side, of which

27 were fatal; 67 were on the right side, of which 12 were fatal. The difference in the case

fatality rates reflects the anatomic location and the vulnerability of the abdominal organs

on the two sides.

When there were no thoracic injuries of consequence, the case fatality rates did not

differ substantially from the rates in the total series (11 deaths in 02 injuries on the left, 0

deaths in 30 injuries on the right).

In most of the injuries (S4 percent), the wound of entrance was in the thorax. In

avulsing wounds and through-and-through wounds caused by small arms, it was often impossible» to tell whether the course of the missile was from the thorax into the abdomen, or

vice versa. In about a quarter of all cases, the thoracoabdominal wounds were complicated

by other injuries.

Resuscitation.—Many casualties with both thoracic and thoracoabdominal wounds

were brilliant illustrations of what resuscitation can accomplish. One patient with a thoracoabdominal wound, whose blood pressure and pulse could not be obtained when he was

iirst seen, received 17 units of plasma and 0 units of blood in the 10 hours before operation.

He entered the operating room with a pulse of 110 and a blood pressure of 115/80 mm. Hg.

On the other hand, shock was sometimes entirely irreversible. In these 105 patients

with thoracoabdominal injuries. 47 needed intensive replacement therapy because of their

poor condition and the severity of their wounds. Six of the forty-seven received 22 percent

of all the blood and 30 percent of all the plasma given to this special group. They were

finally deemed operable, but all six died of shock within the first 24 hours after operation.

Pulmonary injuries.—There was no active bleeding in any of the OS lacerations of the

lung in these thoracoabdominal wounds. Suture repair was effected in 20 cases in which a

bronchopleural fistula already existed or in which it was thought that one might develop.

The other lacerations were left alone. The chest injury usually contributed only a small

amount of the blood aspirated from the chest at operation, Jlost of it came from injuries

of the spleen and, in small amounts, from injuries of the stomach and the small intestines.

Surgical approach.—There is no information as to the surgical approach in 25 cases in

this series. In 30 wounds, 22 of which were on the left side, the approach was by the

thorax. In 44 wounds, separate thoracotomy and laparotomy incisions were used, thoracotomy being the initial procedures in 33 cases and laparotomy in 11 cases. In the remaining

57 eases, 30 of which were on the left side, a laparotomy incision was used and no intrathoracic surgery was done.

If the wounding agent was a shell fragment, thoracotomy was the preferred mode of

approach. The reasoning was that because of its larger size and its tumbling;, rotating

progress, such a missile was likely to create a gaping, sucking wound of the chest and

diaphragm, whereas a diaphragmatic wound caused by small arms fire was likely to be

sealed over. If the wounding agent was a bullet, the thoracic approach was preferred only

74G 04V—05 37
538 THORACIC SURGERY

if there was evidence of a cardiac or vascular injury, a severe laceration of the lung, or

herniation of abdominal organs through the diaphragm. Otherwise, a laparotomy was

thought to be quicker and less shocking than the management of a bullet wound through a

transdiaphragmatic incision, which would require enlargement of the diaphragmatic

perforation to permit satisfactory exploration and repair.

As a rule, the transdiaphragmatic approach was used on the left side for penetrating

wounds of the chest at the level of, or below, the seventh rib if the wound was caused by

a projectile whose course was in an almost transverse plane. On the right side, the same

indications were used if it was certain that the projectile had not proceeded to the region

of the duodenum, right colon, or pancreas, all areas to which approach is blocked by the

right lobe and main bulk of the liver. Wounds of the diaphragm located over the extraperitoneal surface of the liver could not be repaired by laparotomy alone; thoracotomy was

required for adequate exposure.

The type of abdominal incision was governed by the course of the projectile and, to a

lesser extent, by the degree of angulation of the costal margin at the xiphoid process. A

subcostal incision in a patient with a wide costal Hare provided excellent exposure for

repair of the diaphragm and stomach and for exploration of the spleen and kidney, with

splenectomy and nephrectomy if necessary. In the asthenic individual, a rectus incision

provided good exposure and had the additional advantage of simplifying the placement of

a stal) wound for exteriorization of an injured colon.

Complications.—In the 75 cases in which the liver was injured, there was no recognized instance of either hepatopleural fistula or bile empyema. Drainage in wounds of the

liver was proportionate to the severity of the laceration. Volumes up to 1,500 cc. on the

first day were not uncommon, and some wounds were still draining rather large amounts

when the patients were evacuated.

Drainage from renal injuries was negligible, and it was concluded that a stab wound

to provide for either urine or blood was probably unnecessary unless a major calyx of the

renal pelvis was involved.

The chief complications in the 105 thoracoabdominal wounds were as follows:

Two bronchopleural fistulas developed within 24 hours of operation but closed spontaneously after institution of catheter drainage through the second interspace.

Two patients with atelectasis were successfully treated by bronchoscopy. Lesser

degrees of atelectasis probably occurred and went undetected. Two patients had lobar

pneumonia, in one case associated with an early empyema. This was the only instance of

empyema observed before evacuation.

Wound infections were uncommon and usually not serious, but three wound disruptions

occurred, one of which was fatal.

Paralytic ileus was present in most cases, sometimes for 4 to 6 days, in extensive injuries of the liver, retroperitoneal hematomas, or large homoporitoneum.

Analysis of fatalities.—Autopsies were performed in 21 of the 39 deaths in this series.

The fatalities were distributed as follows :

Eighteen patients died of shock, fifteen within the first 24 hours after wounding.

Eight patients died of acute pulmonary edema, five with a profuse terminal serohemorrhagic accumulation of fluid in the bronchial tree. In the four cases in which autopsy was

performed, the fluid was found to originate in the lung, which was grossly enlarged, heavy,

firm, and engorged with blood. Microscopic study revealed edema ; acute passive congestion: and red blood cells in the alveoli, as well as areas suggestive of the consolidation of

bronehopneumonia. In three of the four cases, the surgeon had no doubt that the cardiovascular system had been overloaded. One of these patients had received a unit of blood

and 8 units of plasma before operation, and 4 units of blood and 11 of plasma during the

operation. Another had received 1.500 cc. of physiologic salt solution and 2,000 cc. of

blood in Alsever's solution over 2

J

/4 hours.
APPENDIX 539

Five patients died of pneumonia.

Three patients died of peritonitis, one with pneumonia.

Two deaths occurred from overlooked injuries. One patient succumbed to a rapidly

spreading retroperitoneal infection from a missed perforation of the cecum. The other

died on the fifth postoperative day, from hemorrhagic shock, after the clot in a missed

perforation of the inferior vena cava became dislodged.

One patient with extensive laceration of the liver apparently died from biliary

peritonitis.

One death was caused by the migration of a shell fragment, which was dislodged from

the inferior vena cava and traveled to the right pulmonary artery, where it acted as an

embolus.

One patient suffered an evisceration of a perforated stomach, small intestine, and

transverse colon through a 7-by-0-cm. avulsed wound of the left lower chest laterally.

After operation, his blood pressure ranged from 80 to 00 mm. Hg, and he was irrational and

almost uncontrollable. His condition was presumably due to chronic shock. When renal

shutdown was part of the picture, as it was in this case, no therapy was effective.

Whether fat embolism played a part in any of these deaths is not possible to say.

None of the microscopic specimens studied in the 21 autopsied eases were positive for fat.

KENNEDY GENERAL HOSPITAL THORACIC SURGERY CENTER

General Considerations

The soundness of policies of early management of combat-incurred chest wounds could

be evaluated by a study of the case fatality rates and morbidity rates of the casualties who

survived to reach forward hospitals. Similarly, the soundness of policies of management in

all oversea hospitals could be evaluated by an analysis of the residual status, and the necessity for further care, of the casualties received later in hospitals in the Zone of Interior.

An analysis of the first 500 (of an ultimate 2,350) casualties with combat-incurred chest

wounds, received in the thoracic surgery center at Kennedy General Hospital after it had

become fully operational in June 1044. provides interesting and useful data of this kind.

Before these data are accepted absolutely, however, two qualifying statements arc

necessary:

1. It is only fair to emphasize that in a comparative analysis made retrospectively

from field medical records and forward hospital records, it'was not always easy, or indeed

possible, to recognize all the circumstances that confronted surgeons working under combat conditions and that might have influenced their decisions concerning therapy.

2. The figures are frequently overlapping and, in a number of instances, though the

records provided no actual proof, it was thought that the incidence of certain injuries and

complications was probably higher than the stated figures indicated.

The material for this analysis was obtained by a careful review in each case of the

field medical record, the records of previous hospitalizations overseas, the serial roentgenograms taken during the course of treatment, and the condition of the patient on his

admission to the chest center. The clinical status of each patient was thus surveyed from

the point of vantage of his latest hospitalization and in the light of his previous treatment.

As a result, it was possible to make an objective evaluation of the character of the original

injury, its initial management, the subsequent therapy, and the complications which followed special wounds and special techniques of management. The composite data permitted the comparative evaluation of surgical versus conservative therapy, forward

thoracotomy and the relation of morbidity to its performance or omission, the use or

omission of drainage in the closure of chest wounds, and similar routines.
54D

Had a review of the last 500 patients admitted to the center been possible, there is no

doubt that, as policies overseas had become stabilized in the light of experience, the outcome of the analysis would have been quite different.

Basic Data

All 500 wounds of the chest included in this survey were penetrating- or perforating.

Wounds limited to the chest wall very seldom reached thoracic surgery centers in the Zone

of Interior. Small arms fire was responsible for only a few injuries, the great majority

being caused by bombs and other high explosives.

The original injuries (the figures are sometimes overlapping) included:

211 retained foreign bodies of significant size.

130 sucking wounds.

75 thoracoabdominal wounds or combined thoracic and abdominal wounds.

02 pulmonary lacerations.

43 bronchopleural fistulas.

13 pulmonary contusions.

9 tension pneumothoraces.

S blast injuries.

4 fractures of the sternum.

3 wounds of the esophagus.

2 wounds of the trachea.

2 wounds of the pericardium.

As far as could be determined from the records, the chest wound was entirely uncomplicated in only 10 cases. Complications which occurred overseas included:

Hemothorax in 453 cases. In 151 of these cases, the hemothorax became infected, and

in another 40. it became organized without infection.

Subphrenie abscess in 12 cases.

Pneumonitis and Hing abscess about foreign bodies in 11 cases. The same complications developed in the 4 hematomas of the lung in the series.

Hemoptysis secondary to the presence of a foreign body in S cases.

Atelectasis in 0 cases.

Pericarditis with effusion in 8 cases.

Infected costal cartilage in 7 cases.

Bronehopneumonia in 5 cases.

Diaphragmatic hernia in 5 cases.

Pulmonary infarction in 3 cases.

Esophageal fistula and paraesophageal abscess in 3 cases.

Pericardial tamponade in 2 cases.

Suppurative pericarditis in 2 cases.

These complications (again, the figures are sometimes overlapping) were managed as

follows :

Drainage of empyema in 151 cases, in 40 of which secondary drainage was also

necessary.

Thoracentesis in 47 cases.

Decortication in 40 cases.

Drainage of subphrenic abscess in 12 cases.

Pericardial aspiration in 11 cases.

Closure of bronchopleural fistula in 0 cases.

Repair of diaphragmatic hernia in 5 cases.

Resection of ribs for osteochondritis in 4 cases.

Drainage of suppurative pericarditis in 2 cases and drainage to relieve pericardial

tamponade in 1 case.
APPENDIX 541

When these 500 patients were received at Kennedy General Hospital, the chest wound

was healed in 314 cases (02.8 percent), and no further treatment other than rehabilitation

was needed. The remaining ISC patients presented. 213 complications, not all of which, as

will be pointed out, developed from the original wound. Some of them were the result of

the therapy employed. These complications included :

Retained foreign bodies in 131 cases.

Chronic empyema in 82 cases.

Bronehopleural fistula in 36 cases.

Draining sinus in 20 cases.

Hemothorax iu 21 cases, in 12 of which the process was of the organized type. These

figures should also be evaluated in comparison with the 82 cases of chronic empyema present

when these casualties were received at Kennedy General Hospital.

Diaphragmatic hernia in 4 cases.

Esophageal listula or paraesophageal abscess in 3 cases.

Pericardial effusion in 2 cases.

Special Types of Injuries

Sucking wounds.—The 130 sucking wounds listed in this series were of such a size as

to require immediate closure when they were first seen in held or evacuation hospitals. A

considerably larger number of patients had similar wounds, but they were so small as to be

of no clinical significance. They responded promptly to packing or to debridement and

primary closure. It should be noted, however, that infection developed in almost 10 percent

of the cases in which the wound was closed primarily without drainage.

In larger sucking wounds, it was the practice to occlude the wound temporarily by

packing and to close it permanently later, when debridement was done. Thoracotomy was

done at this time in 7S of the 156 cases.

In a number of cases, the chest wound was only partly closed after debridement, and

intercostal water-seal drainage was instituted. The records showed that convalescence

was smoother in this group of patients than in any other patients with sucking wounds.

In several cases in which a bronehopleural fistula was present and had not been recognized, tension pneumothorax developed after closure of a sucking wound.

Thoracoabdominal wounds.—In this scries, 75 of the 500 patients had sustained injuries of tlie thorax and abdomen, either from a single missile that perforated the diaphragm or from separate perforations of the chest and abdomen. The abdominal organs

injured were, in the order of frequency, the liver in 40 cases, the spleen in 10, the stomach

in 15. the kidneys in !), and the small intestine and colon in 7.

All these patients had been treated by prompt surgery, but the order of the procedure

depended upon the severity of the chest wound. The chest injury was given first consideration in large sucking wounds, tension pneumothorax, pericarclial tamponade, or rapidly

developing hemothorax associated with shock and not relieved by conservative therapy.

Otherwise, if the cardiorespiratory physiology was not seriously unbalanced, the primary

attention was devoted to the abdomen.

The diagnosis of concomitant abdominal injury was frequently difficult when the missile had entered the chest, because in chest, wounds in which there was no perforation of

the diaphragm, abdominal pain, tenderness, and rigidity were often part of the picture.

I'rinalysis was always indicated in injuries of the lower chest, to determine whether or not

blood was present. Intravenous pyelograms, which were made later in general hospitals,

occasionally demonstrated defects in the renal pelvis secondary to injuries of the lower

chest.

In the majority of eases in which the injury resulted from a single missile, exploration

and the necessary surgery were successfully carried out through a transthoracie approach.

When there was doubt, concerning the extent and location of the abdominal injury, it was
MO THORACIC SURGERY

FIG CUE 1.—l'osteroanterior roentgenogram showing

large foreign body in contact with esophagus.

the general policy to use a separate abdominal approach because it permitted more extensive

exploration.

The liver apparently tolerated the presence of metallic foreign bodies quite well. At

any rate, no abscess resulted from failure to remove them, though biliary drainage followed

the injury in a number of cases. When hepatic injuries were explored transpleurally, both

the subphrenic space and the pleural space were usually drained. When this precaution

was omitted, bile empyema, which occurred in 14 cases, and subphrenic abscess were both

possibilities. The most serious instances of bile empyema occurred when the wound was

closed without drainage.3

Intratracheal anesthesia was employed in all thoracoabdominal injuries, regardless of

the surgical approach. The reason is obvious: If a tear of the diaphragm was present,

atmospheric air entering from the abdominal incision could cause collapse of the lung on

the affected side or even tension pneumothorax.

Tracheoesophageal injuries.—There were only 3 injuries of the cervical esophagus

and only 2 injuries of the upper end of the trachea in these 500 patients, but there were 3

similar injuries in the next 300 patients admitted to the Kennedy General Hospital chest

center. The thoracic esophagus was not injured in any case in the series studied, even

though, in a number of instances, ragged shell fragments were seen by roentgenograms to

be lodged in the posterior mediastinum close to it (fig. 1). The high immediate ease fatality rate resulting from the hemorrhage and the mediastinal infection commonly associated

with injuries of this kind accounts for the small number of patients seen with them in

Zone of Interior hospitals.

Three of the live patients with tracheal and esophageal injuries were submitted to

immediate tracheotomy, and four had gastrostomies for feeding purposes within 4 to 10

days after wounding. All five developed fistulas of the esophagus associated with abscesses,

which had to be drained. When the tracheotomy tubes were removed, from 2 to 3 weeks

after operation, none of the patients had any difficulty in breathing.

Two patients with injuries of the esophagus developed strictures which required dilatation, and four of the five with combined injuries of the esophagus and the trachea developed persistent paralysis of the recurrent laryngeal nerve. Because these are extremely

serious injuries, the eventual outcome in these cases was regarded as being as satisfactory

as possible.

;1 Experience in the Mediterranean theater indicated that there was a significantly higher incidence

of bile empvema "when the diaphragm was closed "with catgut rather than "with silk.
Al'PEXDIX 543

FiGUinc 2.—Posteroanterior roontgenogram showing

Lipiodol visualization of bronchopleural fistula, narrow empyema track, and drainage site at some distance

from fistula.

Bronchopleural fistulas.—The records indicated that 45 of the 500 patients in this series

had clinically significant bronchopleural fistulas immediately after sustaining their chest

wounds. The chances are that fistulas were also present in a number of other cases but were

so small that they required no special treatment and gave rise to no difficulties.

Thirty-six patients had bronchopleural fistulas when they were admitted to the chest

center at Kennedy General Hospital, the majority secondary to their original injuries.

Eight, however, followed the removal of foreign bodies, and six became evident only after

the development of empyema. In other words, not all of these 3G fistulas were part of the

original 45 fistulas.

All patients with fistulas observed at the chest center were studied by roentgenograms,

after the introduction of iodized oil, to determine the size of the residual empyema space

and the anatomic relation of the fistula to the site at which drainage had been instituted

after thoracotomy (fig. 2). If the fistula was shown to lie at some distance from the cutaneous wound and drainage would have been necessary through a long, narrow, empyematous

track, healing was accomplished more rapidly if drainage was established directly over the

fistula. When secondary drainage was instituted, exploration often showed that healinghad been prevented by the presence of necrotic spicules of rib, bits of clothing, and other

foreign bodies embedded in (he pulmonary tissue. The removal of these objects and the

excision of scar tissue about, the fistula were usually followed by prompt healing, though

in an occasional case, these measures did not suffice and closure of the fistula had to be

accomplished by means of a muscle flap.

Retained Foreign Bodies

As the incidence of immediate and delayed complications shows, the major problems

in the management of injuries of the chest concerned retained foreign bodies; hemothorax

and Pneumothorax; empyema ; and the use of thoracotomy, witli or without drainage, in

forward areas.
m THORACIC SURGERY

« AM

mm

FIGURE •'!.—Posteroanterior roentgenogram showing

pneumonitis und hbrosis associated with retained foreign bodies.

Management overseas.—Of the 211 patients observed with intrathoracic foreign bodies

of considerable size when they were first examined after wounding, 47 underwent removal

of the objects at the primary operation and 33, after an interval of several weeks. Many

other fragments were noted in other patients when roentgonologic examination was carried

out. but their size and location were such as to make them of no clinical significance.

Throughout the war, differences of opinion continued to exist as to the clinical significance of metallic foreign bodies and the indications for their removal. The chief reason for

removing them was the possible development of hemorrhage or infection, as well as other

complications, but the incidence of these manifestations in this series was not great. In the

104 cases in this series in which the objects were not removed at initial wound surgery,

hemoptysis occurred later in 8. draining sinuses developed in 8. lung abscesses in 7. and

pneumonitis in 0. In other words, there were no untoward manifestations in 135 of the

104 cases in which the foreign bodies were not removed at initial wound surgery. Moreover, practically all of these complications developed within 2 to 4 weeks after wounding.

In many cases in this series, the removal of the foreign bodies at the initial operation

was part of the procedure of debridement, hemostasis. and repair of lacerated lung tissue.

In this group, the removal was an incidental step in the operation.

In other instances, however, initial wound surgery was undertaken primarily for

the removal of the foreign body. The objects were often hard to locate in newly traumatized tissue, and fresh trauma was created. Bronchopleural fistulas were sometimes

created and went unrecognized. If the injury was small, the chest was frequently closed

without drainage. As a result of these various circumstances, the incidence of postoperative infection in this group of patients was almost 30 percent.

Generally speaking, infection was most frequent in the cases in which dirt, particles

of clothing, and similar debris entered the chest with the foreign body. This extraneous
APPENDIX 545

FIGURE 4.—Foreign bodies in contact with largo blood vessels. A. Postoroanterior roentgenogram. B. Same.

material was more likely to be the cause of infection than the metallic object itself.

Foreign bodies unaccompanied by other debris were usually found at operation, as previous

roentgenologie evidence had shown, to be associated with surprisingly little reaction and

with no infection. Objects in contact with large blood vessels were practically always

well encapsulated in fibrous tissue.

Management in the Zone of Interior.—Of the 131 patients who entered Kennedy General Hospital with roentgenologie evidence of metallic foreign bodies still in situ, only 1!)

harbored missiles considered of clinical significance because of their size, shape, location,

or clinical manifestations. Only 23 of these 40 objects were removed, on the following

indications:

1. Large, irregular shell fragments lying within the lung parenchyma were removed

without hesitation, particularly if there was an associated pneumonitis or fibrosis dig. 3).

2. Similarly, no hesitation was felt about removing foreign bodies lying in the mediastinum in contact with the esophagus (fig. 1) or with large blood vessels (fig. 4).

3. Foreign bodies associated with lung abscesses (fig. • >) or empyema were removed

at the time the necessary drainage was instituted. Four patients with retained foreign

bodies had either pneumonitis or lung abscesses when they were admitted to the center.

All four had draining sinuses, and three complained of hemoptysis.

4. In other cases, foreign bodies causing hemoptysis or intercostal pain were removed

whenever it could be demonstrated that they were directly responsible for these symptoms

(fig. 6). In most such cases, the onset of symptoms occurred shortly after wounding.

There was no evidence of infection or other reaction in any case in this series in which

roentgenologic examination showed no abnormalities for 2 to 3 months after wounding.

This was not. of course, an infallible rule: In one of these cases gross hemoptysis appeared

a year after injury.'

ö. In an occasional case in which operation was not otherwise indicated, the object

was removed because of the psychologic factors of fear or pain on the part of the patient.

»Attention is called to the patient observed in the Mediterranean theater who required

pneiimoneetomy for a retained foreign body lü years after wounding.

74G-0411 —05 3S
546 THORACIC SURGERY

tR

Fiia.-isii • >.—Retained foreign bodies giving vise 1<> infection. A. 1'osteroanterior roentgenogram showing Inng abscess associated willi retained object. At operation, clothing

and other debris were found in the abscess cavity. 15. Posteroanterior roentgenogram

showing foreign body partly embedded in lung parenchyma and protruding into empyema

cavity.

As the war progressed,, the policy at the Kennedy General Hospital thoracic surgery

center became increasingly conservative, and foreign bodies were removed only on strict

indications. The postwar experience will have to determine the late possibilities for harm

of retained foreign bodies and thus establish clear-cut criteria for their removal. It is

unfortunate that plans for a formal follownp of men with retained shell fragments never

came to fruition (vol. I).

Tetanus foxoid was always given before operations for the removal of foreign bodies.

Otherwise, the preoperative and postoperative regimen, including the use of penicillin, was

the same as for other thoracic operations.

Hemothorax

Management overseas.—Hemothorax was recorded after wounding in 455 of the 500

patients in this series. Of percent. In many cases, it was present in association with other

conditions of serious import, such as sucking 'wounds, lacerations of the lung tissue, and

retained foreign bodies.

The most severely injured patients in this group were submitted to thoracotomy in

frontline hospitals, on entirely justifiable indications. In many other cases, however,

casualties whose injuries were considerably less severe were also submitted to thoracotomy,

on indications that were far from clear cut. The effectiveness of the method of treatment

employed in each case is best determined by the presence or absence of infection. The

figures are as follows :

Of 74 cases treated expectantly, without any positive therapy. 30 became infected

(40.5-1: percent). In 34 cases, the hemothoraces were small and spontaneous healingoccurred. Infection occurred in 0 of the 12 eases of bronchopleural fistula.

Of 15G cases treated by thoracotomy, 7."5 (4S.0S percent) became infected (figs. 7 8

and 9).
APPENDIX 547

B

FiGriiE (i.—Retained foreign bodies giving rise to symptoms. A. Lateral roentgenogram showing metallic foreign bodies responsible for hemorrhage 1 year after wounding.

P>. l'osteroanterior roentgenogram showing retained metallic foreign body responsible

for intercostal pain.

lit

IP*

KiGiriiK 7.—Early thoraeotomy without drainage in penetrating bullet wound of chest.

Immediate thoracofoniy was performed for hemostasis and to remove the bullet, which was

found so located in the mediastinum that it could not be removed. The chest was closed

without drainage. A. l'osteroanterior roentgenogram showing postoperative hemothorax.

Note bullet in left: apex. The hemothorax later became infected and required open

thoracotomy drainage. P». l'osteroanterior roentgenogram showing total empyema space.
PIIOKACIO SUKGEKY

FIGTRE 8.—Early thoracotomy without drainage in penetrating shell-fragment wound

of right ehest. A. l'osferoanterior roentgenogram showing retained shell fragment and

hemothorax. B. Same, after oiierafion. showing pneumothorax secondary to bronchopleural

fistula. The wound was closed without drainage, and the resulting empyema had to be

drained on three occasions.

FIGURE 9.—Early thoracotomy without drainage in perforating wound of right chest.

A. l'osferoanterior roentgenogram showing preoperative hemothorax. V,. Same. 2 days

after thoracotomy without drainage, which was omitted because the amount of contamination was thought to be minimal. C. Same, showing fluid level in right hemithorax indicative of postoperative empyema.
APPENDIX 549

Of 225 cases treated by repeated tlioracenteses. only 38 (10.SO percent) became infected.

If (be 13 cases are excluded in which aspiration was inadequate and only the 212 properly

treated patients are considered, the proportion of infection falls to 11.8 percent. In 11

cases in this group, the chances of good results were reduced by the associated bronehopleural fistulas.

Of the 4!) patients whose hemolhoraces became organized. 20 bad either bad no aspiration of the ebest or only a single aspiration, and 7 bad been aspirated only twice. Nine

bad been treated by thoracotomy. All of these patients underwent decorticafion overseas.

The comparative figures leave no doubt of the soundness of thoracentesis as the preferred method of treatment in cases in which immediate operation is not indicated for

some reason other than the presence of a hemothorax. The circumstances of military

medicine were always in favor of the simplest method of treatment, in tins instance thoracentesis, as compared to more complicated methods, in this instance thoracotomy. The

necessity for evacuation, the changes of medical personnel from echelon to echelon, and the

complicated care required in handling thoracotomy drainage all help to explain the higher

incidence of infection when thoracotomy was used in preference to thoracentesis.

Management in the Zone of Interior.—All the cases in which decorticafion was done

at Kennedy General Hospital further confirmed the advantages of this operation (fig. 10).

It proved a logical means of developing an easily obtainable cleavage plane between the

fibrous encasement of the lung and the adjacent viscera, pleura, pericardium, diaphragm,

and chest wall. When the peel was separated from these structures, reexpansion of the

lung occurred promptly, the lung tissue herniating through the line of incision as soon as

separation was completed.

The experience at this center also confirmed the general opinion that the best results

were obtained when the operation was done between 1 and (i weeks after wounding. If the

lung was allowed to remain collapsed for 3 months or more, some iibrosis of the parenchyma

frequently took place, and reexpansion after operation was delayed.

There is no doubt that decorticafion. as it was practiced in AVorld "War II. was responsible for many of the good results obtained in casualties with chest wounds (fig. 11) who,

in the past, would have become invalids from chronic fibrotborax.

Empyema

Management overseas.—Of the 151 patients who developed empyema in association

with their chest injuries, 82 had chronic empyema when they were admitted to the chest

center. In 02 of the 151 cases (11.00 percent), the cause of the empyema could be traced

directly to the circumstances of the original injury, such as its initial severity, the extensive

contamination introduced by the missile, an associated laceration of the lung, or the

presence of a bronehopleural fistula.

In the remaining 8!) cases, the development of the empyema could be traced wholly or

in part to two causes. (1) failure to carry out adequate aspiration of a hemothorax when

no other surgery was necessary, and (2) failure to provide postoperative wafer-seal

drainage when surgery bad been done.

Xo patient who bad water-seal drainage developed an empyema of any clinical significance, but infection resulted in 31.1 percent of the patients who had been submitted to

thoracotomy without postoperative drainage and in IS percent of those who had had inadequate tlioracenteses after operations in which surgical drainage was omitted (figs. 7, S.

and 0). In another 0.1 percent of the cases, the thoracotomy tube had been removed too

soon. The analysis of these cases thus suggests that the incidence of empyema in combatincurred chest injuries could he appreciably reduced if thoracentesis were performed

adequately after operation and if adequate water-seal drainage were provided in all cases.
55( THORACIC SURGERY

FIGURE 10.—Observations at decortication. A. Organized liemotliorax

after evacuation of fibrinous mass from pleural space. Xote organized

fibrin on visceral pleura. 13. Easily obtainable plane of cleavage between

fibrous encasement and visceral pleura. C. Keexpansion of lung by

positive pressure anesthesia after removal of fibrous encasement.

Drainage was carried out overseas in all lot cases of empyema, on an average of '.'>%

weeks after the infection was delected. Secondary drainage was necessary in 4(5 eases

In the first months of the war. there was a decided tendency to perform open thoracotomy

for infected liemotliorax, early in the illness, and total empyema seems to have followed

this mode of treatment rather frequently (fig. 12). Later, this policy was almost entirely

discontinued, and drainage was deferred until this risk no longer existed.
Al'l'EXDIX 551

^§1»

FICUUE 11.—Infected organized hemothorax managed by decortication. A. Posteroantorior roentgenogram before operation. P>. Same, allowing results of decortication.

Management in the Zone of Interior.—Tlio majority of patients admitted to the chest

center with chronic empyema had been adequately drained, and healing was progressing

well. If drainage was not adequate, secondary drainage was instituted. Most of the

cavities were either small or moderate-size.

Adjunct treatment of chronic empyema usually consisted of continuous suction with 30

to 50 cm. of negative pressure. Breathing exercises and blow bottles were also employed,

but the experience was that reexpansion of the lung was more apt to occur, and to occur at a

faster rate, when suction was employed. Dakinization of the wound was also employed in

a few cases. Other constituents of therapy included repeated transfusions of blood and

plasma, high-vitamin diets supplemented by the administration of vitamins by other routes,

and general hygienic measures.

As time passed, it was found that empyema secondary to hemothorax could be treated

by decortication with practically the same degree of success as could be secured in organized

hemothorax without infection. "When this method of treatment came into use, it was only

an occasional patient with empyema who had to be submitted to thoracoplasty.

Thoracotomy in Forward Hospitals

Many of the cases in this series proved, as has already been intimated, that the mere

presence of a penetrating or a perforating wound of the chest did not, in itself, constitute

an indication for thoracotomy in a forward hospital. Many operations, in fact, designed

to stop hemorrhage or to prevent infection were themselves followed by these and other

complications, particularly when the chest was closed without drainage.

Of the 500 patients in this series, 156 were submitted to debridement, with thoracotomy

and repair of injured pulmonary tissue, within 24 to 48 hours after wounding. Of these,

6 percent developed organized hemothoraces, and 70 (48.7 percent) developed infection.

These patients fared much worse than the 225 patients with hemothorax treated by

thoracentesis, in only 10.8 percent of whom was additional treatment necessary because of

infection.
rilORAUr Nl'RdERY

^dfe

IIP1

II A

*•*»*#8M jpg»»"

B

Fiona-: 12.—Infected hemothorax and total empyema. A. 1'osteroanterior roentgeuogram showing early infected liemotliorax with mediastinal shift. H. Same, showing total

residual empyema after early open thoracotomy drainage. C. Same, showing healed ehest

after continuous suction therapy over 4-month period.

It must he granted that tile surgical group included the severest injuries, for which

prompt surgery was mandatory and in which complications might have developed if operation had not been done. Furthermore, it was not always easy to determine from records

alone the circumstances which led frontline surgeons to follow the courses which they did.

Nonetheless, in 0(i of the lot; cases in which early thoracotomy was (lone, the field medical

records show no clear-cut indications for the procedure. The majority of the patients

in this group presented both hemothoraces and retained foreign bodies, but neither can be

considered a valid indication for thoracotomy, and there seems to he no doubt, from the

subsequent incidence of infection after the operation, that they would have fared at least

as well, and probably better, if they had been treated conservatively.
AITEXDIX

Since chemotherapy and antibiotic therapy were employed routinely in both the group

treated conservatively and the surgical group, a comparison of results from this standpoint

would shed no light on the incidence of infection in the two groups. An analysis of the use

or omission of drainage in the surgical group, however, produces some useful data :

In addition to the 150 patients submitted to thoracotomy as a primary procedure, 33

other patients underwent the same operation at a later time overseas. In these IS!) cases,

drainage was instituted in 81 and omitted in 108. In 07 of the 81 drained cases (.82.7 percent), healing occurred smoothly, and there was no need for secondary surgery. The

patients who became infected were, for the most part, those with the most severe injuries.

In contrast, in 01 of the .108 cases in which drainage was omitted (50.5 percent),

secondary operations were required. Furthermore, healing in the undrained group covered

an average of 14 weeks, while the average in the drained group was 10 weeks.

The higher incidence of postoperative infection, the greater necessity for secondary

surgery. and the longer convalescence all make clear that a thoracotomy closed without

drainage achieved desirable results in a much smaller proportion of cases than a thoracotomy supplemented by adequate drainage. The contrast was particularly evident in the

10 patients who were found at primary thoracotomy to have lacerated lung tissue. When

the wounds were closed without drainage and operation was not followed by adequate

thoraeontesis, many of these patients required secondary drainage for infection (fig. 7).

Other considerations also suggested that routine water-seal drainage after thoraeotomy

in frontline hospitals was a far safer plan than closure without drainage. The conditions

under which a surgeon had to care for the wounded in the combat zone usually did not

permit him to supervise postoperative care except for a brief period. It was therefore not

possible for him to supervise personally the thorough aspiration of a hemothorax, which

was essential in all undrained chest cases. Another practical consideration was that waterseal drainage required considerably less time and attention than repeated thoracenteses.

This was an important matter in a busy frontline hospital.

As these cases indicated, transportation was not a contraindication to water-seal

drainage. While the patient was en route to the rear, the thoracotomy tube could be

clamped and the bottle temporarily disconnected, or a flapper type of drain could be used,

as was done in a number of these cases in which results were excellent.

Conclusions

An analysis of the first 500 chest injuries received at the thoracic surgery center at

Kennedy General Hospital indicated that the oversea management of these cases was generally good. In a Zone of Interior chest center, as might have been expected, mortality

is minimal: (here were no deaths in this series. Morbidity, however, is a matter of consequence. This study suggests that it can be reduced by the following policies:

1. Thoraeentesis should be substituted for operation in the management of hemothorax

unless other indications for early surgery exist.

2. Thoracotomy in forward hospitals should be limited to such clear-cut indications as

sucking chest wounds, tension pneumothorax, and hemorrhage. The mere existence of a

chest wound is not an indication for forward surgery.

3. Thoraeentesis should be performed adequately after operation, or adequate waterseal drainage should be instituted.
INDEX

Abdomen:

effect of pain in, on cough reflex, 212

foreign bodies in 305

pain in, 541

inblast injuries, 40

regidity in, in blast injuries, 40

tenderness in, 541

wet lung with wounds of, 141, 165, 212

52!!, 533

Abdominal approach, in—

diaphragmatic hernia, 196

Ihoracoabdoniinal wounds, 114, 122-125,

138, 541-542

Abdominal component:

management of, in thoracoabdominal

wounds, 118-121

of cough mechanism, 212

of thoracoabdominal wounds, 139

Abdominal contents, herniation of, through

diaphragm, 103

Abdominal Undings, in blast injuries, 40

Abdominal incision, in thoracoabdominal

wounds. 537-538

Abdominal stimuli, experimental production of bronchial spasm by, 209

Abdominal symptoms (signs), in—

cardiac wounds, 76

chest wounds, 109, 541

Abdominis recti muscles, paralysis of, 47

Abrasions, of—

chest wall. 3

epicardium, 63, 65

Abscess, of—

esophagus, 439

lung. 145, 175-178

mediastinum, 145

pleural cavity, 273

Abscess formation, about—

intracardiac foreign bodies, 357

retained foreign bodies, 380

Accessibility of foreign bodies, as indication for removal, 320

Acidfast bacilli, in tubereulomas, 426

Acroinioclavicular injuries, 12

Actiiionijiccs hovis (isracli), 431-432

Actinoinycosis, 431-432

Activation of latent tuberculosis, by

wounding, 426-428

Acute fulminating lung abscess, 428

Acute gastric dilatation, 145, 157

during catheter aspiration. 227

effect of cough reflex on, 212

in wet lung, 217

Acute massive atelectasis, 210-211

ADAMS, E., 197

Adhesions:

in diaphragmatic hernia, 191

in organizing hemothorax, 250-251

release of:

at decortication, 288

in infolded lung, 185-186

role of, in infolded lung, 184

Adhesive pleuritis. »S'cc Infolded lung.

Adjunct therapy:

in chronic empyema, 551

See also Replacement therapy; Blood replacement; Plasma replacement; ets.

Administrative considerations, in—

bronchiectasis, 424

lung abscess, 428-429

postpneumonie empyema, 430-431

Admissions, statistical definition of, 242

Adrenalin :

in blast injuries, 42

sensitizatlon of heart, 66

Aeration of bronchi, decrease of, in wet

lung. 211

Afferent pain impulses, 219

Age factor, in thoracoabdominal wounds,

136

Age incidence, of bronchiectasis, 416

Age range, in followup studies, 445

Air leaks, demonstration of, 18

Air replacement, after thoracentesis, 266-

269, 536

i unless otherwise specified, all entries in this index refer to injuries and diseases of the chest

and their management in World War II.

555
556 INDEX

Airway: Angiocardiographie localization, of retained

maintenance of, in wet lung, 210 foreign bodies, 408-400

use of, after thoracoabdominal surgery, Angle, of auscultation, 44

1-ß Anoxemia. in—

Sec alxo Aspiration : Thoraeentesis, Tra- liemothorneic empyema, 283

cheobronehialtree; etc. wet lung. 207n

Aleutian Islands. 403 Anoxia :

Alsever's solution, 538 as cause of death. 530

Alveolar bed. decrease of. in wet lung. 210 associated with pulmonary transudation,

Alveolar capillaries, oxygenation of. in wet 151

lung. 210 in atelectasis. 105

Alveolar response, in wet lung. 207-20S in cardiac wounds. 52

Alveoli, rupture of, in blast injuries, 30 in wet lung. 207n. 200. 210. 212. 214. 219.

Ainerbach. 400 220. 234

American Association for Thoracic Surgery, in wound disruption. 174

237, 273, 280 Anoxic anoxia, in wet lung, 210

Amphibious landings, initial wound surgery Anterior chest wall:

in. 330 disruption in wounds of. 173

Anaerobic eollulitis. of shoulder region, 44 wounds of. 1S3

Anaerobic infection, in organizing heino- Anterior drainage, in liemothoracie empythorax, 247, 201 ema. 405

Anastomosis, in intestinal wounds. US Anterior transplueral approach, to wounds

Anatomic considerations, in thoracoabdom- of heart. 00

inal wounds. 100-108, 130. 537 Antibiotic therapy:

Anatomic location : attenuation of pleural infections by, 273

influence of, in sucking wounds, 10 in organizing hemathorax. 273

of foreign bodies, 353-355 negative cultures after, 283

Anatomy, of intercoastal nerves. 115 with primary thoractomy. 553

Anemia, after blood replacement, 154 Anuria. 140

Anesthesia. 241, 530 in pericardial wounds. 00

development of. between World Wars, 302 Anxiety, in tension pneumothorax, 140

effect of level of, in thoracospinal wounds, Anzio Beachhead. 2.'!. 137. 181-183, 442

i" Aorta :

for deeortication. 280 foreign bodies in, 304

inblast injuries. 42 migratory foreign bodies in. 380

in bronehoseopic aspiration, 220 wounds of, 534

in catheter aspiration. 224 Apical collapse:

in etiology of wet lung. 212-213 after rib resection drainage, 270

in intercoastal nerve block. 221 in infected organizing hemathorax, 2S2

in myocardial contusions. OS Apical suture. 378

in thoracoabdominal wounds. 113-114, Appetite, in liemothoracie empyema. 27G

310. 310 Apprehension:

in wounds of bronchi. 22 in wet lung. 212. 214

site of. in intercoastal nerve block, 221 over retained foreign bodies. 325

Anesthesiologist: Ardo. 513

duties of. at deeortication, 280 Armies :

role of. at operation,113 Fifth U.S. Army. 113. 207. 442

Anesthetic equipment, shortages of. 113 Seventh T.S. Army. 101. 442. 425. 502

Aneurysm (s). 430. 437. 430 Army Records Center. 443

of myocardium, 02 Arrhythmia—

Anginal symptoms, with retained foreign in cardiac contusions. 00, OS, 07

bodies. 88 in cardiac wounds. 52

Angioblasfic proliferation. 240. 255 with retained foreign bodies, SO
INDEX our

Arterial circulation, migratory foreign

bodies iu, 391

Arterial embolism, of foreign body to innominate artery, 300

Arterial insullieiency, caused by embolic

foreign bodies. 301

Arteriovenous flstula(s), 40

of internal mammary artery, 450

Ascending aorta, foreign body in, 85

Asphyxia, in sucking wounds, 8

Asphyxiation, in sucking wounds, 8

Aspirating wounds. »SVe Sucking wounds.

Aspiration:

as diagnostic measure, in—

hemothoracie empyema, 200

hemotborax, 263

in cardiac tamponade, 01, 02

in bemotborax. 154, 245. 302, 401, 404, 507,

520

in infolded lung, 184

in lacerations of lung, 402

in perioardial wounds. 04

in presumed hemothorax, 45

in spontaneous nontuberculous pneumothorax, 432

in tboracoabdominal wounds, 112

in traumatic pleuritis, 4

in wet lung. 217

of gastric contents, 157, 222

broncboscopy for, 228

pneumonia as cause of death, 534

associated with actinomycosis, 431

»S'c'<? also Thoraeentesis; Tracheobronchial

tree; etc.

Aspiration-instillation therapy, of postpneumonic empyema, 430-431

Assignment, of thoracic surgeons, 102, 400

Astma, resemblance of wet lung to, 214

Atabrine. 410

Atelectasis :

after lobectomy, 419, 420

after removal of retained foreign bodies,

349

after tboracoabdominal operation, 129

antecedent to pneumonitis (pneumonia),

159

as cause of death, 533

in tboracoabdominal wounds, 140

differentiation of, from hematoma of lung,

100. 496

in crushing injuries, 30

in diaphragmatic hernia, 193, 190

in head injuries, 46

Atelectasis—Continued

in tboracoabdominal wounds, 538, 542

in untreated wet luug, 210

in wet lung. 210. 228, 235, 502

incidence of, 210-211. 232

management of, at decortication, 204

relation of wet lung to, 210-211

subsequent" to wet lung, 208

with retained foreign bodies. 349

Atrium, wounds of. 536

Atrophy, of—

extracostal musculature in cloted hemothorax, 205

optic nerve, 31

Atrophie—

before bronchoscopy, 126

in blast injuries, 42

in pulmonary edema, 162

in wet lung, 231, 235

Atypical pneumonia, 416-417

Auburn, 473

Auricle:

control of hemorrhage from. 02-93

contusions of, 67, 69-70

exposure in wounds of, 90

foreign bodies in, 88, 353, 354

lacerations of, 09-70, 92-93

migratory foreign bodies in. 390-301, 303

removal of foreign bodies from, 373-374

wounds of, 58, 71-72, 89, 99

Auricular fibrillation, after cardiac surgery,

05

Auricular hemorrhage, death from, 80

Auscultation, in wet lung, 215

Austria. 442

Autotransfusion, 532

Auxiliary surgical groups:

2d—IS, 20, 21, 24, 27, 31, 32, 42. 40, 40,

51, 52, 05, 72, 87, 85. SO, 01, 03. 04. 00, 101.

302. 103, 110. 112 114 117. 119, 120, 121,

125, 120, 129, 136-141. 14S, 149, 171,

175, 178, 186, 107, 300, 30S-310, 348-351,

442, 520-534

5th—520. 534-530

A-Y nodal rhythm, 379

Avulsing wounds, 537

Avulsion, of—

diaphragm, 103. 120

pulmonary repair, 170

Axillary vessels:

ligation of, 45-46

wounds of, 45

Azochloramid, 320
INDEX

Azygos vein:

foreign bodies adjacent to, 394

hemorrhage from, 65

laceration of, 153, 536

wounds of, 244

Bacterial endocarditis, 356

Bacterial theory, of organizing hemothorax,

246-247

Bacteriologic studies, in tuberculoma, 426

Bacteriology:

effect of. on clinical course in organizing

hemothorax. 262

of actinomyeosis, 431

of empyema, 246-247

of heinothoracic empyema, 2S3

of hemothorax, 273

of infected hemothorax, 23S, 282-283

of intracardiac foreign bodies, 356-357

of lung abscess, 177

of organizing hemothorax, 261-263

of pneumonia. 533

of postpneumonic empyema. 430

of retained foreign bodies, 340, 380, 410,

411. 412

Ball-valve effect of foreign body in heart,

SO

Bandaging in wound disruption, 174

BARACH. A. L.. 220

Barbiturate administration, before—

catheter aspiration, 224

intercostal nerve block, 221

Bare area, of liver. 101

Barnes General Hospital, 405

Basal empyema. after decortication. 406

Basal pulmonary collapse, after rib resection drainage. 276

Base hospitals. Krr Hospitals, base.

Battalion aid stations :

deaths in. 153

emergency occlusion of sucking wounds

in. 0. 140

overhydration in. 233

Battey General Hospital, 401

Battle Creek. 410

Battle of Bulge. 502

Battlefield deaths, from—

ehylothorax. 175

hemorrhage. 153

perieardial tamponade, 65

tracheobronehial wounds, 21

wounds of lung, 17

wounds of major pulmonary vessels, 18

Battlefield occlusions, of sucking wounds, 9

Beach installations, initial wound surgery

in, 530

Bechic blast, 212

BECK, O. S., 05, 60, 89, 00. 91

Behavior of heart, during cardiac surgery,

375-37!)

BELT, R. I)., 5

Berman locator, 408

BETTS, Lt. Col. R. H., 44, 141, 183, 207n, 529

Bift'ontaine, 468

BIGGER, I. A., 60. 91

Bilateral hronchiectasis. 418, 420

Biliary drainage, in wounds of liver, ISO, 542

Biliary empyema, 110, 118. 110, 120-130, 542,

542n

in lacerations of liver, 120

in thoracoahdominal wounds, 110, 123, 538

in wounds of liver. 100, 129

Biliary peritonitis, 133, 529

Biliary pleural (istula, 118, 122

Bisbopstrow, 381

Bizarre courses, of missiles, 108-100

Bizerte, 240, 441. 400, 405

BLADES, Col. B.. 197, 400, 405, 416, 424, 428-

420, 43,2, 436, 523

BI.AXI). U. Col. TV. 1<\. 50

Blast injury(ies), 32-43, 140, 440. 524, 520,

536, 540

as cause of death, 534

clinical aspects of, 34, 30-41

diagnosis of, 41, 43

followup studies in. 473-470

hemothorax with, 240

in cardiac contusions, 66

incidence of, 32-33

management of, 41-42

mechanism of. 37-38

pathologic process in, 34, 38-39

rupture of eardrums in, 41

statistics of, 32-33

Blood:

clotting of, in pleural cavity, 237-23S

effect: of, in—

pleural cavity, 244-245, 255

wet. lung. 210

in gastric contents, 109

shortages of, for replacement, 531

supply of lung, 17, 490, 526

experimental blockage of, 17n

Blood banks, 530

Blood pressure, in—

hemorrage, 154

right heart failure. 102
INDEX 550

Blood replacement, 331-532

after decortication, 298

after thoracoabdominal surgery, 120

at operation, 113, 114

before decortication, 2SS

before lobectomy, 418

during decortication, 289

excess of, 213

in wet lung, 229

in cardiac tamponade, 89

in chronic empyenia, 551

in hemorrhage, 154, 155

in homothoraeie empymea, 276

in lung abscess, 178

in thoracoabdominal wounds, 112, 139, 537,

538

provision for, 530

statistics of, 531-532

,svr <ils)> Replacement.

I'.lood vessels, laceration of, by bone fragments, 535

Blood volume, reduction of, in hemothorax,

2(13. 207

Bloodless phlebotomy, 102

Blow hollies, in—

ateleclasis. 104

chronic empyenia, 551

Blowing wound. Sec Sucking wound.

Blunt trauma, to chest, 05 00

Boeck's sarcoid, 438

Bone fragments :

as indication for primary thoraeotomy,

532, 534

as retained foreign bodies, 325-320

indications for removal of, 117

management: of:

at decortication, 295

in sucking wounds, 10

trauma from. 12. 325-320

Bone injuries, in Zone of Interior, 400

Bony cage, conservation of, at surgery for

foreign bodies. 309

Bony .structures, in repair of chest wall

defects. 412

Boothby-Lovelaee-Bulbulian mask, 217, 229

Boothby-Eovelaee-Bulbulian mask. 217, 229

Bradycardia, in cardiac wounds, 52

Brain, wounds of, 140

Brain abscess, 534

as complication of empyenia, 285

Breath sounds, in—

blast injuries, 40

infolded lung, 185

wet lung, 214

Breathing exercises—

after decortication, 300

in chronic empyenia, 47, 185, 281, 300, 418,

551

BKEWEK, Lt. Col. B. A.. Ill—19, 45, 79, 208,

209. 224, 441-442, 443n, 529

BHIGIIT, E. If"., 00

British experience, with sucking wounds, 9

British Isles, 32

British practices, in cardiac surgery, 95

Bronchi, carbon dioxide in air from, in sucking wounds, 7

Bronchial arteries, foreign bodies in, 79n

Bronchial asthma, S5, 214, 210

Bronchial breathing, in wet lung, 215

Bronchial dilatation:

after acute respiratory infections, 410-

417

differentiation of, from bronchiectasis,

410-417

Bronchial drainage, wound disruption with

omission of, 173

Bronchial infection, in wet lung, 215

Bronchial musculature, function of. 208

Bronchial obstruction:

ateleclasis after, 200

in wet lung. 228

secondary to retained foreign bodies, 410

Bronchial pneumonia, antecedent to empyenia, 274

Bronchial spasm—

after experimental trauma, 209-210

in wet lung, 222

Bronchial tree, effect of nerve block on. 222

Bronchiectasis. 415-424, 524

after wet lung, 502

associated with actinomycosis, 431

clinical picture in, 410

diagnosis of, 410—417

incidence of. 415-410

lobectomy for. 417-419

management of. 417-419

pathologic process in, 410, 417

rationale of lobectomy in, 410. 417-418,

421

Bronchiolar response, in wet lung, 207-208

Bronchiolar spasm, after trauma. 209

in blast injuries, 42
560 INDEX

Bronchitis: Bronchoscopic aspiration :

after exposure. 213 in wet lung. 207n, 223, 227-229

after wot lung, 502 techniques of. 229

antecedent to— Bronchoscopy:

ateleetasis, 1(33 after decortication. 289

pneumonia, 179 after lobectomy. 419

with ateleetasis, 165 at end of operation, 11.'!. 213

wound disruption with, 173 diagnosis of hematoma of lung by, 160

Bronehobiliary fistula. 119, 131 in actinomyeosis, 431

Bronehogenic carcinoma, 433 in atelecfasis. 164. 105. 528

after separation from service, 521-525 in bronchiectasis. 416. 417

differentiation of. from tubercnloma, 42G in head injuries, 46

Bronehogenic cysts, 132, 137, 439 in thoracoabdominal wounds, 125

Bronchography, in bronchieotasls, 410, 417, in tubercnloma. 426

418 in wet lung. 112, 179. 234

Bronchopleural fistula. IS, 145, 169--173, in wounds of esophagus. 28

249n. 309, 525. 535, 537, 540, 541, 543, Bronehospasm :

549 after trauma, 209-210

after decortication. 300, 308, 309 in wet lung. 214, 231

after lobectomy, 420 Bronchospirometry, in bronchietasis, 416,

after removal of retained foreign bodies, 421

349 Bronchovascular markings, increase of, 523

after thoracoabdominal surgery, 129 Bronchus intermedius:

associated with— erosion of foreign body into, Sin

foreign bodies, 329 rupture of subphrenic abscess into. 130

hemothoracic empyema, 400 malignant neoplasms of, 433

caused by removal of foreign bodies, 544 wounds of, IS, 19-20. 21-24. 149, 4GS. 532

complicating— Brooke General Hospital, 400

clotted hemothorax, 309 Bundle branch block. 370

compound fractures of ribs, 10 BuuiiAXK, Maj. B., 207. 208. 529

foreign bodies, 348, 52G BuiiFoiin, Maj. T. II.. 18, 32. 129, 171, 175,

hemothoracic empyema. 200, 309 177. 178. ISO, 207. 20S, 239. 244, 278, 506.

infected hemothorax, 540 529

massive pulmonary gangrene, 17S BCRKI:. Lt. Col. J., 108. 175

organizing hemothorax, 288

sucking wounds, 11, 541 Calcification, in organizing hemothorax. 259

thoracoabdominal wounds, 538 CALXEXDER, Brig. Gen. G. R., 37

wet lung. 215. 223 Capabilities, of thoracic surgeons, 102

in Zone of Interior, 100, 401 Capillary extension, in organizing hemomanagement of. 170-173 thorax. 249. 256, 287

at decortication, 280, 2S4, 2S9, 290, 294, Captive lung. 507. 526

295. 319 Carbon dioxide content of air, in sucking

recurrence of, 171 wounds, S

wedge resection for, IS

wound disruption with, 173

Bronehopneumonia. 540

in pericardial wounds, 90

in thoracoabdominal wounds, 53S

Carbon dioxide inhalations, in—

atelecfasis. 164

wet lung. 232

Carbon dioxide saturation, in blast injuries,

Bronchopulmonary infection : 38

differentiation of actinomyeosis from, Carcinoma,—

431 bronchus, associated with actinomyeosis,

persistence of. 524 431

sucking wound superimposed on, 400 esophagus, 433-43G

Bronchopulmonary suppuration, 525 lung, 433-436
INDEX 561

Cardiac blood flow, obstruction of, 3TS

Cardiac chambers:

foreign bodies in, 94

penetrating wounds of, 63

rupture of, after experimental trauma,

66

Cardiac complications, in bronchieetasis, 41S

Cardiac contusions, management of, 67-69

Cardiac deaths, 534

responsibility for, 08-90

Cardiac disease :

exclusion of. in wet lung, 216

pulmonary edema in, 220

Cardiac effect, of mediastinal flutter, 8

Cardiac embarrassment, in tension vmeuniothorax, 151

Cardiac emboli. 63

Cardiac fibrillation, 534

Cardiac involvement, in thoracoabdominal

wounds. 103

Cardiac irregularity, in blast injuries, 474

Cardiac irrifablity, at operation, 370, 370

Cardiac neurosis. 366

Cardiac pain, from retained foreign bodies,

80. 301

Cardiac shift, in—

atelectasis. 164

hemothorax, 267

tension pnenmothorax, 151

Cardiac standstill, 456

Cardiac surgery, abnormalities after, 04-96

techniques of, 89-03

Cardiac tamponade, 58-63, 72, 07, 90, 373,

534

as cause of death, in thoracoabdominal

wounds. 140

at operation, 91

diagnosis of. 50-61

from laceration of superior vena cava, S5

replacement, therapy in, 89

Cardiac wounds:

associated with abdominal injuries, 537-

538

pathologic process in, 63-64

Cardiophrenie sulcus. reestablishment of,

at. decortication. 294

Cardiorespiratory disturbances, 541

as cause of death, in thoracoabdominal

wounds, 140

in thorabdominal wounds, 139

in wet lung, 219

replacement therapy in, 213

Cardiorespiratory imbalance, in tracheobronchial wounds, 21

Cardiorespiratory pathophysiology, 525

in crushing injuries, 30

Cardiorespiratory reserve, in bronchieetasis,

418

Cardiorespiratory stabilization, 399

in sucking wounds, 9

in thoracoabdominal wounds, 111-112

Cardiorrhaphy, 70

Cardiospasm, 430

Cardiotomy, for removal of foreign bodies,

354-355

Cardiovascular effect of mediastinal flutter,

8

CAKTEK. Col. B. X, 400, 405. 416. 424, 428

Cartilages, infection of, 180-181

Case fatality rates—

for 2d Auxiliary Surgical Group. 533

for 5th Auxiliary Surgical Group, 535

in concomitant wounds, 533

in decortication, 306

in diaphragmatic hernia. 186

in ecchymotie mask, 31. 32

in lung abscess, 175

in malignant neoplasms 433

in relation to timelag, in thoracoabdominal

wounds. 137

in retained foreign bodies, 353

in thoracoabdominal wounds, 136, 138-130,

537

in tracheoesophageal wounds. 542

in wet lung, 207, 232

in World War I. 240

in wounds of heart, 06

of drainage in empyema, 280

of lobectomy, 420

of primary thoraeotomy, 532, 535-536

of rib resection drainage. 308. 310

See (ilao Mortality ; Statistics ; etc.

Case finding methods, in tuberculosis, 424

Case histories:

aspiration, in hemothorax. 311

atelectasis, after lobectomy, 420

bile empyema and subpbrenic abscess,

130-131

blast, injury, 42-43, 474-476

bone fragments as foreign bodies, 518-522

bronchopleural fistula, 171-172

cardiac dislocation, at operation, 376-378

cardiac tamponade, 61-63

cardiac wound with myocardial dysfunction. 99
562 INDEX

Case histories—Continued

cerebral edema, after lobectomy, 420

cerelirovascular accident, after lobectomy,

420

chronic hemothoracic empyema, 405

coronary occlusion, after cardiac surgery,

95

crushing injury, 149

decortication :

after failure of delayed thorncentesis,

321-322

after rib resection drainage, 312-313,

319-321

in chronic hemothorax, 402

in clotted hemothorax, 311-312

in hemothoracic empyema, 313, 316-317

in infected hemothorax, 314-315, 317-

319

in infected hemothorax and pulmonary

necrosis, 323-324

in organizing hemothorax, 27S, 402

delayed aspiration, in hemothorax, 401-402

diagnostic pneumoperitoneum, 342-344

diagnostic pneumothorax, 337

diaphragmatic hernia, ISO, 191, 193, 190

embolic foreign body, in heart, 350

evisceration in thoracoabdominal wound,

539

fatality after removal of foreign body in

lung. 394-395

fluoroscopic localization of foreign bodies,

330

foreign body (ies), in—

ascending aorta, 85

heart, 350

hemothorax in sucking wound, 508-513

hernia of lung, 199

intercoastal aneurysm, 45

intrathoracic complications in wounds of

chest wall, 4

laceration of:

innominate vein, 153

lung. 530

with sucking wound, 463-408

subelavian artery and innominate vein,

155-156

subelavian vein, 153

superior vena cava, 85

lobectomy, for pulmonary tuberculosis.

425

localization of foreign body (ies), 332, 337,

338

Case histories—Continued

massive empyema complicating foreign

bodies, 347-348

massive hemorrhage from bronchus, 155-

156

massive pulmonary hematoma, 490-501

mediastinal abscess, 178

mediastinal foreign bodies, 345

mediastinal wounds, 408-473

migratory intravascular foreign body

(ies), 78-S1, 7Sn, 82-84, 357-304, 3S1-

387, 389-390, 530

mismanaged thoracoabdominal wound,

135-136

multiple indications for removal of intracardiac foreign body, 367

multiple left-sided thoracoabdominal injuries, 133-135

myocardial contusions, 08

myocardial damage with intracardiac foreign body, 305-300

myocardial laceration and contusion. 98-

99

noiicombat-incurred hemothorax, 403

perforating wound of congenital diaphragmatic hernia, 536-537

pericardial foreign body, 375

pneumonectomy, for—

laceration of lung, 536

lung damage, 19

postaspiration bleeding, 269

postpneumonic empyema, 430

profile position in localization of foreign

bodies, 337

pulmonary lobectomy, 19

purulent pericarditis with retained foreign body, 95-90

recurrent empyema after decortication.

309-310

removal of foreign body, 329-332

repair of wound of esophagus, 27

resolution of hematoma of lung, 109

retained foreign bodies, 513

in lung, 409-412, 513-517

rupture of subelavian aneurysm, 45

segmental resection in laceration of lung,

402

serial roentgenologic localization of foreign bodies, 333, 334

stab wound of heart, 84-85
INDEX

363

Case histories—Continued

sucking wound:

cardiac standstill, 453-456

superimposed on bronehopulinonary infection, 456-461

with wet lung, 502-506

symptomatic retained foreign body, 523

thoracoabdominal wounds, 4T6-406, 537

thoracospinal wound, 47-48

transthoraeie approach, in right-sided

thoracoabdominal wound, 135

traumatic aneurysm, of subclavian artery,

244

colostomy, 131-132

through-and-through cardiac wounds, 72-

77, 78

tuberculosis after atelectasis, 165

tuberculosis complicating combat-incurred

wound, 426-42S

unrecognized perforation of splenic flexure. 135

wet lung, 43-48, 232-235

wounds assoicated with thoracoabdominal

wounds, 141

wound (s), of —

auricle, 89

esophagus, 28-30

right main stem bronchus, 23-24

subglottic larynx, 149

Cassino, 442, 450, 463, 502

Catheter aspiration:

after decortication, 289

after thoracoabdominal surgery, 126

antecedent to broncboseopic aspiration,

228

failure of, 228

in wet lung, 112, 120, 233-227, 230

of tracheobronchial tree, 40

Catheter decompression, in—

tension pneufothorax, 536

tracheobronchial wounds, 22

Catheter drainage, in—

bronchopleural fishtulas, 171, 538

lacerations of lung, 402

Catheter management, of sucking wounds,

149

Catheter suction—

during operation, 213

in atelemtasis, 164, 165

in pulmonary edema, 162

in wet lung, 179

Cause(s) of death, in—

blast injuries, 3S-39

cardiac wounds, 97

5th Auxiliary Surgical Group fatalities,

536-537

myocardial contusions, 08

removal of retained foreign bodies, 395

retained foreign bodies, 349

2d Auxiliary Surgical Group fatalities,

533-534

thoracoabdominal wounds, 538-539

Cavitation, in actinomycosis, 432

Cecum, wounds of, 539

Cellular symphysis, in organizing hemothorax, 249

Center, 15th Hospital, 353

Central nervous system, effect of anoxia on,

210

Cerebral anoxia, 210, 534

in blast injuries, 474

in wet lung, 214

Cerebral damage, in blast injuries, 520

Cerebral edema, as cause of death, after

lobectomy, 420

Cerebral embolism, 534

Cerebral malaria, 534

Cerebral symptoms, after blast injuries, 524

Cerebovascular accident, after lobectomy,

420

Cervical emphysema, in wounds of esophagus, 25

Cervical mediastinotomy, 159

Cervical veins, engorgement of, in—

cardiac temponde, 00-01, 02

cardiac wounds, SO

media stinal wounds, 20

tension pneumotborax, 151

Chamber foreign bodies, 88

Chamber wounds, 99

Changes of position, in wet lung, 217

Characteristics of combat, in Pacific Ocean

areas, 400

Chemical pleuritis, in spontaneous noiituber

culous pneumotborax, 432

Chemotherapy:

in organizing hemothorax, 273

negative culture after, 283

with primary thoracotomy, 553

Chest cripples, in World War I, 283, 303,

313, 315, 400, 404, 507, 524

Chest findings, in blast injuries, 40-41

Chest pain, in wet lung. 232
564 INDEX

Chest wall:

chronic draining- sinuses of. 145. 180-181.

507. 541, 544. 545

in Zone of Interior, 401, 412-413

closure of, in thoroeoabdominal wounds,

121

contusions of. 20S, 221

defects of. 145. 140. 181-183, 107

in Zone of Interior, 400, 401, 412

disruption in wounds of, 173

effect of pain in. in wet Inns, 222-223

followup of wounds of, 451-461

foreign bodies in. 332. 303. 304. 408, 513,

523

hemorrhage from, 200

hemothorax with wounds of. 246

infection of, in followed-up casualties, 440

instability of, after thoracolaparofomy,

117

involment of, in enipyema. 274

mobility of, in hemofhoracic enipyema,

274

pain in. in hemothorax. 263

reaction of. to trauma, 20S

restriction of respiration in wounds of, 3

wounds of, 3-4. 23S, 320. 525. 530

nausea and vomiting in, 109

Chloronzodin, 320

Chondritis, 125

Chronic bronchitis, associated with aetinomycosis, 431

Chronic draining sinuses, of chest wall. 145,

180-181. 507. 541. 544. 545

in Zone of Interior. 401. 412-413

Chronic enipyema. 237, 23S. 507, 541

after anterior drainage. 405

after penicillin therapy, 430

delayed decorticafion for, 405-400

development of, during drainage, 280

in World War I. 507

incidence of. 549-551

physical therapy in, 407

prevention of, by decortication, 285

Chronic fibrothorax, 549

Chronic hemothorax. 23S

caused by continued aspiration, 275

in Zone of Interior, 400

pathologic process in, 249

Chronic invalidism, in lung abscess. 429

Chronic lung abscess, 428-429

Chronic spontaneous nontuberculous Pneumothorax. 432

Chronic-ivy:

development of. during rib resection

drainage, 310-311

of actinomycosis, 431-432

of bile enipyema. 129

of enipyema in World War I, 274

of tuberculous wound infection, 427-428

Chronology, of—

clotting in heinolborax, 248

complications. 145

with retained foreign bodies, 349, 544

deaths. 534, 536, 538

in cardiac wounds, 97-98

in thoracoahdominal wounds. 140, 538

hemothorac-ic enipyema. 240. 272

infection in hemothorax, 260

organizing hemothorax, 249, 401

resolution in organizing hemothorax,

259-260

suppuration in organizing hemothorax,

202-263

symptoms with retained foreign bodies,

545

wet lung. 213

CHI-ISCIIIM., Col. E. II., 23, 88. 210. 280,

2S1, 441

Chylothorax. 145, 175

Ciliary action, in trac-heobronchial tree,

20S

Circulatory collapse, after cardiac surgery,

95

Cirencester, 353

Civil War. 197

Civilian casualties, 529. 533, 534

Civilian practice:

bronchiectasis in, 410

retained foreign bodies in, 325

Civilian-type accidents, 11

Civilian-type chest wounds. 240

Civilian-type enipyema, incidence of, 242

Civilian-type lung- abscess, 178

Civitavecchia, 442

Classification, of—

bronehopleural fistula, 109-170

cardiac wounds, 63

diaphragmatic injuries, in thoracoahdominal wounds, 103

shock. 531

wounds, 3-48

Clavicle:

division of. at traeheal repair, 22

fractures of, 11, 12, 413

reflection of, at operation, 153, 155

resection of. in mediastinal wounds, 20
INDEX 565

Clearing stations, 530

initial wound surgery in, 530

overhydration in, 213

triage of sucking wounds in, 9

Cleavage plane, in decortieation, 251, 252-

253, 25S-259, 288

Climate, in—

Mediterranean theater, 442

Pacific, 390

Clinical diagnosis, of—

migratory foreign bodies, 391-392

tlioraeoabdominal wounds, 109

Clinical indications, for removal of foreign

bodies, 327-328

Clinical manifestations, of retained foreign

bodies, 407-408

Clinical picture, in—

Actinomycosis. 431-432

atelectasis, 1G4

blast injuries, 34, 39-41

broncbiectasis, 41G

carcinoma of lung, 433

cardiac contusions, GO

cardiac wounds, 51-57

diaphragmatic hernia, 191, 193

eechymotic mask, 31

heinatoma of hing, 1G5

heniothoracic einpyema. 2(i5-2GG, 272-273,

270, 283

hemothorax, 2G3-207

infolded lung, 185

mediastinal wounds, 20

migratory intravascular foreign bodies,

388-392

patients with residual symptoms after

chest wounds, 202-203

pericardial effusion, 357

pnoumonitis (pneumonia), 179

pulmonary edema, 101-1G2

pulmonary hernia, 197

shock. 21G

tension pneumothorax, 149-151

tlioraeoabdominal wounds. 110

tuberculoma. 42G

wet: lung. 213-215

wounds of esophagus. 25-26

<S'cc alxo Signs; Symptoms.

Closed drainage, in tension pneumothorax of

peritoneal origin, 104

S<:c also Water-seal drainage.

Closed intercostal decompression, in pulmonary lacerations, 526

Closed intercostal drainage, in—

heniothoracic empyeina, 404

hemothorax, 507

sucking wounds, 11

Clostridial infection,in—

fractures of scapula, 44

heniothoracic, 2G2, 283

Clostridial myositis. 140, 145, 175, 534

differentiation of, from—

pulmonary hernia. 197

subcutaneous empysema. 157

of chest wall, 197

CJoxtiidiiini irclcliii empyeina, after decortieation, 307

Closure:

after wound disruption, 174

of chest wall:

in tlioraeoabdominal wounds, 121

technique of, 204

of colostomy, 102, 128, 449, 450, 513

of diaphragm, 119-120

of sucking wounds, 9-11, 112. 174. 52G

of wounds of lung. 17-18

Clotted blood, as culture medium, 247, 273

Clotted hemothorax, 237-238, 239-240, 507

after removal of foreign bodies, 349

as indication for primary thoracotomy,

535

aspiration in, 270

decortieation in. 271, 308-300

differentiation of. from simple hemothorax, 203-265

incidence of, 239

infolded lung in, 185

loculation in. 277

management of, in base hospitals. 302-303

obscuration of foreign bodies by, 340

role of, in infolded lung. 183

Clotting:

antecedent to infected heniothorax, 240

in traumatic pleuritis, 4

mechanism of, in organizing hemothorax,

246-249

prevention of, by thoraeentesis, 26G

Clubbing, of fingers, 273

Coagulative ferments, in organizing hemothorax, 248

Cocaine anesthesia, in catheter aspiration,

224

Collapse, of—

apex, in infected organizing hemothorax,

282

lung, in sucking wounds, 5
INDEX

Collapse therapy, 425

Collateral circulation, in arteriovenous fistulas, 46

Collecting stations, management of sucking

wounds in, 149

Colon:

evisceration of, 539

extermination of, 115, 123, 127-12S, 538

gangrene of, in diaphragmatic hernia, 196

herniation of, into chest, 186, 191, 193

inieidence of wounds of, 541

peristalsis in wounds of, 109

wounds of, 103, 116, US, 123, 538

Coloration, of chronic traumatic hemothorax, 252-254

Colostomy, 118, 323

closure of, 102, 128, 513

in followed-up casualties, 449, 450

Coma, in—

cerebral anoxia, 210

head injuries, 211

wet lung, 232

Combined thoracic and abdominal wounds,

101. 106,532,540

Committee on Surgery, Division of Medical

Sciences, National Research Council, 85

Common iliac artery, embolic foreign body

in, 391

Common iliac Vein, migration of foreign

body in, 391

Commotio thoracis, 32

Complications, 145-205, 540

after decortication, 300

after lobeetomy, 420

after surgery—

for retained foreign bodies, 349

on innominate artery, 393

in crushing injuries, 30

in racitie Ocean areas, 399

in wounds of liver, 118-119

management of, 540

of head injuries, 46

of pulmonary hernia, 199

of retained foreign bodies, 325

of thoracoabdominal wounds, 128, 129-

133. 538

of thoracospinal wounds, 40-48

of wet lung, 502

resulting from therapy, 541

Compound fractures, fat emboli in, 43

Compression asphyxia, 38

Compression pneumothorax, as cause of

oxygen deficiency, 52

Compression injuries. See Crushing injuries.

Concept, of—

hemothorax, 237-23S

replacement therapy, 531

satisfactory recovery, in massive hemothorax, 280

separation from service, for tuberculosis,

424

wet lung, 207-208, 501

Concomitant wounds, 43-48

as cause of death, 534

in tlioracoabdominal wounds, 140-141

case fatality rates in, 533

in blast injuries. 39

in cardiac wounds, 50, 88

in thoracoabdominal wounds, 537

in Zone of Interior, 400, 413

incidence of, 43

influence of. in—

decortication, 300, 308

retained foreign bodies, 329-330

rib resection drainage, 308

management of, in myocardial contusions,

68

Sec alto wounds of special areas.

Conduction defects, in cardiac wounds, 56

Congenital diaphragmatic hernia, 131

Congenital pulmonary hernias, 197

Congeuitally short esophagus. 439

Conservative management, of—

bronohieetasis. 417

crushing injuries, 30

thoracoabdominal wounds, 110

wounds, of—

esophagus, 27

lung, 17-18

Contamination—

in hemothorax, 273

in sucking wounds, 10

of chest wall wound, in thoracoabdominal

wounds, 1.73

Continental Advance Section, 173

Contracture, of—

chest, in infolded lung. 183-184, 185

hemithorax, 237

in clotted hemothorax, 265

in organizing hemothorax, 259

prevention of, by tboracentesis, 266
INDEX 567

Contraindications, to—

diagnostic pneumoperitoneum, 344

intercostal catheter drainage, in infected

hemothorax, 275

local infiltration, in wet lung, 221

Contralateral hemiplegia, after surgery on

innominate artery, 393

Contralateral lung:

function of, in sucking wounds, 8

in bronchiectasis, 420

Contralateral thoracoabdominal wounds, 533

Contrecoup collapse of lung, 1C3

Control of hemorrhage, at cardiac operation,

91

Controlled respiration, in closure of diaphragm, 119

Contusion(s) :

in blast injuries, 38

of auricles, CT, 69-70

of brachial plexus, 46

of chest, 32

hemothorax after, 246, 2SG

of chest wall, 3-4, 208, 221

of heart, 63, 65-69, 97, 98

of intercostal muscles, in blast injuries, 39

of lung, IS, 30, 47, 161, 165, 216, 272, 540

in thoracoabdominal wounds, 103

of myocardium, 50, 69, 98-99

of ventricles, 66-07, 68, 69-70

pneumonia after, 30

Convalescent furlough, after lobectomy, 419

Conversion of internal to external suckingwound, J05-100

COOPF.I:. F. W., S9

Coramine, 508

Coronary arterial insufficiency, 88

Coronary artery, wounds of, 58, 530

Coronary infarction, 06

Coronary occlusion:

after cardiac surgery, 95

in cardiac contusions, 66

resemblance of, to—

cardiac contusion, 60

myocardial contusions, OS

Coronary thrombosis, 6S, 91-92, 9S

Coronary vessels:

impingement of foreign bodies on, SS

reflex spasm of, 60

Cortical impairment, in cerebral anoxia, 210

Costal cartilages:

infection of, 117, 540

wounds of. ISO, 412

Costal fixation, in flail chest, 16

Costal periosteum, noninvolvement of, in

hemothoracic empyema, 273

Costochondral separation, 11

Costophrenic fringe, of lung, 183, 1S4

Costophrenic gutter, obliteration of, in organizing hemothorax, 253

Costophrenic sinus, fibrin formation in, 248

Costophrenic sulcus, redevelopment of, at

deeortication, 288, 294

Cotton sutures, in repair of diaphragm, 1S9

Cough:

in blast injuries, 40

in bronchiectasis, 417

in hemothoracic empyema, 266

in wet lung, 213-214, 216-217, 228

persistence of, 524

Cough mechanism, after wounding, 208-209

Cough reflex :

after intercostal nerve block, 115-116

after thoracoabdominal surgery, 126

depression of:

by morphine, 212, 219

in wet lung, 207n, 208

in atelectasis, 164

in compound fractures of ribs, 12

in crushing injuries, 30

in thoracospinal wounds, 47

in wet lung, 179. 228

in wound disruption, 174

restriction of, in wounds of chest wall, 3

suppression of, 211

in wet lung, 217

Coughing:

after deeortication, 300

after nerve block, 222

in management of wet lung, 217, 232

precipitation of, by—

carbon dioxide inhalation, 232

introduction of catheter, 227

Counterincision, for removal of retained

foreign bodies, 513

Course of missile(s), 156

effect of, in sucking wounds, 5

in cardiac wounds, 53, 54, 64, 72, 70

in mediastinal wounds, 20

in scapular fractures, 44

in thoracoabdominal wounds. 103, 108-109,

110, 137, 537-538

in wounds, of—

esophagus, 26, 27

lung, 17

Crepitation, in subcutaneous emphysema. 157

Crimean War, 197
m INDEX

Criteriii. of— Debrideinent. 240, 301. 525. 532

cure, in decortication, 303 ease fatality rates in, 533

diagnosis, in blast injuries, 41 defects of chest wall after. 181-183

followup studies, 441 in compound fractures of ribs, 12. 16

Crosshatehing. of parietal pleura at decorti- in evacuation hospitals, 117

cation, 274. 203 in forward hospitals. 445

CKOWI.EY, JIaj. R. T., 307 in scapular fractures. 44

Crushing, of— in thoracoabdoniinal wounds. 121

intercostal nerve, at thoracotoniy, 222 of sucking wounds. 0. 10, 52. 535. 541

phrenic nerve, 120 removal of foreign bodies at, 320, 328

in repair of diaphragmatic hernia, 196 »See M/.S-O Initial wound surgery.

Crushing injury (ies). 30-32. 00. 140 Deeholin. determination of circulation time

diaphragmatic hernia after, 1S6 by. 40S

pulmonary hernia after, 107 Decompression. inCultural studies, before decortication, 2S7 acute gastric dilatation. 157

Cyanosis mediastinal emphysema. 150

during catheter aspiration. 227 subcutaneous emphysema. 157

in atelectasis, 1G4 sucking wounds. 140

in bronehieetasis. 421 tension pneumothorax. 151. 530

in cardiac wounds, 52. 53 traeheobronehial wounds. 22

in clotted hemothorax. 535

in hematoma of lung. 105

in tension pneumothorax, 151

in thoracoabdoniinal wounds, 100, 112. 125

in wet lung. 207n, 217. 232

Cyclopropane anesthesia, for decortication.

289

Cyst of esophagus. 438

Cystic duct, bronchial spasm after experimental fraction on. 209

D'Aniii-Ai-, A. L., 241

Dakinization. in chronic empyenia, 551

DAVIES. II.. 244

Decortication. 273. 278-289. 507. 540. 549

after rib resection drainage. 298

antecedent to removal of foreign bodies.

340-347

concept of. 281

criteria of cure in. 303

development of. 278—281

for empyenia (organizing hemothorax),

on followed-up casualties, 449

in bile empyenia. 120-130

in broncbopleural lisfula. 170

in chronic empyenia. 551

in clotted traumatic pleuritis. 4

in European theater. 301

Dead space : in j^f^-i-pd organizing hemothorax. 282-

after lobectomy, 300 .>S;j

in hemothoraeie empyenia, 272 in illfoMorl ]m]„ lsfi

in hemothorax. 273 in Mediterranean theater. 301-324

in pletiral cavity. 240, 249n in n(mtl..nilu,.lti(. empvema. 300-301

obliteration of. at decortication. 285, 297 in 01.„,lnizin„ hemothorax. 240. 402

DEAX. I). M.. 34. 41 jn spontaneous nontuberculous pneumoDeath(s) : thorax. 432

caused by vascular erosion by foreign in tboracospinal wounds. 47

bodies, 380 in tuberculous empyenia. 301

chronology of. 97-98. 140, 534, 530. 538 in wounds of esophagus. 28

from hronchiectasis. 415 in Z(m(1 ()f int,,,.;,,!., 405-400. 549

from wet lung. 210 indications for. 200. 271. 281-280

in iixed hospitals, 527, 530

in forward hospitals. 529-530 of diaphragm. 288. 293

in thoracic surgery centers. 530 l'1'»"1 of <*'« «« in. 251. 252-253, 258-

on battlefield. 17. 18. 21, 05. 153,175 259, 279. 288. 290, 291. 297

time of, in cardiac wounds, 97-98 postoperative management after, 298-300

tfvc also Battlefield deaths ; Case fatality principles of. 288-289

rates : Mortality ; etc. rationale of. 279-280
INDEX 569

Decortication—Continued

results of, 301-303

selection of cases for, 281

statistics of, 300-311

status of lung at, 272-273

steps of, 201-21)4

technique of. 280-208

timing of. 120, 240-2.11, 250-200, 28G-2S7,

300, 315, 317, 322, 400-407

hive alxo Primary decortication ; Secondary

decortication.

Decubifus ulcers, in thoraeospinal wounds,

47

Deep breathing, after decortication, 300

Defects of chest will, 145, 140. 181-183, 107

in sucking wounds, 11

in Zone of Interior, 400, 401, 412

Deflbrinating effect, of visceral motion, in

lieinothorax, 248

Definition, of thoraeoabdominal wounds, 101

Deflection, of missiles, 108

Degrees of shock, 531

Delayed aspiration, in hemothorax, 402

Delayed decortication, in Zone of Interior,

405-400

Delayed primary wound closure, 320, 412,

440, 450n

in sucking wounds, 11

in thoraeoabdominal wounds, 121, 128

DKLOUME. E., 301

Dental sepsis, as cause of lung abscess, 42S

Denudation, of lung tissue, 3 70

Denver. 405. 424, 480

Dependent open drainage, in hemotlioracic

einpyeina, 404

De Pe/.zer catheter, use of, after decortication. 208

Depression, of cough reflex—

by morphine. 212

in wet lung, 207n, 208, 200

Dermoid cysts, of esophagus, 430

Descending colon, wounds of 110, 127-128

DETAKATS. G., 209, 231

Devitalized muscle, as culture medium, 247

DeWitt General Hospital, 473

Dextrose infusions—

after decortication, 29S

in thoraeoabdominal wounds, 126

Diagnosis :

by exploration in thoraeoabdominal

wounds. 110-111

in broiiehopleural fistula, 170

74G-9ilv—05 39

Diagnosis—Continued

in combined thoracic-abdominal wounds,

541

in mediastinal emphysema, 150

of blast injuries, 41, 43

of brachial plexus injuries, 40

of bronchiectasis, 410-417

of cardiac contusions, 00

of cardiac tamponade. 50-01

of cardiac wounds. 51-57, 88

of diaphragmatic hernia, 193

of heinotoina of lung. 100, 400

of hemorrhage, 154-155

of hemotlioracic empyema, 205-200, 272-

273.

of hemothorax, 203-207

of infolded lung, 185

of mediastinal neoplasms, 430

of mediastinal wounds, 10-20

of migratory foreign bodies, 301-302

of pneumonitis (pneumonia). 170

of pulmonary hernia. 107

of subcutaneous emphysema, 157

of thoraeoabdominal wounds, 22, 100-110

of tuberculoma. 420

of wet lung. 215-210

of wounds of esophagus, 24-27, 28. 345

Diagnostic aspiration, in wounds of esophagus, 20. 28

Diagnostic criteria, in thoracoabdoininal

wounds. 110

Diagnostic pneuinoperitoneum, 341-344

Diagnostic pneumathorax, 337, 344

Diapedesis, in ecchymotic mask, 31

Diaphragm:

action of, in wet lung, 217

avulsion of, 103, 120

closure of, 110-120, 542n

decortication of, 288, 203

disruption of, 140

elevation of, in—

clotted hemothorax. 205

infolded lung, 185

organizing hemothorax, 253, 203

fixation of, in organizing hemothorax, 203

followup studies in wounds of, 440

foreign bodies in (on), 304, 407-HIOS, 523

herniation of abdominal contents through.

103

immobilization of, in clotted hemothorax,

205

lacerations of, 103

in crushing injuries, 30
INDEX

Diaphragm—Continued

perforations of, 101-141

repair of, 128, 538

role of, in—

cough mechanism, 212

infolded lung, 183

shoulder pain in wounds of, 109

sucking wounds of, 136

testing of, 522

use of, in pleural closure, 10

wounds of, 101-141,149, 293, 446

Diaphragmatic hernia, 119, 120, 131, 145,

1S0-19O, 540, 541

clinical picture in, 193

diagnosis of, 193

etiology of, 191

in Zone of Interior, 401

management of, 196

pathogenesis of, 191

Diaphragmatic pleura, foreign bodies in, 394

Diaphragmatic surface of heart, foreign

bodies on, 373

Diaphragmatic zone of chest, 106

Diet—

after decortieation, 298

before decortieation. 28S

before lobectomy, 418

Differential diagnosis, of—

blast injuries, 32

bronchiectasis, 416-417

bronchogenic cysts, 437

clostridial myositis, 175

hematoma of lung, 166, 496

hemothorax, 260

infected hemothorax, 272-273

infolded lung, 185

mediastinal foreign bodies, 345

mediastinal tumors, 438

oxygen deficiency, 52

pericardial cysts, 438

pulmonary hernia, 197

right heart failure, 162

subcuetaneous emphysema, 157

sucking wounds, 22

tracheobronehial wounds, 22

tuberculoma, 426

wet lung, 210

wounds of esophagus, 25

Digital hemostasis, 392

Dilatation, of esopbageal stricture, 542

Diodrast, localization of retained foreign

bodies by, 40S-409

Disability claims, 443

Disability discharge, in—

blast injuries, 474

bronchiectasis, 415

laryngeal malignancy, 433

malignant neoplasms, 433

mediastinal neoplasms, 433

mediastinal wounds, 468

thoracoabdominal wounds, 476

Disability pensions, 523-52<'.

Diseases of chest, 415^140

in Pacific Ocean areas, 399

postseparation development of, 524-525

Dislocation of heart, at operation, 370, 375,

376-378

Disorientation, in wot lung, 214

Displacement of lung, in organizing hemothorax. 259

Disposition:

after lobectomy, 419

follOAvup studies in, 450^51

in bronchiectasis, 424

in Zone of Interior, 400

boards, policies of, 400

,s'cc also Return to duty.

Disruption—

after closure of sucking wounds, 9

of diaphragm, 140

Diversion, of fecal stream, 128

Diverticula, of esophagus, 439

Dizziness, during thoracentesis, 269

Dome of diaphragm, foreign bodies in, 138

DOUD, Maj. E. A., 44, 47. 124, 154, 155

Drainage, 539

after decortieation, 295, 29S

for bile empyema, 129-130

after lobectomy, 419

after primary thoraeotomy, 553

after removal of foreign bodies. 347

for empyema in World War I, 274

for wound infection, 451

in actinomycosis, 431

in bronchopleural fistulas, 543

in cardiac lacerations, 71

in cardiac wounds, 93

in clotted hemothorax, 265

in diaphragmatic hernia, 196

in empyema, 170, 540, 545

clinical course in, 280

in fixed hospitals, 449

in hemothoracic empyema, 404

in lung abscess. 170, 178, 394, 428

in massive gangrene of lung, 178

in mediastinal wounds, 20
INDEX 571

Drainage—Continued

in pericardial wounds, 05, 96, 540

in postpneumonic empyema, 430-431

in subphrenie infections, 130, 476, 540

in thoracoabdominal wounds, 120-121

in wounds of—

esophagus, 27, 28

kidney, US

liver, 118-119, 121-123, ISO, 538, 542

lung, 18

pancreas, IIS

rectum, 12S

in Zone of Interior, 450

inadequate use of, 240

into pleura 1 cavity in cardiac wounds, 58

of multiple empyemas, 27S

of paraesophageal abscess, 542

of pericardium, 95

Drainage tubes:

as foreign bodies, 327

management of:

after decortication, 298, 300

after thoracoabdominal surgery, 127

Draining sinuses—

associated with foreign bodies, 544, 545

of chest wall, 145, 1S0-1S1, 400, 401, 412-

413. 507, 541

DRIXKER, C. K., 161, 209

DKURY-WITITE, .1. II., 34

Dullness, in infolded lung, 185

Duodenum, wounds of, 121, 123, 538

Duration, of—

effect of intercostal nerve block, 223

effect of paravertebral nerve block, 223

hospitalization in thoracoabdominal

wounds, 13S

recovery with decortication, 280

DUVAT., P., 117n

Duval-Barasty extrapleural exposure, 89

Dyspnea, 413

associated with foreign bodies, 328

associated with pulmonary transudation,

101

associated with wound disruption, 174

during thoracentesis, 209

following chest wounds, 202

studies on, 203

in atelectasis, 164

in blast injuries, 474

in bronchiectasis, 416,421

in bronchopleural fistula, 170

in cardiac wounds, 52, 53

Dyspnea—Continued

in clotted hemothorax, 535

in diaphragmatic hernia, 103

in hemotoma of lung, 165

in myoeardial contusions, 68

in organizing hemothorax, 281

in tension pneumothorax, 149

in thoraeoalidominal wounds, 109

in wet lung, 213-214, 215. 216, 217, 219

in wounds of esophagus, 25, 30, 345

persistence of, 145, 523-524

in followed-up casualties, 450

Early ambulation, after—

decortication, 300

lobectomy, 419

thoracoabdominal surgery, 126

Eeehymosis, in blast injuries, 38

Eecbymotic mask, 31-32

Ecfopic heart beats, at operation, 90

Ectopic stimuli, as cause of death, 99

Edema of wounding, 248

EDWARDS, A. TUDOR, 373

EDWARDS, E. R., 244

Effects of blood, on pleural structures, 244-

245

EGGERS, C, 274

Elastic component of peel, in hemothorax,

250-251

Elective incision, in—

primary thoracotomy, 532

thoracoabdominal wounds, 128

Elective removal of foreign bodies, 325

Electric localization of foreign bodies, 332

Electrocardiography:

after cardiac surgery, 95, 380

at cardiac surgery, 375-379

in cardiac wounds, 51, 50-57

in intracardiac foreign bodies, 305-300

in myoeardial contusions, 09

in perforating wounds of heart, 70

in retained foreign bodies, S9

in stab wound of heart, 85

Elevation of diaphragm, in—

clotted hemothorax, 205

infolded lung, 185

organizing hemothorax, 293

ELKM, Col. D. C, 59, 00, 05, SO, 01

ELLIOTT. 1st Lt. C. V., 442

Embolic foreign bodies, 353, 380-393, 539

Embolic spread, after decortication, 303
ad INDEX

Embolism : Empyema—Continued

after lobeetomy. 410 in wet lung, 215

caused by migratory foreign bodies, 78, 94 in wounds, of esophagus, 25

in cardiac wounds. 97 in Zone of Interior, 404-107, 450, 551

risk of, in intracarcliac foreign bodies, 350 incidence of. 301-302. 535-53G

Emergency measures, in tension Pneumo- in sucking wounds. 11

thorax. 151. management of, 549-551

Emergency occlusion, of sucking wounds, prevention of. by decortication, 297

9-10 recurrence of. after decortication. 298

Emergency surgery, in thoracoabdominal relation of. to wound infection, 451

wounds. 112 statistics of, 241-243, 549-551

Emergency tboracotomy, bronehoscopy be- surgical risk of, 274-275

fore. 228-299 technique of surgery for, in World War I,

Emphysema. 145, 157-160, 534 274

differentisition of. from clostridial myosi- wound disruption in. 174

tis, 17.1 Sec ulxn special varieties.

in bronchiectasis, 419 Empyema commission, 2S0

in crushing injuries, 30 Empyema necessitatis, 310

of mediastinum, 20 Encased lungs, 237

Empyema. 17S, -143 Enehenberg. 481

after clotted hemothorax, 237 Endocardium :

after decortication, 300, 307. 30S nonsuture of, 93

after inadequate aspiration, .149 pathologic process in wounds of, 63

after lobectomy, 420 Endotracheal anesthesia—

after mediastiual surgery, 439 for decortication, 289

after organizing hemothorax, 247 for repair, of—

after remoyal of foreign bodies, 349 diaphragmatic hernia, 196

after thoracoabdominat operation, 129 pulmonary hernia, 199

after wound disruption, 9 in thoracoabdominal wounds. 106. 113. 542

as cause of death, in thoracoabdominal Endotracheal aspiration, in diaphragmatic

wounds, 140 hernia. 190

associated with— Endotracheal intubation—

actinomyeosis, 431 as cause of cardiac irritability, 379

bronchopleural fistulas, 171, -143 before laparotomy, 13G

compound fractures of ribs, 12 Endotracheal suction, in wounds of lung. 18

diaphragmatic hernia, 100 Engorgement of cervical veins, in—

draining sinuses of chest wall, 412 cardiac famponade. 60-61, 62

retained foreign bodies. 829, 348, 349, cardiac wounds. 80

545 right heart failure, 162

bacteriology of. 24G-247 tension pneumothorax. 151

deaths from, 534 Environmental characteristics, of Pacific

differences from, in World War I, 273-275 Ocean areas, 399

drainage of, 170, 540 Epicardium:

drainage operations, in World War I, 274 abrasions of, 63, 67

in crushing injuries, 30 management of. during cardiac exposure,

in eechymotie mask. 31 370, 379

in fixed hospitals, in followed-up casual- suture of, 93

ties, 449 Epiphrenic diverticula of esophagus, 439

in lacerations of lung, 468 Erosion—

in paraplegia, 47 caused by migratory foreign bodies, 392

in sucking wounds, 11 caused by retained foreign bodies, 395

in thoracoabdominal wounds, 120, 476, of great vessels, by foreign bodies, 3S0

53S of lung, by rib fragments, 170
INDEX 0(Ö

Errors in diagnosis, of diaphragmatic

hernia, 193

Excherichia coli, 309

Exchcrichia infection, in organizing hemothorax, 202

Esophagogastrie junction, wounds of, 125

Esophagojejunostomy, 434

Esophagopleural fistula, 2S, 308

management of, at decortication. 284

Esophagus:

carcinoma of, 433-430

clinical picture in wounds of, 25-20

compression of, in mediastinal emphysema, 159

cyst of, 43S

diagnosis of wounds of, 24-2T, 28

differential diagnosis of wounds of, 25

exploration in wounds of, 27

fistula (s) of. 540, 541,542

foreign bodies adjacent to, 320, 394, 545

incidence of wounds of. 24

lethality of wounds of, 27

malignant neoplasms of, 439

management of wounds of, 27-30

stricture of, 439, 542

wounds of, 19-20. 24-30, 103, 149, 345, 408,

525, 520, 532, 534, 540, 542

Estimation of surgical risk, in decortication,

270

Ether anesthesia:

atelectasis after, 103

inthoracoabdominal wounds, 113

Ether technique, of foreign body localization, 408

Etiology, of—

abdominal findings, in blast injuries, 40

atelectasis, 103, 105

bronchopleural fistula, 170

cardiac tamponade, 58

chronic empyema, 549

chronic parietal sinuses, 180

clostridial myositis, 175

diaphragmatic hernia, 191

draining sinuses, of chest wall, 412

dyspnea, in wet lung. 214

ecchymotic mask, 31, 32

empyema. 240. 275

infolded lung, 183-185

hemothorax, 238

lumbar pain, in wounds of esophagus, 25

lung abscess, 428

organizing hemothorax. 240-249

pneumonia, 179

Etiology, of—Continued

pneumonitis, 179

postoperative pneumonia, 104

pulmonary edema, in shock, 210

pulmonary hernia, 197

recurrent empyema, 309

residual chest pain, 203

subcutaneous emphysema, 157

wet lung. 211-213

wound disruption, 173

European (heater, 353-395, 399, 442. 529, 534

casualties returned from, 399. 404

decortication in, 301

diaphragmatic hernia in, ISO

empyema in, 240

evolution of clinical policies in, 535

foreign bodies in, 353-395

Evacuation:

for logistic reasons, 402

improvements in, 530

of casualties, after thoracentesis, 270

of gastric contents, 113

Evacuation hospitals:

case fatality rates, of thoracoabdominal

wounds in, 137

decortication in, 287

hemothoracic empyema in, 271.

initial wound surgery in, 530, 535

management of—

sucking wounds in. 9, 541

thoracoabdominal wounds in. 101-102,

lll,llln,117

overdosages of morphine in, 212

overhydration in, 213

Evacuation policies in oversea theaters, 399

Evaluation, of—

oversea surgery, in Zone of Interior. 539-

554

wet lung, 232

Evisceration—

after thoracoabdominal surgery. 129

in thoracoabdominal wounds, 114

of abdominal organs, 539

Evolution, of—

clinical policies, 532

in European theater, 535

in Mediterranean theater. 441-442. 525-

527. 535

surgical policies, 530-531

Excisional surgery, in chronic parietal

sinuses 180-181

Exercise tolerance, after chest wounds, 202
574 INDEX

Expectant; treatment, in— Extraplenral technique, in cardiac surgery,

infolded lung, 185 so

organizing hemothorax, 240 Extrasystoles—

Expectoration, in blast injuries, 40, 41 during intracardiac maneuvers, 370, 37S

Experimental blocking of pulmonary ai tery, in cardiac wounds, 52

17n Extrinsic tumors, about esophagus, 439

Experimental cardiac tamponade, 89 Exudates, in—

Experimental studies, on— hemothorax, 248

blast injuries, 34-39 organizing hemothorax. 247. 249. 254

broncliospasm, 231

cardiac tamponade, 89 Factors of mortality, in thoracoabdominal

intracardiac foreign bodies, 356 wounds, 138-141

thoracic contusions, 60 Failure of resuscitation, in cardiac wounds,

thoracic trauma. 209 52

Exploration : EALOIS, Jlaj. W. H., 529

at decortication, 290-291 Fascia :

in bronchogenie cysts, 437 closure of sucking wounds by, 10

in mediastinal wounds, 20 repair of chest wall defects by, 412

in thoracoabdominal wounds, 110-111 Fascia propria, drainage through, 12S

in wounds of— Fat embolism, 32, 140, 101, 539

bronchi, 22 in blast injuries, 43

esophagus, 27 Faucompierre, 477

kidney, 538 Federal Records Center, General Services

spleen, 538 Administration, 443

Exploratory thoraeotomy. technique of 402 Femur, fractures of. 141, 306

Exposure: Fibrillation, in cardiac wounds, 52

at decortication. 289-290 Fibrin:

contributory to pneumonia, 533 deposition of, after wounding. 507, 526

in cardiac surgery, 89 formation of, in hemothorax, 245, 240-247

in removal of— Fibrin component, of—

foreign bodies, 340 hemothorax, 248

intracardiac foreign bodies. 309 organizing hemothorax, 248, 249-250. 251,

migratory foreign bodies, 392 252, 253. 255. 258-259

of mediastinal neoplasms, 438 peel (rind), 249, 250, 251. 252, 253. 378

respiratory infections after, 213 Fibrin foam, plugging of pulmonary leaks

Exteriorization of colon, 115. 118, 123, 127- with, at decortication, 295

128, 538 Fibrinoübrinous peel. 250

Extracardiac approach to heart, 370 Fibrinopurulent pericarditis, 391

Extracardiac removal, of ventricular foreign Fibrinous pericarditis. 05

bodies, 375 after cardiac surgery, 95

Extraeostal hematoma, 206

Extracostal musculature, atrophy of

clotted hemothorax, 205

in

Fibroblastic proliferation, 240

in organizing hemothorax, 255

Fibrocaseous tubereulomas, 426

Fibrolysin, 247

Extraperitoneal closure, of eolostomy, 1 28 Fihroplasia, in—

Extraplenral approach, in thoracoabdominal organizing hemothorax, 256

wounds, 12 uninfected organizing hemothorax. 287

Extraplenral hemorrhage, in blast injuries. Fibropla stic peel, 250

40 Fihrosis—•

Extraplenral mediasfinotomy, 178, 394 about retained foreign bodies, 329

Extraplenral removal of foreign bodies, 246, as indication for removal of retained for304 eign bodies, 545

in chest wall. 394 in organizing hemothorax. 258
INDEX 575

Fibrosis—Continued Fluoroscopy, in—Continued

of lung, 25S-259 wounds, of—

in hemothoracic empyema, 275 esophagus, 28

with delayed decortication, 540 great vessels, 85

Fibrothorax, 23, 23S, 259, 280, 283. Flutter valve, management of sucking

diagnosis of, 265 wounds by, 9,11

Field hospitals: Flutter valve drainage—

ease fatality rate, of thoracoabdominal during transportation, 553

wounds in, 137 in tension Pneumothorax, 149

hemothoracic empyema in, 271 Followup studies—

initial wound surgery in, 530, 535 after separation from service, 441-527

management of— on thoracoabdominal wounds, 138

hemorrhage in, 153 Foreign bodies, 520, 540, 541

sucking wounds in, 9, 541 adjacent to heart, 395

thoracoabdominal wounds in, 101-102, anatomic location of, 353-355

111, 117 as cause of—

morphine overdosage in, 212 bronchial occlusion, 416

negative explorations in, 110-111 chronic parietal sinuses, 180

overhydration in, 213 draining sinuses of chest wall, 412

thoracentesis in, 239 as indication for primary thoracotomy,

vascular injuries in, 244, 34S 328, 532, 535, 553

See also Hospitals, field. associated with—

Fifth U.S. Army, 113, 207, 442 bronchopleural fistulas, 171

Fingers, clubbing of, 273 hematoma of lung, 166

Fistula formation, in multiple empyemas, bronchopleural fistulas after removal of.

277-278 309, 543

Fistula (s) :

complicating hemothoracic empyema, 309

of esophagus, 439, 542 embolic to heart, 99

See also special types. followup studies on, 513-522, 523

Fitzsimons General Hospital, 405, 412, 424, hemoptysis with, 540

425, 433, 4S0 hemothorax with, 546

in (about) great vessels, 49-100, 320. 328. Fixation, of— 348, 353-395, 545 chest, in blast injuries, 40, 41

migratory foreign bodies, before removal, indications for removal of, 380

393

Fixed hospitals. -Sec Hospitals, fixed.

in chest wall, 408, 451, 523

in diaphragm, 394

Flail chest, 12-1G, 1S3, 212, 219 in dome of diaphragm, 138

effect of, on cough reflex. 212 in esophagus, 439

management of, 10 in European theater, 353-395

wet lung in, 235 in etiology of bronchopleural fistulas. 543

Flatulence, in diaphragmatic hernia, 193 in heart, 49-100, 353-395

Fluid balance, in thoracoabdominal wounds, indications for removal of, S0-SS

120 in hemothorax, 273

Fluoroscopic localization, of foreign bodies, in liver, 110,118, 394, 523, 542

328, 330-338, 353 followup studies on, 446, 450

Fluoroscopic studies, in hemothorax, 244 in lung, 40S, 462, 523

wedge resection of, 18 Fluoroscopy, in—

bronchogenic cysts, 437 in lung abscess, 177

cardiac tamponade, 00 in mediastinum, 20, 3S0, 394. 408, 408

cardiac wounds, 53-55 in Mediterranean theater, 325-351

migratory foreign bodies, 391-392 in myocardium, 69, S9

pericardial wounds, 65 in organizing hemothorax, 282, 288
516 INDEX

Foreign 1 todies—Continued

in pericardium. 04, 65, 80, 394, 313

in pleura, 304

in pulmonary artery, 17n. 204

in region of diaphragm, 523

in subphrenie space, 304

in thoraeoabdominal wounds. 123-124, 137,

47G

in vertebral column. 304

in Zone of Inferior. 400. 401. 407-412. 543-

546

incidence of, 325

complications of, 349-351

indications for removal of. 117. 325-328,

307-408, 513

localization of. 353

by diagnostic pneumoperitoneum. 341-

344

by diagnostic Pneumothorax, 337

in Zone of Interior. 408-409

location of. 332

management of:

at decortication, 290. 295

in oversea hospitals, 544-545

removal of, 180. 240n

in fixed hospitals. 440. 450. 513

in sucking wounds. 10

role of. in—

bronchopleural fistulas. 170

infections. 240

statistics of, 327. 348-351, 303-305, 407-

408

techniques of removal of, 34G-348

timing of removal of, 328-332

wedge resection of, 18

Foreign Body Registry, 407. 54G

Formal incision, in removal of foreign

bodies. 329

Formal thoracotomy. in sucking wounds, 10

Forward hospitals :

cardiac surgery in, SS-K9. 94

deaths in.520-530

debridement in, 445

hemafoma of lung in, 400

management of—

afelectasis in, 1G4

hemol borax in, 401, 404

wounds of esophagus in, 27-28

pneumoperitoneum in, 110

primary thoracotomy in, 301. 441. 442, 530,

544

Forward hospitals—Continued

thoracotomy in—

followup studies on. 441-442, 445

incidence of, 271

indications for, in hemorrhage in, 155

lacerations of lung in, 462

Fowler's position, in—

catheter aspiration, 221

wet lung, 217

Fractures. 533

associated with chest wounds. 413

fat embolism with. 101

of clavicle. 11.413

of femur, 141, 300

of glenoid fossa. 12

of ribs. 11-1G. 212. 413

effect of, in cough reflex, 212

in crushing injuries, 30

in followed-up casualties, 451

in thoraeoabdominal wounds, 102

in wet lung, 232

management of, at decortication. 289

of scapula, 12. 44-15. 413. 451

of shoulder girdle. 44-45

of spine. 451

of sternum. 212. 451, 540

of vertebrae. 45

8'fY: ulxo special types and areas.

France, 442. 477. 481. 487, 493. 508

FHKNCII, Maj. R. JI.. 37

Friction rub. after cardiac surgery, 04

Fulminating empyema. in wounds of esophagus, 25. 28

Fundal hemorrhage, in ecchymotic mask, 31

Fungus infections, in Pacific Ocean areas,

309

FU.VK. F. II.. 197

Fusion of ribs, in empyema, 274

Gallbladder, wounds of, 103, 121

Ganglioneuromas. of mediastinum. 437

Gangrene—

caused by migratory foreign bodies. 392

of colon, in diaphragmatic hernia, 191, 19G

of extremity, caused by embolic foreign

body. 391

of lingula.301, 392

of lung, 1.78

Gastric contents :

aspiration of. 222, 228

blood in. 109

evacuation of, in thoraeoabdominal

wounds. 113

pleural contamination by. 115
INDEX Oft

Gastric contents—Continued Healing, by—

spillage of, into— granulation of draining sinuses of chest

pericardium, OS wall, 412-413

pleural cavity, 103 secondary intention, 450fn

Gastric juice, litmus test of. 20-27 Heart:

Gastric siphonage after tlioracoabdominal behavior of, during cardiac surgery, 375-

surgery, 12(5 379

Gastrointestinal decompression, in— causes of death in wounds of, 97

tlioracoabdominal wounds, 12(5 clinical picture in wounds of, 51-57

wet lung, 217 contusions of, 03, 05-09, 97, 98

Gastropleural fistula, 133 diagnosis of wounds of, 51-57. 88

Gastrorrhaphy, 123, 127. 538 dislocation of, at operation, 375, 370-37S

Gastrostomy, in— effect of hemothorax on, 203

traclieoesopliageal wounds. 542 foreign bodies in (about), 49-100, 325. 320,

wounds of esophagus. 27, 28 353-395

GAY, Lt. Col. E. D., 529 hemorrhage from, 154, 535

General anesthesia, in blast injuries, 42 incidence of wounds of, 49-50, 85

General status, after decortication, 300 lacerations of, 03. 09-74, 94, 97, 98

General surgical teams, 2d Auxiliary Ssurgi- lethality of wounds of, 72, 9S-99

eal Group, 532 management of—

German prisoners of war. tlioracoabdominal penetrating (perforating) wounds of,

wounds in, 130 71-78, 99

Germany. 442. 490. 497. 529 wounds of, 85-89. 94

Glenoid fossa, fractures of, 12 mortality rate in wounds of. 90-97

Glottis : overlooked wounds of, 534

closure of. in cough mechanism, 211, 212 pathogenesis of contusions of. 00

influence of status of, in sucking wounds, pathologic process in contusions of. 00-07

5 penetrating wounds of, 71-78, 97

Gloucestershire, 353 perforating wounds of, 03, 71-78, 97. 99

GRAHAM. E. A.. 5, 273, 280 stab wounds of, SI—85

Granulation, healing by. in draining sinuses statistics of wounds of. 94-99

of chest wall. 412-413 through-and-through wounds of. 93

Great vessels' timing of surgery in wounds of. 88-89

compression of. in mediastinal emphysema, wounds of. 20, 49-100, 244. 525-532. 534,

iri<) 530, 540

foreign bodies in (about), 320, 32S, 348, in tlioracoabdominal wounds, 103

353-395.545 »S'ce also Cardiac; Perieardial; special

wounds of. 85. 40S. 525. 532 regions.

Gross pathology, of chronic hemothorax, Hemaf ocrit determinations, in—

249-255 hemorrhage, 154

Gunzenhausen. 497 tlioracoabdominal wounds, 120

Gutter wounds. ISO Hematoma :

complicating foreign bodies, 353

differentiation of, from hemothorax, 250

formation of, about foreign bodies, 393

identity of hemothorax with, 201

HADHKLD. (>.. 34. 38, 39

HAICTIT, C, 224

Halloran General Hospital, 402, 402fn, 405.

409. 410. 411. 413. 420

Hammond General Hospital. 405 of lung. 145, 149. 105-109. 520. 540

II YRKIXGTOX. S. TV., 437 followup studies of. 490-o01

Hazards of diagnostic pneumothorax. 338- of mediastinum in wounds of esophagus.

340 27

Head wounds. 40, 513 of organizing hemothorax to. 250

wet lung in. 211.210 resemblance of hemothorax to, 302

74(l-!)41v- on 40
o'(8 INDEX

Hemafopoiotie neoplasms, 433

Homaturia, 109

Hemiazygos vein, laceration of, 153

Hemidiaphragin. reattachment of, in parietal

defects, 183

Ilemiplegia, 350

after cardiac surgery, 95

Hemithorax, eontracture of, 237. 205

Hemolytic streptocoecic infection, of modiastinum, 178

Hemoporitoneum, 538

Hemoptysis, 401. 413

caused by foreign bodies, 327. 348, 407. 410,

513. 523. 524, 540, 544, 545

in pulmonary artery, 84n

in blast injuries, 40, 41

in eccliymotic mask. 31

in hematoma of lung, 166, 496

in thoracoabdominal wounds, 109

in wet lung. 207, 215, 216-217

Hemorrhage, 145,153-156

after decortication. 402-403

after thoracentesis, 269, 520

as cause of death. 534

in cardiac wounds, 71, 72, 99. 348

as indication for—

cardiac surgery, 89

primary tlioracotomy, 525, 532-535. 536.

551-553, 554

tlioracotomy, 269

at decortication. 289. 291-293

caused by foreign bodies, 349, 526, 544

in myocardium, 88

caused by migratory foreign bodies, 392

control of, at cardiac surgery, 91

diagnosis of, 154-155

from intercostal muscles in blast injuries,

39

from pulmonary lacerations, 149

hematoma formation after, 165

in blast injuries, 32, 39, 41

in cardiac contusions, 67, 68

in cardiac wounds, 52, 53, 58, 64. 71, 72. 97

in compound fractures of ribs, 16

in contusions of lung, 18

in crushing injuries, 30

in eccliymotic mask, 31

in lacerations of lung, 154, 536

in mediastinal wounds, 20. 468

in stab wounds of heart, 84

in thoracoabdominal wounds, 112, 122, 144,

537

in traeheobronchial wounds, 22, 542

Hemorrhage—Continued

in wet lung, 215, 216

in wounds of—

bronchi, 22

kidney, US

liver, 122

lung, 18

spleen. 109, 122

incidence of, 153

management of, 155

Hemostasis:

at cardiac surgery, 372, 375

by digital technique, 392

Hemostatic cardiac grip, 375, 378

Hemothoraeic empyema, 237-324, 507. 523

associated with paraplegia, 47

bacteriology of, 283

clinical picture in, 265-266, 272-273, 276

complicating foreign bodies, 346

criteria of cure in. 303

decortication in, 271. 283-284

diagnosis of, 265-266, 272-273

in Pacific Ocean areas, 399

in Zone of Interior. 400, 401, 404-407

incidence of, 238

management of, 275-278

pathogenesis of, 273

pathologic process in, 2S1

rib resection drainage in, 276-277

Hemothorax. 237-324. 526, 540, 541, 543, 546-

549

after lobectomy, 420

after thoracoabdominal surgery, 127

as cause of—

oxygen deficiency. 52

respiratory embarrassment, 112

as contraindication to extrapleural cardiac

surgery, 90

as hemostatic agent, 197

aspiration in, 404

associated with shock, priority of management of, 541

clinical picture of, 263-267

concept of, 237-238

diagnosis of, 263-267

differential diagnosis of, 266

etiology of, 238

followup studies in, 506-513

in base hospitals, 239

in contusions of chest wall, 4

in crushing injuries, 30

in eccliymotic mask, 31

in thoracoabdominal wounds, 109
INDEX 579

Hemothorax—Continued

in wet Inns, 214, 215, 217, 232

in wounds of esophagus, 26

in Zone of Interim-, 401

incidence of, 237, 238-243, 500, 530

management of:

in forward hospitals, 401

in Zone of Interior hospitals, 549

simple type of, 207-270

natural history of. 243-245

nomenclature of, 238, 254-255

origin of, 153, 243-244

pathophysiology of. 203

recurrence of, after aspiration, 154

relation of volume of, to case fatality rates,

530

resemhlance of, to hematoma, 302

role of, in infolded lung-, 183

statistics of, 230

aspiration of. 271

Sec also special varieties.

Hepatic abscess, 120, 130

Hepatic complications, in bronchiectasis, 418

Hepatic flexure, wounds of, 123

Hepatic infection, as factor in mortality, 450

Hepatieocolic ligament, 123

Hepatitis, 513

after lobectomy, 420

Ilepatization, of lung, 38

Hepatopleural fistula, 53S

Hernia, of—

diaphragm in Zone of Interior, 401

lung, 145, 107-202

in Zone of Interior, 401

management of, 19S-109

Sec (ilno special varieties.

Herniation:

into pleural cavity, 139

of abdominal contents through diaphragm,

103, 139, ISO

of colon into chest, 101, 193

of hollow viscera into chest, 193

of liver into—

chest, 191, 193

chest wall defect, 197

of lung at decortication, 291

of omentum into chest, 103,193

of spleen into chest, 193

of stomach into chest, 191, 193

HEUER, G. .T., 31

Hiatal hernias, of esophagus, 439

Hilar blood vessels, wounds of, 19

Hippocrates, 273

Histology, of malignant neoplasms, 433

Histopathology, of organizing hemothorax,

255-201

Historical note, on hemothorax, 237

Historical Unit, U.S. Army Medical Service,

413, 529

History, in thoracoabdominal wounds, 108,

110

Hodgkins disease, 430—137

HOEFLICII, Capt. AY. F. A., 442

Holding period, in—

forward hospitals, 530

Mediterranean theater, 449, 451

Hollow viscera:

herniation of, into chest, 193

wounds of, 100, 115,139, 140

HOLTZ, Col. .1., 155

Hospital Center, 15th—353

Hospital, 53d Station, 240

Hospitalization:

after forward thoracotomy, 446

duration of, in thoracoabdominal wounds,

138

Hospitals, base:

cardiac surgery in, 88-89

decortication in, 287

hemothoracic empyema in, 271

hemothorax in, 239

management in, of—

atelectasis. 104-165

clotted hemothorax, 302-303

thoracoabdominal wounds, 102. 127-133

wounds of esophagus, 28

pulmonary resection in, 18

removal of foreign bodies in, 320

removal of intracardiac foreign bodies in,

72

thoracentesis in, 270

Sec also Hospitals, fixed; Hospitals, general ; Hospitals, station.

Hospitals, evacuation:

llth-^142

36(11—506

3Sth—12, 207

94th—442, 459, 403, 474, 515, 518

Hospitals, field:

11th—442, 453, 468, 477, 487, 493, 502, 508,

523

54th—482

60th—3S2

60th—442, 497, 502

SOth—442
j)8() IND11X

Hospitals, fixed : Hypoxia, in—

blast' injuries in. 474 hemothorax, 207

deatlis in, 450, 530 wet lung, 232

delayed primary wound closure in. 41.>

management" of foreign bodies in, 520 Ileum. wounds of, 123

removal of foreign bodies in, 32S-332, 349- Ileus :

350. 351. 513 effect of. on cough reflex. 212

reparative surgery in. on followt d-up in thoraeoabdoniinal wounds, 538

casualties, 440 in wet lung, 217

Sec also Hospitals, base; Hospitals, gen- Immobilization, of—

oral: Hospitals, station. diaphragm, in clotted hemothorax 205

Hospitals, general: shoulder, in fractures of scapula. 1 2

named: Inadequate bronchial drainage, 170

ISarnes. 405 Inadequate debridement. 240

liattey. 401 disruption after, 173-174

Brooke. 400 Inadequate oxygenation of alveoli, in wet

DeWitt. 473 lung, 200

Fitzsimons. 405. 412, 424, 425, 433 480 Incarceration of stomach, in d aphragIlalloran. 402. 402n. 405, 400, 410. 411, matic hernia, 103

413. 420 Incidence, of—

Hammond, 405 atelectasis, KB. 210-211. 232

Kennedy, ISOn. 410, 417, 431, 432, 434, bilateral bronchiectasis, 418, 420

430, 4SG. 520, 530-554 blast injury,32-33

Madigan. 510 bronehieefa.sis, 415-HG, 418. 420

l'ercy Jones. 410 bronchogenic cysts. 437

Valley Forge, 475 bronchopleural fistulas, 543

Walter Keed. 107, 100. 202. 204, 400 401, cardiac tamponade. 58

405. 407. 408, 410, 424, 42S. 432, 405. cardiac wounds. 40-50, H7i

400. 523 chronic empyema, 540-551

numbered: chronic parietal sinuses. ISO

12th—300-308 civilian-type empyema. 242

21st—10, 20. 45,105,173, 271, 300 clotted hemothorax. 230

23d—175, 480. 403, 523 complications, of—

lobectomy, 420 24th—400

retained foreign bodies, 340-351, 544 33d—K!5 thoraeoabdoniinal wounds, 120

30th—300-30,8. 480 compound fractures of ribs, 12

40th—401 concomitant wounds, 43

70111—131 defects, of chest wall, 412

12Sth—381 diaphragmatic hernia, 180-187

154th—383 ecehymotie mask. 31-32

155th—303-305 empyem a, 535-530

150th—300 after wound disruption, 0

100th—353. 357, 307, 374, 378, 380, 381. in Mediterranean theater, 301-3( 2

383. 380. 300. 301, 302 in sucking wounds, 11

300th—230, 300 in World War I, 240

HOYT. Ft. Col. W. F.. 405. 413 in Zone of Interior hospitals, 540-

with retained foreign bodies, 340

551

Hunsox. Maj. T. R., ISOn

flail chest. 12

HUOIIES. Wi.j. F.. ISOn. 410 heniatoma, of lung, 105

Huplemonf, 451 hemothoraeie empyema, 238

Hypernea. 102, 232 in Zone of Interior, 404

Hypotension, in cardiac (amponade. 50 hemothorax, 237, 238-243, 500
INDEX 381

Incidence, of—Continued

hernia, of Inns. 11)7

infected homothorax, 535-53G

after primary thoracotomy, 540-549, 553

infection, after—

primary removal of foreign bodies, 544-

545

primary thoracotomy, 553

thoracentesis, 540

infolded lung, 183

lacerating wounds, 531

lipomas. of mediastinum, 43S

lung abscess, 175, 232, 42S, 535-53G

malignant neoplasms, 433

mediastinal abscess, 178

mediasiinal wounds, 10, 4CS

migratory foreign bodies, 78, 380-381

osfeomyelitis, 179-1S0

penetrating wounds, 531

perforating wounds, 531

pneumonitis (pneumonia), 178-179

postscparation diseases, 524-525

pressure (tension) pneumothorax, 148-

140

pulmonary hernia, 197

pulmonary tuberculosis, 424

residual symptoms, following chest

wounds, 202

retained foreign bodies, 325

shock, 531

statistical definition of, 242n

surgical emphysema, 157

thoracoabdominal wounds, 101,13G

thymomas, 438

tracheobronehial wounds, 21

traoheoesophageal wounds, 542

tuberculoma, 425-420

wet lung, 211, 501. 502

wound infection, 412

wounds, of—

colon, 541

esophagus, 24

kidney, 541

liver. 541

small intestine, 541

spleen, 541

stomach. 541

»Sec also Statistics.

Incision :

for deeortication, 2S8, 280-290

for removal of foreign bodies, 340, 394

for removal of intracardiac foreign bodies,

370-375

Incision—Continued

in thoracoabdominal wounds, 110-117,

537-538

in wounds of—

esophagus. 27

heart, 80-01

Kcc alxo Techniques.

Incompatibility reaction, 140

Indications, for—

blood replacement, 531

bronchial aspiration, In wet lung. 223-224,

227-220

catheter aspiration, in wet lung, 223-224

deeortication, 200, 271, 270, 2S1-2SG, 405-

400

diagnostic pneumothorax, 338-339

drainage, in thoracoabdominal wounds,

120-121

exploration, in—

blast injuries, 40

mediasiinal wounds, 20

thoracoabdominal wounds. 110-111

wounds, of bronchi, 22

forward thoracotomy, 441-442, 445-44G

lobectomy, 10

in bronehiectasis, 417-418, 421

in tuberculosis, 425

nonclosure, of cardiac lacerations, 01-92

paravertebral nerve block, in wet lung,

219, 221

primary deeortication, in hemothoracic

empyema, 270

primary thoracotomy, 525, 530, 532, 535,

551-553, 554

pulmonary repair, 17-18

removal, of—

bone fragments, 117

foreign bodies, in—

(about) great vessels, 3S0

pulmonary arteries, 78. 70n

intracardiac (juxtaeardiac) foreign

bodies, 5G. SG-SS, 355-308

intrahepatic foreign bodies, 110

migratory foreign bodies, 78, 392

retained foreign bodies, 117, 325-328,

305, 544-540

in Zone of Interior, 407-408

rib resection drainage, 277

selection of therapy, in hemothoracic

empyema, 270
m INDEX

Indications, for—Continued Infection—Continued

surgery,in— after removal of foreign bodies, 304

bronehopleural fistulas, 171 after thoracentesis, 200. 553

cardiac contusions, 68 as cause of wound disruption, 174

cardiac wounds, 72, S7-S0, 08-00 as indication for removal of—

mediastinal tumors. 438-439 foreign bodies, 327

pericardial wounds, 04 intracardiac foreign bodies, 350

pulmonary hematomas. lGß caused by—

thoracoabdominai wounds, 102 retained foreign bodies, 325, 303-304,

tuberculomas, 420 305, 411, 523. 544-545

tuberculosis, 424, 420 foreign bodies in (about) great vessels,

wounds, of trachea, 22 3S0

thoraeentesis, 267, 540 migratory foreign bodies, 78, 391, 302

in infected hemothorax, 275 rib fragments, 16

thoracotomy in— complicating atelectasis, 164-165

compound fractures of ribs, 16 effect of, in organizing hemothorax, 251,

hemorrhage, löo 258

transdiaphragmatic approach, in tl ora- in cardiac wounds, 08

coabdominal wounds. 537-53S in coastal cartilages, 117, 180-181, 412,

transfhoracic approach, in thoracoabd omi- 540

nal wounds, 138 in etiology, of bronchopleural fistulas, 543

wedge resection, of lung, IS in pericardial wounds, 64

Indigestion, in diaphragmatic hernia, 19: in scapular fractures, 44

Inductees, screening of, 140, 424 in thoracoabdominai wounds, 115

Induction, roentgenotogie examination be- in wet lung, 215

fore, 416 in wounds, of liver, US

Industrial compensation. 524 of hronchogenic cysts, 437

Indwelling catheter, in wet lung. 227 of chest wall, in followed-up casualties,

Infected hematoma : 440

complicating foreign bodies, 353 of fractures, of clavicle, 11

management of, at decorticafion, 20 " prophylaxis of—

Infected hemothorax, 237, 238, 230-243, 201. by early decortication, 287

272-273,506-507. 540. 546-540 in sucking wounds, 9

antecedent to empyema, 240 Inferior cervical ganglion, block of, 46

caused by bone fragments, 16. 535 Inferior vena eava :

complicating paraplegia, 47 migration of foreign body in, 300, 530

criteria of cure in, 303 wounds of, 539

differentiation of, from hemothoracic

pyema, 272-273

incidence of. 535-536

emInflammatory effects, of unaltered blood, 245

Influenza, antecedent to empyema, 274

management of, 2i5-27S Infolded lung, 145, 183-186

rib resection drainage in, 310-311 differentiation of, from hemothorax, 200

statistics of, 307-30S in organizing hemothorax, 250

with retained foreign bodies, 535 management of, 1S5-1S6

Infected organizing hemothorax: at decorticafion, 205-206

bacteriology of, 2S2-2S3 Infusions, at operation, 114

decorticafion in, 2S2-2N3 Inhalation anesthesia, in wet lung, 213

differentiation of, from hemothoracic em- Initial wound surgery:

pyema, 283-284 followup studies in, 445-448

Infection: in clearing stations, 530

after closure of sucking wounds, 0 removal of foreign bodies at, 544

after primary thoracotomy, 553 thoracotomy at, 441, 442 i

after primary wound closure, 541 Innominate aneurysm, 45
INDEX 583

Innominate artery:

foreign bodies adjacent to, 394

migratory foreign bodies in, 3S9-390, 393

wounds of, 244

Innominate vein, laceration of, 153,150

Inspiration, in cough mechanism, 211

Instability of chest wall, after thoracolaparotomy, 117

Instillation, of penicillin—

after closure of sucking wounds, 11

after deeortication, 298, 300

after surgery, 127, 240

for foreign bodies, 347, 394

in infected hemotborax, 275

Interauricular septum, 72

Intercostal aneurysm, 45

Intercostal artery:

hemorrhage from, 535

laceration of, 244

Intercostal catheter, thoracentesis by, 532

Intercostal decompression, in—

pulmonary lacerations, 52G

tension pneumothorax, 151

Intercostal drainage, in—

broncbopleural fistulas, 170-171

hemotborax, 507

infected hemotborax, 275

sucking wounds, 11

thoracoabdominal wounds, 120-121

Intercostal incision, for deeortication, 289-

290

Intercostal muscle suture, in sucking

wounds, 10

Intercostal muscles, involvment of, in blast

injuries, 39

Intercostal nerve block, 23G, 525, 532

after thoracoabdominal surgery, 12G

at, deeortication, 297

at tboracotomy, 222, 223

effect of, 219-221

in atelectasis, 105

in blast injuries, 42

in compound fractures of rib, 12

in costochondral separations, 11

in differential diagnosis, of thoracoabdominal wounds, 109

in flail chest, 16

in management of residual symptoms, 203,

204

in rib fractures, 11

in thoracoabdominal wounds, 112,115

in wet lung, 219-223

Intercostal nerve block—Continued

in wound disruption, 174

results of, 222-223

technique of, 221-222

Intercostal nerves :

damage to, 202

prevention of surgical trauma to, 204

Intercostal spaces :

dysfunction of, in organizing hemotborax,

281-2S2

narrowing of, in—

clotted hemotborax, 205

infolded lung, 185

wet lung, 216

Intercostal structures, closure of sucking

wounds by, 10

Intercostal vessels:

hemorrhage from, 153, 420-536

lacerations of, 154, 243-244

recurrence of hemorrhage from, 155

Intercostal water-seal drainage, in—

clotted hemotborax, 263

sucking wounds, 541

Intermittent sucking, of chest wound. 5

Internal mammary artery :

arteriovenous fistula of, 450

hemorrhage from, 153, 154, 535, 530

wounds of, 244

Internal pneumonolysis, 407

Internal sucking wounds, 105

Interventricular septum, 72

Intestinal contents, pleural contamination by

spillage of, 103,115

Intestinal obstruction, in—

biliary peritonitis, 133

diaphragmatic hernia, 191

thoracoabdominal wounds. 126

Intestines, perforations of, 112

Intra-abdominal damage, in thoracoabdominal wounds, 103

Intra-abdominal pressure, after blunt trauma, 66

Intra-arterial migration, of foreign bodies,

33-40, 62, 3S0-393

Intracardiac foreign bodies. 94

Intracardiac maneuvers, 375, 378-379

Intracardiac thrombosis, 378

Intrahepatic abscess, in hepatic lacerations,

129

Intraperitoneal closure, of eolostomy, 12S

Intrapleural adhesions, in retained foreign

bodies. 329
m INDEX

Intrapleural bleeding. as ciiuse of tension Kennedy General Hospital. ISOii, 393, 416,

Pneumothorax. 14N 437, 433. 432, 434. 439, 480, 529, 539-554

Intrapleural decompression, in lacerations KI:.\T. E. 11., 438

of lung. 402 Kidney :

Intrapleural fluid collections, differentiation drainage in wounds of, 538

of, from imlmcmaiy hemafoma, 300 exploration of, 538

Intraiileural foreign bodies, 348-351 herniation of. into chest. 193

Intrapleural bemoiTbage, as cause of deatb. incidence of wounds of. 541

034 wounds of, 103. 309. 315. 33S, 121, 137

Intrapleural infection, in bronehopleural Kinking of right heart vessels, in meclifistulas, 3 71 astinal flutter. 8

Intrapulmonary foreign bodies, 34S-3.11 Korean war. 137. 524

adjacent to great vessels, 353-354

Infratboraeie beniafonia. 4 Laceration(s) :

Infrathoracic manipulations, as cause of incidence of. 531

cardiac irritability, 379 of auricle, 02-93

Intrafraeheal penicillin, in broncbiectasis. of azygos vein, 353

417.438 of blood vessels, by bone fragments, 535

Intravascular migration, of foreign bodies, of brachial plexus, 40

78-85. 380-303 of cardiac chambers, 09-70

Iutravascular tbrombi. 254 of chest wall. 3

Intravenous adininistration, of morphine, of diaphragm, 303

212 in crushing injuries. 30

Intravenous fluids, rapid administration of, of esophagus. 20

161 of great vessels. 85

Intravenous migration, of foreign bodies, of heart. 03. 09-74. 04, 97, 98

390-391 case fatality rates in. 90-97

Intravenous pyelograms, 541 nonsuture of. 70. 03-02. 94. 95

Irradiation, for— of hemiazygos vein, 353

carcinoma of lung. 433 of innominate vein. 353. 350

mediastinal tumors, 438-430 of intercostal vessels, 154, 243-244

Irreversible changes, in broncbiectasis. 430 of liver. 129

Irreversible shock. 537 of lung. 10-3 7. 317. 145. 354. 355. 100, 170,

272. 294. 320, 520. 532. 534. 530, 537- Irritating packs, in chronic empyema. 275 538, 540. 540. 549. 553

Italian campaign. 80. 230 by rib fragments. 170

Italy. 32. 40. 304, 30!), 442. 502. 513, 529 followup studios in, 402-408

in compound fractures of ribs, 12

Jacksonian convulsions. 304 in fhoraeoabdominal wounds. 103

JACOISS. Mai. T. T.. 308, 375 tension pneumothorax after, 145

Jaundice, 513, 534 of myocardium. 09, 70. 9S-99

after lobectomy, 420 of pericardium, 04

as factor in mortality. 450 of subelavian artery. 350

associated with— of subelavian vein, 353

cardiac contusion. 08 of superior vena cava. 153

intracardiac foreign bodies. 350 of ventricles. 58

.TAKVIS. llaj. K, 300 LAII'PLV.T. C..437

.Te.junostomy. in wounds of esophagus, 28 Lamination of peel, in infected hemothorax,

Jon.xso.x. Lt. Col. .T., ISOii 293

Joint resection, in costochondral separa- Ltuii-ct. 34

tions. 31 Landings, in southern France. 373, 442

Landmines, traumatic amputations from, 43

KAY. ylaj. E. 15.. ISOn, 410, 433, 439, 520 LAXGSTOX. jfaj. H. T.. 307
IXDEX 585

Laparotomy—

in blast injuries, 40

in thoracoabdominal wounds, 110

incision, in thoracoabdominal wounds. 116

Laryngoseopic aid, in catheter aspiration,

221

Larynx :

neoplasms of, 133

wounds of. 20,145

Latent infection, in organizing hemothorax,

203. 282-283

Lateral intercostal drainage, 127

Lateral thoracotomy. in thoracoabdominal

wounds. 117

Laf issimus dorsi. 22

Lavage. at deeortieation. 200, 207

Lavage of pleural cavity—

at operat ion. 115.120

in thoracoabdominal wounds, 124

Learning curve. 130. 241, 530-531

LEES. Maj. "YV. M, 44, 183

Left main stem bronchus :

cafliefer aspiration of, 227

wounds of, 23

Left-sided thoracoabdominal wounds, 123-

125.127-128

complications of, 120

management of, 111

Lciomyoma. of esophagus, 130

Lel'ezze. 103,171. 515

Lethality, of—

bile empyema. 120

carcinoma, of—

esophagus. 134

lung. 433

cardiac confusions, 70

cardiac tamponade. 58

cardiac wounds, 51-52, G5, 72, 08-00

combined thoracic and abdominal wounds,

101

complications of foreign bodies, 340

drainage with labile mediastinum, 281

foreign bodies in heart, 351, 355-350

foreign body embolism, 35G

hemorrhage, 151-155

lacerations, of pulmonary vessels, 34S

mediastinal infection, 178

mediastinal wounds, 10.108, 520

migratory foreign bodies, 78, 302, 303

myocardial contusions. 67

sucking wounds, 5

Lethality, of—Continued

thoracoabdominal wounds, 10. 102. 130,

176

according to location, 130

thoracospinal wounds, 47-18

tracheobronchial wounds, 21

visceral wounds, 111

wounds, of—

bronchi, 22

esophagus, 21, 27, 345

great vessels, IS, 211

hollow viscera, 130

solid viscera. 130

thoracic duct, 103

Leukocytic response, in infected organizing

hemothorax, 262

Level of rib fractures, in thoracoabdominal

wounds. 102

Levin tube:

decompression by, in wounds of esophagus,

28

diagnosis by, in wounds of esophagus, 26

in preoperative preparation, 72

in thoracoabdominal wounds, 113

LEWIS, T„ 210

Ligament of Treitz. 123

Ligation, of—

axillary vessels, 45—MS

pulmonary vessels, 18

subclavian vessels, 45-46

Ligation technique, in lobectomy, 410

LLIEXTIIAL, II., 92. 286

Limited duty, return to. 450. 468. 474

Line-of-duty bronchiectasis. 424

Lingula. occlusion of arterial supply to. by

foreign body, 300

Lingulectomy, in bronchiectasis. 418. 410

Lipiodol diagnosis, in wounds of esophagus.

26, 28

Lipiodol localization, of retained foreign

bodies, 408

Lipiodol visualization, in empyema. 543

Lipomas. of mediastinum, 438

Liver:

bare area of. 101

deaths, 140

drainage in wounds of, 538

followup studies in wounds of, 446

foreign bodies in, 394, 305. 450. 523, 542

herniation of:

in diaphragmatic hernia, 101. 103

into chest wall defect, 197
586 INDEX

Liver—Continued

ileus in wounds of, 53S

incidence of wounds of, 541

lacerations of, 129

migration of foreign bodies from, 7Sn, 390

penetrating wounds of, 110

sealing off of diaphragmatic wound by, 100

wounds of, 103, 109, 115, 11S-110, 121-123,

128.137. 53S. 539

Sec also Hepatic.

Lobar ateleetasis, 200

in wet lung, 22S

Lobar pneumonia, 179

antecedent to empyema, 274

in tlioracoabdominal wounds, 538

Lobectomy, 155

complications of, 420

for removal of migratory foreign bodies, 78

in actinoniycosis, 431, 432

in broncliiectasis, 417-419

in forward hospitals. IS

in hemothoraeic empyema, 309

in Hodgkiirs disease, 430-437

in lung abscess, 429

in mediastinal tumors. 439

in pulmonary hematoma, 490

in pulmonary lacerations, 520

in spontaneous nontu'oerculous Pneumothorax, 432

in tuberculoma, 420

in tuberculosis. 425

in wounds of bronchi, 22

in wounds of lung, 10,18

indications for, in broncliiectasis, 417-

418, 421

rationale of, in broncliiectasis, 410, 417-

418, 421

results of, in broncliiectasis, 421^123

return to duty after, 400

technique of, 419

Lohotomy, for removal of foreign bodies, 329

Lobular ateleetasis, 200

in wet lung, 209, 215, 210, 228

Lobulation, in organizing liemothorax, 254

Local anesthesia :

application of, during bronchoscopic aspiration, 22S

for bronehoscopy, 104

in bronchopleural iistulas, 170

in removal of foreign bodies, 332

in wet lung, 221

Localization :

in generalized empyema, 280, 281

of foreign bodies, 322-340, 353

in (about) heart, 53-55, 72, 89

in tlioracoabdominal wounds, 123

in Zone of Interior, 408-409

techniques of, 332-340

Localized phase of lung abscess, 178

Location, of—

foreign bodies, 332

as indication for removal, 325-326, 328,

34S,395

wounds, 531, 535, 530

as diagnostic aid, 100-108

as indication for forward thoracotomy,

445-440

effect of, on sucking, 5

LOCKWOOD, A. L., 2S0

Loculation, in—

clotted liemothorax, 277

hemothoraeic empyema, 273

postpneumonie empyema, 301

Loculations, aspiration of, 270

Loison, 92

Long-term followup studies of war wounds,

411,441-527

Los Angeles, 443

Loss of consciousness, in—

diaphragmatic hernia, 193

head injuries, 211

Lower nephron nephrosis, 101

Sec also Renal.

Lumbar pain, in wounds of esophagus, 25

Lung:

abscess, 145, 175-17S, 428-429, 523, 524,

540

about bone fragments, 535

about foreign bodies, 327

associated with actinoniycosis, 431

associated with foreign bodies, 347, 348,

349, 535, 544, 545

complicating clotted liemothorax, 309

complicating hemothoraeic empyema,

309-310

drainage of. 170,394

in compound fractures of ribs, 12

in crushing injuries. 30

in organizing liemothorax, 288

in Zone of Interior. 401

incidence of. 232, 535-530

management of, 178

at decortication, 280, 283-284, 295

recurrence of, 178

wedge resection of, IS
INDEX 587

Lung—Continued

blood in gastric contents in wounds of,

109

blood supply of, 17

carcinoma of, 433-436

collapse of, in sucking wounds, 5

contusions of, 18, 30, 47, 101, 105, 210, 272,

540

in thoraeoabdominal wounds, 103

disruption, in wounds of, 173

effect of liemotliorax on, 203

fibrosis of, 258-259

in liemotlioracic einpyema, 275

with delayed (lecortieation, 549

followup studies on—

Iiematoma of, 490-501

lacerations of, 402-40S

foreign bodies in, 393, 407-40S, 402, 513,

523. 520

Iiematoma of, 145, 149, 165-109, 450, 520,

540

lieinorrliagefrom, 535, 530

hepaf ization of, 3S

hernia of, 145, 197-202

in Zone of Interior, 401

hemiation of, at decortication. 291

involvement of, in liemotlioracic empyema,

274, 270

lacerations of, 10-17, 145, 154, 155, 106,

170, 272, 294, 326, 520, 532. 534, 530,

537-538, 540, 540, 549, 553

in compound fractures of ribs, 12

in thoracoalxlominal wounds, 103

malignant neoplasms of, 433

management of, at decortication, 294-297

management of wounds of, 17-19

massive gangrene of, 17S

mechanical changes in, in liemotlioracic

empyema, 272

noninvolvement of, in liemotlioracic empyema, 274

preexisting involvement of, in postpneunionic (metapneumonic) empyema, 272

reaction of, to trauma, 209

reexpansion, failure of, 532

reexpansion of:

after decortication, 280, 294, 297, 419

after physical therapy, 407

after spontaneous nontuberculous Pneumothorax, 432

in liemotliorax, 507

Lung—Continued

release of, at decortication, 290

suture of, in sucking wounds, 10

thromboptastin content of, 24S

tissue, denudation of, 170

wounds of, 16-19, 243-244

Sec also Pulmonary.

LYLE, II. II. M., 391

Lymph drainage, of lung, 520

Lymphatic neoplasms, 453

of mediastinum, 439

Lymphoblastoma, of mediastinum. 436

LYOXS, Maj. C, 279

Madigan General Hospital, 510

Magill catheter. 164

Magnetic foreign bodies, 408

Major pulmonary vessels, battlefield deaths

from wounds of, 18

MAKIXS, G. II., 49, 53, 197

Malaise, in liemotlioracic empyema, 283

Malignant neoplasms, 433-439

incidence of, 433

of esophagus, 439

of larynx, 433

of mediastinum, 433, 430

Malignant teraloid tumors, 437

Malignant thymoma, 43S

Management, of—

abdominal component in thoracoabdominal

wounds, 11S-121

actinomycosis, 432

acute gastric dilatation, 145,157

airway in wet lung, 219

atelectasis, 104-165

blast injuries, 41-42

bronehiectasis, 417-419

bronchiogenie cysts, 437

bronchopleural fistulas, 170-173

at decortication, 2S0

carcinoma, of—

esophagus, 434

lung, 433

cardiac contusions, 67-09

cardiac lacerations, 70-71

cardiac wounds, 85-89

chronic parietal sinuses, 180-181

clostridial myositis, 175

complications, 540

compound fractures of ribs, 12-10

concomitant wounds, 43

eostochondral separations, 11

crushing injuries, 30
588 INDEX

Management, (if—Continued Management, of—Continued

damaged intercostal nerves. 203 subcutaneous emphysema. 157

diaphragmatic hernia. 100 sucking wounds, 0-11, 520, 535, 541

drainage tabes, after— tension pneumothorax, 20,151-155. 53,0

deeortieation, 208 teratoid tumors of mediastinum, 487

removal of foreign bodies. 347 thoraeoabdominal wounds, 101-102, 526,

draining sinuses, of chest wall. 112-113 512

empyema. 510-551 in base hospitals, 127-188

in Zone of Interior hospitals, 551 thoraeospinal wounds, 47-48

«ail chest, 10 thymomas, 438

foreign bodies, in— trachoobronohial wounds. 22

heart and great vessels, 10-100. 853-395 traumatic osteomyelitis, 179-180

Zone of Interior, 407-412, 545, 510 unhealed wounds at deeortieation, 289

fractures, of— n-Qt lung, 217-282, 501-502. 525-526

clavicle. 11 wound disruption. 171

scapula, 12 wounds, of—

hematomas, of lung, 10G, 100. 520 esophagus. 27-80

hemorrhage, 155 kidney. 118. 121

hemothoracic empyema, 275-27S liver. 118-119. 121-123

hemofliorax, 520. 580 lung, 17-19

in forward hospitals, 101 small intestine, 118

in oversea hospitals, 510-510 spleen, 11.8

in Zone of Interior hospitals, 519 stomach. 118

infected hemothorax, 275-27S »SV<? alxo Techniques; Special types of

infolded lung, 185-180 therapy.

left-sided thoraeoabdominal wounds. 123- Manipulative management, of migratory

125 foreign bodies, 892

lesions, of esophagus, 130 Manomefry. in bronehopleural fistulas. 170-

lung abscess, 178, 420 173, 5-13

at deeortieation, 2S0, 294-207 Manpower losses, from simple rib fractures,

mediastinal tumors, 488—130 11

migratory foreign bodies, 391-392 "Manual of Therapy, ETO," 85

organizing hemothorax, 402-403 Manual on thoracic surgery, XRC, 85. 237

osteoehondritis, 170 Manubrium Storni, 155

parietal defects, 289, 200, 201 Marbling of peel, in infected hemothorax,

penetrating (perforating) cardiac wounds, 251

72 Marcianese, 112

pericardia] cysts. 13S Mass ligation technique, in lobecfomy, 419

porieardial wounds, 64-05 Massive clotting, in infected organizing

postdeeortieation empyema, 300 hemothorax. 282

postpneumonic empyema, 300-301, 130—131 Massive gangrene, of lung. 178

primary nerve tumors, of mediastinum. Massive hemothorax, differentiation of.

138 from wounds of esophagus. 25

pulmonary contusions, IS Massive tissue contamination, as cause of

pulmonary edema, 102 death, in thoraeoabdominal wounds. 110

pulmonary hernia, 108-109 Materials (methods), of followup studies,

pulmonary lacerations, 520 142-144

residual symptoms, 204 MATKEK, Ma.i. E., 197

rib fractures, 11-10 MF.ADE. Lt. Col. Ii. II., Jr., 189n. 100, 410, 432,

right-sided thoraeoabdominal wounds, 529

121-123 Measles, antecedent to empyema, 274

sequelae, in Zone of Interior, 400-401 Mechanical obstruction, of trachoobronehial

simple hemothorax, 207-270 tree, in wet lung. 200
INDEX 589

Mechanism, of—

blast injuries, 37-38

clotting in organizing heinothorax, 246-249

cough,211-212

Mediastinal abscess, 145, 178

Mediastinal emphysema, 20,157-100

in cardiac wounds, 53

in wounds of esophagus, 25

Mediastinal foreign bodies, 345, 348-351,

353-354, 380, 393, 394, 408, 513. 530

confusion of, with intrapulmonary missiles, 345

Mediastinal hemorrhage, 209, 535

as cause of death, 534

in blast injuries. 39

in cardiac wounds, 53

Mediastinal infections, in—

tracheoosophageal wounds. 542

wounds of esophagus, 24-25

Mediastinal involvement, in—

thoracoabdominal wounds, 103

wounds of esophagus, 28

wounds of heart, 93

Mediastinal shift:

in clotted heinothorax, 535

in liemothorax. 207

in sucking wounds. 8

in tension pneumotliorax. 151

in wet lung. 210, 214, 210

wound description with, 174

Mediastinal vessels, hemorrhage from, 154

Mediastinifis, 140. 178

as cause of death, 534

Mediastinotomy, in wounds of esophagus, 27

Mediastinum:

decortication of, 293

fixation of. in hemothoracic empyema, 200

followup of wounds of, 4GS-473

function of, in sucking wounds, 8

malignant neoplasms of, 433

neoplasms of. 430-439

relation of, to tension pneumotliorax, 145

retraction of, in infolded lung. 185

status of, in—

empyema, 280-281

hemothoracic empyema. 281

teratoid tumors of. 437

teratoma of, 439

wounds of, 19-21. 27, 139. 149. 525, 520. 532

Medical Statistics Division, Office of The

Surgeon General. 32, 175, ISO, 241, 433

Mediterranean theater, 23, 39, 45, 85, 95, 101,

114, 128,153. 155, 105n. 170, 20S. 210, 213.

237. 209, 275, 324, 399, 420, 442. 501. 525-

520. 527, 529. 542n, 545n

casualties returned from, 399, 404

decortication in, 301, 324, 405

diaphragmatic hernia in, lsG-189

empyema in. 240, 349

evolution of policies in, 441. 525-527, 535

foreign bodies in, 49-100, 325-352

liemothorax in, 237-329

lung surgery in, 18-19

management of—

cardiac wounds in. 80-88

intracardiac foreign bodies in, 94-95

migratory foreign bodies in, 78

thoracoabdominal wounds in, 130-141

wet lung in. 207-230

wounds of heart in, 49-50, 80-88

Meningitis. 140, 189. ISOn. 410, 480, 529

Mental confusion, in cardiac wounds, 52

Mesentery, bronchial spasm after experimental traction on. 209

Metallic foreign bodies, as cause of chronic

sinus formation, 180

Metapneumonic empyema, 23S, 272. 273

in World War I, 275n

Metastatis brain abscess, 308, 311

Middle East, hemothoracic empyema in. 310

Mignano Monte Lungo, 502

Migratory foreign bodies, 02, 78-84. 88. 89-

90, 353. 354. 388-390, 392. 530, 539

diagnosis of, 391-392

management of. 391-392

statistics of, 392

technique of removal of, 392-393

Migratory intravascular foreign bodies. 380-

393

Miliary abscess (es) :

in hemothoracic empyema. 283

management of, at decortication. 322

Miller-Abbott decompression, 133. 157

MISCALL, Lt. Col. I/., 300

Missile(s) :

course of. 150

in cardiac wounds. 04, 72

in thoracoabdominal wounds. 109. 110,

137

dcllection of. 108

effect of course of, in sucking wounds. 5

projection of course of, 154

tracks of. associated with hematoma of

lung. 100
INDEX

Mobility of ehest wall, in hemothoraeic 0111-

pyema, 274

Modesto, 405

Modifications of deeortioation, 297

MOOKE, Mnj. R. L., 402n, 420

Morale factor, in return to duty, 451

Mo]'l)idity—

after forward thoracotomy, in Mediterranean theater, 441, 539

in Zone of Interior, 554

of thoracoabdominal wounds, 141

of wet lung, 2.32

Morphine—

after thoracoabdominal surgery, 12(!

in blast injuries, 42

in causation of wet lung, 212-213

in thoracoabdominal wounds, 112

in wet lung, 217, 219

in wounds of esophagus, 25

Morphine poisoning. 140

Mortality:

in fixed hospitals in followed-up casualties,

450

in Mediterranean theater, 441

relation of wet lung to, 502

See also Case fatality rates ; Deaths ; Statistics.

Mountain fighting, in Mediterranean theater,

213

Multiple empyemas, with fistula formation,

277-278

Multiple rib resection drainage, 27S

Multiple thoracoabdominal wounds. 139

Multiple wounds:

mortality of, in followed-up casualties, 450

wet lung in, 234, 502

Multiplicity:

as indication for removal of foreign bodies.

32S

of thoracoabdominal wounds, 135

Multiplicity index, 139

Mural thrombi—

after cardiac surgery, 95

in cardiac contusions, 07

in cardiac wounds, 03-04

in vena cava, SO

Muscle:

thromboplastin content of, 24S

use of, in pulmonary herniorrhaphy, 199

Muscle flap, closure of—

bronchopleural fistulas, 543

chest wall defects, 412

chest wounds. 183

Muscle grafts :

closure of cardiac wounds by, 70, 93

in lacerations of lung, 402

Muscle plug, closure of sucking wound by, 10

Myasthenia gravis, 439

Myocardial damage, as indication for removal of intracardiac foreign bodies, 350,

357-300

Myocardial. dysfunction, as cause of death,

99

Myocardial infarction. 97

after cardiac surgery, 95

in cardiac contusions, 00

in cardiac wounds, 98

Myocardium:

aneurysm of, 92

contusions of. 50, 09, 98-99

eleetroeardiography in wounds of, 50

foreign bodies in, 09, 88. 89, 94

lacerations of, 09, 70, 98-99

pathologic process in wounds of, 03

petechial hemorrhages of, 00-07

stab wound of, 85

suture of, 93

wounds of, 04, 05, 97

Naples Blood Bank, 531

Xarrowing of intercostal spaces, in—

clotted hemothorax, 205

organizing hemothorax, 2S1-2S2

wet lung, 210

Nasal decompression, in diaphragmatic

hernia. 190

Xasal intubation, after thoracoabdominal

surgery, 120

National Research Council, S5, 237

Natural history, of hemothorax, 243-245

Nausea (vomiting), in—

chest wounds, 52, 53, 70, 109, 193

diaphragmatic hernia, 193

Navy experience, with blast injuries. 33

Nebulized penicillin, 41S

Neck, wounds of, 20

Negative explorations, 110-111

Negative pressure suction, in chronic

empyema, 551

Neoplasms:

bronchial occlusion from, 410

of mediastinum, 430-439

Nephrectomy, 118, 121,123,125, 128, 538

Nerve injuries, associated with chest

wounds, 413
INDEX 591

Neurofibroma, of—

esophagus, 439

mediastinum, 437, 438

Neurogenic sarcoma, of mediastinum, 43S

Neurologic examination, in investigation of

residual symptoms, 203

Xeurologic injuries, 46-48

Neuropsychiatrie manifestations, 413

Neurosareoma, of mediastinum, 436

Neurosurgical wounds, ateleetasis after, 179

Niciior., Lt. Col. A. Tl., 35G

Nicnor.sox, G. JM., 64

NicnoLsox, W. F., 310

Nitrons-oxide-oxygon anesthesia, in thoracoabdominal wounds, 113

Nitrous-oxide-oxygen-ether anesthesia, for

decortication, 2S9

Nomenelature, of—

hemothorax, 23S, 254-255

sucking wounds, 5

teratoid tumors, 437

thoracoabdominal wounds, 101

wet lung, 20S

Nonclosure of skin and subcutaneous tissue,

in—

chronic sinuses of chest wall, 1S1

lacerations of heart, 94, 95

sucking wounds, 11

thoracoabdominal wounds, 121

Non-gas-forming bacteria, in organizing

hemothorax, 262

Xonhemolytic Stapliylococcns aureus

empyema, 247

Noninterference in pulmonary hematoma,

496

Nonspecific bronchitis, complicating ateleetasis, 165

Nonsuture of lacerations of heart, 70, 91-92,

95

Nontraumatic empyema:

decortication in, 300-301

in Zone of Interior, 429-431

North Africa, 49, 164, 179, 207, 240, 306, 529,

531

North African campaign, 86,114

North African theater, 207, 278, 2S6, 325,

446, 449

Sec also Mediterranean theater.

Norwegian forces, in United Kingdom, 155

Numbness following chest wounds, 203

Nutrition—

after decortication, 306

in hemothoracic empyema, 276

Nutritional status :

improvement of, before decortication, 2S8

in Pacific Ocean areas, 390

Nylon sutures, in repair of diaphragm, 1S9

Obiiterative pleuritis, 275

Obliterative surgery, in chronic hemothorax,

275

Obstruction, of—

blood flow, 378

bronchi, in wet lung, 209-210

superior vena cava, 20

Occlusion, of sucking wound, 112, 148, 174,

526

Ocular involvement, in ecchymotic mask, 31

Office of The Surgeon General, 32. 175, 186,

241, 400, 407, 433

Oliguria, 140

Omentum, herniation of:

in diaphragmatic hernia, 193

in pleural cavity, 103

O'NEILL, C. S., 391

Open drainage:

in residual basal empyema, 406

See also Rib resection drainage.

Open pneumothorax, associated with foreign

bodies, 332

Open thoracotomy, in—

infected hemothorax, 551

spontaneous nontuberculosis pneumothorax, 432

Optic nerve, atrophy of, 31

Organizing hemothorax. 238. 239-240. 507,

540,543,549

after primary thoracotomy, 553

bacteriology of, 261-263

criteria of cure in, 303

decortication for, in followed-up casualties, 449

delayed decortication for, 450-406

diagnosis of, 263-265

differentiation of, from infolded lung. 185

effect of, in infolded lung, ISO

etiology of, 246-249

histopathology of, 255-261

in Zone of Interior, 401-403

management of, 402-403

pathogenesis of, 243-249

prevention of, by thoracentesis, 266-269

pulmonary effects of, 25S-259

resolution in, 286-287

statistics of, 307-30S, 401

Origin, of hemothorax, 243-244

Orthodiagrams, in cardiac wounds. 56
INDEX

Orthopedic care, of special fractures. 12

Orf liopnoa, in wet Inn«'. 214

Osteochonrlritis. IT!). 540

Osteoehondroma. 4:1s

Osteomyelitis. 145, 17!)-lsO

of ribs. ISO

Otolaryngologic examination, in bronchiectasis. 41S

Overdosago, of morphine, 212-213

OvKisiioi.T, K. IT.. 20711

Overhydration:

in blast injuries, 41-42

in causation of wet lung, 213, 217, 220

in thoracoabdominal wounds, 112-113, 126,

538

pulmonary edema from, 101

Overlooked injuries, 01, 530

as cause of death, 534

Overlooked spinal injuries, 4G

Oversea hospitals, management of—

ompyema in, 549-551

foreign bodies in, .544-545

hemothorax in, 540-540

Oversea surgery, evaluation of, in Zone of

Interior, 530-554

Oxygen absorption (consumption), in bronchiectasis. 421

Oxygen administration—

during bronchoscopie aspiration. 220

in wet lung. 220-231. 234

Oxygen content of blood, reduction of, in

hemothorax, 203

Oxygen deficiency :

differential diagnosis of. 52

in cardiac contusions, 00

in cardiac wounds. 52, 53

in wet lung. 200. 210, 217

Oxygen therapy—

after lobectoniy, 410

in blast injuries, 42

in catheter aspiration, 227

in pulmonary edema, 102

in thoracoabdominal wounds, 112. 125

in wound disruption, 174

Pacific Ocean Areas, si at us of casualties returned from. 300-400, 404

Packing, in wounds, of liver, llS-110

Pain:

as cause of respiratory restriction, 112

as indication for removal of—

foreign bodies, 327

intrathoracic foreign bodies. 300

caused by migratory foreign bodies. 301

during fhoracentesis, 200

effect of:

in wet lung, 20S, 211. 217. 222-22.".

on cough reflex, 212

following chest wounds, 203

in abdomen, in—

blast injuries, 40

chest, wounds. 100

in abdominal wounds, 212

in blast injuries, 30. 41, 42

in chest wall, 3, 525

as cause of ineffective cough. 105

in diaphragmatic hernia, 103

in hemothorax. 203

in organizing hemothorax, 2S1

in rib fractures, 413

in shoulder, in thoracoabdominal wounds,

100

in thoracoabdominal wounds, 109,112

in wet lung, 210. 217

persistence of. 145, 523-524

in costocliondral separations, 11

in followed-up casualties, 450

relief of, in—

compound fractures of ribs, 11, 12

wet lung, 219

restriction of respiration by, 214

with intracardiac foreign bodies, 350

with retained foreign bodies, 407, 545

Palming technique, 01

PALTAUL, R., 391

rancreas. wounds of, IIS, 53S

Paradoxical pulse, in cardiac wounds, 52, 53

Paradoxical respiration, 12, 174

effect of. on cough reflex, 212

in flail chest. 10

Paraesophageal abscess, 540, 541, 542

Paraesophageal hernia, 439

Parallax technique, of localization of foreign bodies, 332

Paralysis—

in brachial plexus injuries, 413

of recurrent laryngeal nerve. 542

Paraplegia, 47, 450

complicating empyema, 308

Paraspinalis muscles, use of, in wound

closure. 121. 183
INDEX 593

Taravertebral incisions, in subscapular injuries:, 44

Paravertebral nerve block :

in dilTerenlial diagnosis, of thoraeoab-

(loininal wounds, 100

in wet lung. 210-223, 235

results of, 222-223

technique of, 221-222

Parosthesias, 202

Parietal pleura :

fusion of ribs with, in empyema, 274

in organizing hemothorax, 250-251, 250

management of, at—

decortication. 280, 200, 207, 315

delayed decortication, 400

1'AiiKEii, Maj. E. F., 230, 244

PASTE , W., 210

Taten!: foramen ovale, migration of foreign

body through,301

Pathogenesis, of—

cardiac contusions, 60-07

chronic hemothorax, 238

diaphragmatic hernia, 101

fistula formation, in empyema, 277

hemotboracic empyema. 273

organizing hemothorax, 230, 243-240

secretions, in wet lung, 215

subcutaneous emphysema, 157

subphrenic abscess, 130

tension pneumofhorax, 103-100, 145-148,

140

wet lung. 207-211

Pathologic process :

after wounding, 320

in atelcctasis, 103

in blast injuries, 34, 38-30

in hroncbiectasis, 410, 417

in bronohopleural fistula, 100-170

in cardiac contusions, 00-07

in cardiac wounds, 03-04

in chronic hemothorax, 240

in compound fractures, of ribs, 12

in contusions, of lung, IS

in crushing injuries, 30

in diaphragmatic hernia. 101-103

in ecchymotic mask, 31

in empyema, in World War I, 274

in heuiatoinas. of lung. 105, 400

in hemotboracic empyema, 272-273

in infolded lung. 183-185

in lnng abscess, 178, 420

in migratory foreign bodies, 302

in pulmonary hernia, 107

Pathologic process—Continued

in scapular fractures, 44

in thoracoabdominal wounds, 102-100

in tuberculoma, 420

in wounds, of chest wall, 3—1

Pathophysiology, of—

bronchiectasis, 421

cardiac tamponade, 50-00

chest wounds, 208-211, 525

flail chest, 12

hemorrhage, 153

hemothorax, 237, 203, 507

hernia, of lung, 107

infolded lung, 183-185

mediastinal emphysema, 157-150

pericardial wounds, 05

sucking chest wounds, 5-8

thoracoabdominal wounds, 541

wet lung, 207-211. 217

Pattern of migration, of intravascular foreign bodies, 3S8-301

Pectoral girdle, wounds of, 5

Pedicle-flap closure, of—

sucking wounds, 11

trachea, 22

Pedicle-graft closure, of sucking wounds, 10,

11

Pedicle-graft repair, of chest wall defects,

412

Peel (rind) :

antecedent development of, in hemotboracic empyema, 272

at delayed decortication, 400

constricting effect of, in hemotboracic

empyema, 273

in hemotboracic empyema, 281. 283-284

in nontraumatic empyema. 300-301

in organizing hemothorax, 250-255, 25S250, 27S

in uninfected organizing hemothorax, 2S7

incision of, at decortication, 201

management of, at decortication, 288, 200

timing of decortication, in relation to

status of, 285-280

Pendulum respiration, 8

Penetrating thoracoabdominal wounds. 110,

122-123

Penetrating wounds. 208. 238, 534-535

incidence of, 531

migratory foreign bodies in, 301-302

of cardiac chambers, 03

of esophagus. 24

of great vessels, 85
594 INDEX

Penetrating wounds—Continued Perforating tlioracoabdoininal wounds, 110.

of heart. 71-78, 97, 99 121-122, 123-125

of liver, 110 Perforating wounds, 20S, 23S, 534-535

of ventricles, 5S incidence of, 531

Penicillin: of diaphragm, 101-141

after decortication. 298, 300 of heart, 63, 71-78, 97, 99

after tlioracoabdoininal surgery, 126 of intestines, 112

availability of. 530 of rectum. 128

before decortication, 2SS of stomach, 103-104,112

before lobectomy, 419 pulmonary hernia after, 197

during lobectomy, 420 Pericardial aspiration, 540

in actinomycosis, 431, 432 Pericardial cysts, 438

in blast injuries, 42 Pericardial effusion, 53, 541

in broncbiectasis, 417 after cardiac surgery, 65, 93, 95

in crushing injuries, 30 as indication for removal, of intracardiac

in head injuries, 40 foreign bodies, 356, 357

in heinothoraeic empyema, 309 Pericardial friction rub, 389

in liemothorax, 302 Pericardial graft, use of, for cardiac closure,

in infected liemothorax, 275 373

in lung abscess, 178, 429 Pericardial hemorrhage, 55

in management of foreign bodies, 347, 394, Pericardial involvement, in thoraeoabdoni411,412.546 iiial wounds, 103

in organizing liemothorax, 247 Pericardial tamponade, 540

in pneumonia, 179, 428 priority of management of, 541

in postpneumonic empyenia, 301 430-431 Pericardial vessels, wounds of, 58

in prevention, of— Pericardial wounds, management of, 64-05

lung abscess, 175-177 Pericardicentesis, 95

pneunionitis (pneumonia), 179 Pericardiophrenic vessels:

in sinusitis, 418 division of. 72

in tlioracoabdoininal wounds, 139 hemorrhage from, 153

in wounds, of esophagus, 27, 28 Perieardiotomy, for removal of foreign

instillations of. 127, 240 bodies, 355

after closure of sucking wounds,11 Pericarditis, 540

after decortication, 298 caused by migratory foreign bodies, 391

after removal of foreign bodies 347, 394 in cardiac wounds, 98

Penicillin protection: Pericardium :

decortication under, 281, 2S4, 300, 307 closure of cardiac wound by, 70-71, 93

in surgery for chronic parietal sinuses, 181 decortication of, 293

in traumatic osteomyelitis, 179 drainage of, 95

Penicillin therapy, 241, 412 foreign bodies in (about), 89, 94, 325, 353,

wound disruption during, 174 374-375, 394, 573

Penrose drains, in— involvement of, in diaphragmatic hernia,

191 fractures of scapula. 44

wounds, of liver, 119, 122 procaine hydrochloride injection of, 90

Pensions. 443 removal of foreign bodies from, 374-375

wounds of, 49-50, 04-65, 96. 244, 540

Pentothal sodium, in— Periehondral sutures, 180, 204

blast injuries, 42 Pericostal sutures, ISO, 1S3, 204, 347

thoraeoabdoniiiial wounds, 113 at decortication. 298

Percussion note, in— Periosteum :

blast injuries, 40 closure of sucking wounds by, 10

wet lung, 214 use of, in pulmonary herniorrhaphy, 199

Percy Jones General Hospital, 416 Peripheral eniphysematous blebs, 432
INDEX 595

Peripheral nerve injuries, 400

Peripheral Nerve Registry, 407

Peripheral obscuration, in chronic traumatic

hemothorax, 250

Peripheral vascular failure, differentiation

of wet lung from, 216

Peristalsis, significance of, in thoracoabdominal wounds, 109

Peritoneal contamination:

as cause of death, in thoracoabdominal

wounds, 140

as cause of oxygen deficiency, 52

in thoracoabdominal wounds, 102,112,120

shook from, 525

Peritoneal fluid, effect of, on cough reflex,

212

Peritoneal origin, of tension pneumothorax,

103-100

Peritonitis—

as cause of death, 534

from migratory foreign body, TSn

in thoracoabdominal wounds, 140

as factor of mortality, 450

in thoracoabdominal wounds, 539

l'etechial hemorrhages, in cardiac contusions, 00, 07

Petrolatum-impregnated gauze, for occlusion

of sucking wound. 9

Pharyngeal involvement, in ecchymotic

mask, 31

Phosphorus burns, 534

Phrenic emphraxis, 424

Phrenic nerve:

crushing of, 120

in repair of diaphragmatic hernia, 196

paralysis, after lobectomy, 419

revision of, 72

Phrenicectomy, 537

Physical findings, in—

ateleetasis, 164

infolded lung, 185

retained foreign bodies, 332

tension pneumothorax, 151

Physical therapy—

after chest surgery, 407

in hemofhoracic empyema, 404

Physiochemical changes, in hemothorax, 245

Physiologic components, of resuscitation. 530

Physiologic considerations, in diagnosis of

thoracoabdominal wounds, 100-108

Physiologic disturbances, in cardiac wounds,

52-53

Physiology, of respiration, 5-8, 208

Plasma:

content, of organizing hemothorax, 254, 255

infusions of, before decortication, 2SS

loss of, in wet lung, 209

replacement of, 531-532

after decortication, 29S

after thoracoabdominal surgery, 126

at operation, 114

excess of, 213, 229

in chronic empyema, 551

in thoracoabdominal wounds, 112, 537,

538

statistics of, 531-532

Plastic peritonitis, 133

Plastic repair, of pulmonary hernia, 199

Pleura :

foreign bodies in, 393, 394, 407-40S, 513,

526

injection of, in thoraeospinal wounds, 40-

47

late involvement of, in organizing hemothorax, 250-251

penetration of, in compound fractures of

ribs, 12

trauma to, in wounds of chest wall, 3-4

neural adhesions, 149

on followup roentgenograms, 522

Pleural cavity:

abscess of, 273

drainage into, in cardiac wounds, 58

Pleural contamination:

as cause of death, in thoracoabdominal

wounds, 140

from spillage of gastric (intestinal) contents, 115

ill thoracoabdominal wounds, 103,112, 115,

120,123-124

in transdiaphragmatie approach, 114

Pleural defect, closure of, in sucking wounds,

10

Pleural drainage, in wound disruption. 174

Pleural effusion, 450

after removal of foreign bodies, 394

after repair of diaphragmatic hernia, 190

after wounding, 507

in ecchymotic mask, 31

in wounds of chest wall, 3-4

Pleural fluid, modification of, after trauma,

248

Pleural lavage, in thoracoabdominal wounds,

120.124
INDEX

l'Ieural sjiaec:

in hemothoracic empyema, 272

status of, in empyema, 281

Pleural structures, effects of blood on, 244

Pleural thickening. on follownp roentgonograms, 523

Pleuroalveolar involvement, in bronehopleural fistulas, 100-170

Pleuroeulaneous fistula. UN

Pleuropulmonary lysis. 2.S4-2N5

Pleuropulmonary sepsis. 17N

Plombieres, 487-508

Pnoumoneetomy, IS. 10, 155

for actinomycosis, 431-432

for bronehogenie carcinoma, 524

for carcinoma of lung, 433

for lacerations of Inns'. 030

for massive gangrene of lung, ITS

for migratory foreign bodies, S4n

for removal of migratory foreign bodies.

78

for retained foreign bodies. 545n

for tuberculosis, 425

Pneumonia. 145, 178-170. 215

after separation from service, 525

after tboracoabdominal operation. 120

after untreated wet lung, 210

as cause of deatli, 533

in thoracoabdoniinal wounds. 140

complicating clostridial myositis, 534

differentiation of. from hemothorax. 200

in blast injuries, 41

in crushing injuries, 30

in eeehymotie mask. 31

in thoracoabdoniinal wounds, 539

in wet lung, 215

pulmonary edema in, 220

sulfonamide therapy in, 420

Pneumonic episodes, in bronehieetasis. 417

Pneumonitis. 145. Ki5, 178-17!). 540

after lobectomy, 41S

after untreated wet lung. 210

after wet lung, 502

antecedent to lung abscess, 178

as indication for removal of retained foreign bodies, 545

associated with actinomycosis, 431. 432

delay of decortication for clearance of, 280

differentiation of. from pulmonary hematoma.400

in crushing injuries. 30

Pneumonitis—Continued

in fixed hospitals, 440

in head injuries, 40

in hemothoracic emphysema, 200

in retained foreign bodies, 340, 544

Pneumonolysis. 424-425

Pneumonomalacia, 277

Pneumoporicardium. 58. 05

after cardiac surgery. 05

l'neumoperitoneum, 110

Pneumothorax. 543

after laceration of lung. 402

after operation, for—

diaphragmatic hernia. 100

tuberculosis, 424

after thoracoabdoniinal surgery, 127

as cause of respiratory embarrassment,

112

as hemoslatie agent, 197

associated with pneumopericardium, 05

creation of, in pulmonary herniorrhaphy,

100

effect: of, in hemothorax. 273

in bronchopleural fistula, 170

in compound fractures of ribs, 12

in crushing injuries, 30

in mediastinal wounds, 20

in wet lung, 215. 235

in wounds of esophagus. 25

pathophysiologic effects of, 203

role of. in—

infolded lung. 183

organizing hemothorax, 240

Sec nlxo special varieties.

Policies:

evolution of, 530-531, 532

in European theater, 535

in Mediterranean theater, 525-527, 535

governing return to duty, 400

Pontocaine hydrochloride anesthesia, in

catheter aspiration, 224

Portable suction machine, 224

Portal vein, wounds of, 137

Position :

at wounding. 413

changes of. in wet lung. 217

effect of, in—

sucking wounds, 5

tension pneumofhorax. 140

thoracoabdoniinal wounds, 108

Positioning—

at decortication, 280

at intracardiac surgerv. 374
INDEX 597

Positioning—Continued

at removal of migratory foreign bodies, 393

at roentgenologie examination. In thoraeoabdominal wounds, 10S

at thorncoabdominal surgery, 124

in blast injuries. 42

in catheter aspiration, 224, 227

in diagnostic pneumoperitoneum, 341

in localization of foreign bodies, 336

in paravertebral nerve block, 221

Positive pressure anesthesia—

at decortication, 201,204

at delayed decortication, 40G

at internal pneumonolysis, 407

at removal of foreign bodies, 332

in tlioracoabdominal wounds, 113

Positive pressure oxygen, in—

blast injuries, 42

prevention of wet lung, 220-230

pulmonary edema, 102, 533

tlioracoabdominal wounds, 47

wet lung. 220-231, 525

Postatel ectatiepnenmonia, 104

Posterior mediastinotomy, 27

Posterolateral drainage, in sucking wounds,

11

Posterolateral incision, in -wounds of

trachea. 22

Posterolateral intercostal drainage, 127

Posterolateral tboracotomy, in tlioracoabdominal wounds, 117

Posterolateral transploural incision, in

wounds of esophagus, 27

Postinfluenzal empyema, 273

Post mortem examinations, 530, 534

Post mortem findings, in—

blast injuries, 38-39

cardiac contusions, 00

cardiac wounds, 52, 530

experimental blast injuries, 30-37

tlioracoabdominal wounds, 538

wet lung, 207

Postoperative abnormalities, after cardiac

surgery, 94-90

rostoperative acute gastric dilatation, 157

Postoperative atelectasis, 103

Postoperative care, improvements in, 530

Postoperative complications, of—

diaphragmatic hernia, 190

wet lung, 207

Postoperative deaths, in cardiac wounds,

97-98

Postoperative edema, of upper extremities,

40

Postoperative effusions, after removal of foreign bodies, 394

Postoperative management—

after cardiac surgery, 380

after decortication, 208-300

after lobectoniy, 410

after primary thoraeotomy, 553

after removal of foreign bodies. 320, 304,

540

after vascular surgery, 45-46

in diaphragmatic hernia, 100

in fractures of scapula, 44

in tlioracoabdominal wounds, 125-127, 139

in wounds of esophagus, 27-28

Postoperative pulmonary hernias, 197

Postoperative recurrence, of intercostal

hemorrhage, 155

Postoperative tension Pneumothorax, 14S

Postoperative wound infection, in tlioracoabdominal wounds, 117

Postpneumonic empyema, 238, 272, 273

decortication in, 300-301

Postseparation adjustments, to civilian life,

524, 527

Posttherapeutic tension pneumothorax, 14S

Postural drainage, before lobectoniy, 41S

Postural management, of—

flail chest, 16

tboracospinal wounds, 47

Postural therapy, in atelectasis, 164

Pottor-Bueky diaphragm, in cardiac wounds,

53

P-R intervals, 279

Prccordial crunch (click), 20, 53

Precordial friction rub, in cardiac wounds,

52

Precordial pain, after cardiac surgery, 95

Precordial region, experimental trauma to,

66

Prc-existent bronchiectasis, 424

Pre-existcnt respiratory infections, 213

Preoperative bronchoseopy, 532

Preoperative care, in—

surgery for foreign bodies, 329

tlioracoabdominal wounds, 139

rreoperative complications, in retained

foreign bodies, 348-349

Preoperative deaths, in cardiac wounds, 97,

98

Preoperative localization, of foreign bodies,

332
598 INDEX

Preoperative preparation—

for cardiac surgery, S9

for closure of colostomy, 128

for decortication. 2S7-2SS

for lobeetomy, 418-119

for removal of foreign bodies, 540

in tlioracoabdoniinal wounds, 111-113

in traclieobroneliial wounds, 22

Preoperative pulmonary function, in chronic

empyema, 405

Pressure symptoms, in bronchogenie cysts,

437

Pressure waves, in blast injuries, 37-38, 30,

60

Primary closure, of—

draining sinuses, of chest wall, 412-413

sucking wounds, 541

Primary decortication:

advantages of, 2S5

in infected hemoihoracic empyema, 27(5

Primary nerve tumors, of mediastinum, 437-

43S

Primary removal of foreign bodies, 544-545

Primary suture, in sucking wounds, 9

Primary thoracofomy, 525, 543, 551-553

case fatality rates in, 533

drainage aft or, 553

empyema after, 549

in European theater, 535

in hemothorax, 540

in Mediterranean theater, 530

in sucking wounds, 541

indications for, 525, 530, 532, 535, 551-553,

554

restriction of, 530

statistics of, 532, 551-553

Primary wound closure, of parietal defects,

1S3

Principles, of—

decortication, 2SS-2S9

management, of wet lung, 219

surgery, in intracardiac foreign bodies,

309-370

Priority of chest surgery, in tlioracoabdoniinal wounds, 02, 113, 114, 110, 122, 541

Prisoners of war, ease fatality rates in, 529,

533

Problems, of long-term followup studies, 443

Procaine hydrochloride:

reactions to, 221

topical application of, at cardiac surgery,

370, 379

Procaine hydrochloride block, of inferior

cervical ganglion, 40

Procaine hydrochloride injection, of—

intercostal nerves, at decortication, 297

pericardium, 48, 90

Profile position, in localization of foreign

bodies, 330

Prognosis, in cardiac tamponade, 59-00

Projection of course of missile, 154

in thoracoabdominal wounds, 10S-109

Prophylactic decortication, 315, 317

Prophylactic sulfonamide therapy, 104

Prophylaxis, of—

chronic empyema, 302-303

infection, in sucking wounds, 9

lung abscess, 175, 177

pneumonia (pneumonitis), 179

postlobectomy atelectasis, 420

wet lung, 210-217

by positive pressure oxygen, 229-230

wound disruption. 174

Protein component of diet—

after decortication, 298

before lobeetomy, 418

Protein component, of pleural fluid, 245

rrotein deficit, correction of, before decortication, 288

Pscitdonionus infection, in organizing hemothorax, 202

Psychic (psychologic) indications, for removal of retained foreign bodies, 327-328,

545

Psychoneurosis—

after separation from service, 524, 527

in blast injuries, 474

in mediastinal wounds, 4GS

Psychosomatic indications, for removal of

retained foreign bodies, 407-408

Psychotherapy, in management of residual

symptoms, 204

Psychotic manifestations, in cerebral anoxia,

210

Pulmonary arteries :

foreign bodies in, 78, 79n, 394

migration of foreign bodies into. 02, 79n,

84, 388-390. 392, 393, 539

thrombosis of, 534

wounds of. 209

Pulmonary capillaries, oxygen deprivation

of, in wet lung. 209

Pulmonary causes of death. 533
INDEX 599

Pulmonary complications, of—

head injuries, 46

wot lung, 213

Pulmonary cripples in World War I—283,

303, 313, 315, 400, 404, 507, 526

prevention of, by deeortication, 280

Pulmonary damage, in thoracoabdominal

wounds, 103, 537

Pulmonary edema, 145, 161-162, 229-230

after lobeetomy, 420

after thoracoabdominal operation, 129

as cause of death, 533

caused by overhydration, 213

in blast injuries, 32, 41

in cardiac contusions, 6S

in ecchyrnotic mask, 31

in thoracoabdominal wounds, 126, 538

in thoracospinal wounds, 47-4S

in wet lung, 32, 207, 214, 215, 229, 234

Pulmonary effects, of organizing heniothorax,25S-259

rulmonary embolism, 140

as cause of death, 534

with retained foreign bodies, 349

Pulmonary emphysema, 523

in blast injuries, 474

Pulmonary function, after delayed deeortication, 405-406

Pulmonary hematoma, in wet lung. 214, 216

Pulmonary hemorrhage, 269

in thoracoabdominal wounds, 103

Pulmonary infarction, 540

Pulmonary infection, in retained foreign

bodies, 327

Pulmonary invalidism, from wet lung, 210

Pulmonary marsupialization, 393-394

rulmonary parenchyma, infection of, in

thoracospinal wounds, 46-47

Pulmonary reexpansion, after deeortication,

28S, 2S9, 303, 300, 307, 30S, 300, 310

Pulmonary reserve, in hronchiectasis, 410

Pulmonary stabilization, after wounding,

328, 329

Pulmonary transudation, 161

Pulmonary veins, approach to heart by, 370

Pulmonary vessels :

migration of chamber foreign bodies to,

88

removal of migratory foreign bodies from,

78

Pulse—

after deeortication, 298, 306

in cardiac wounds, 53

in hemorrhage, 154

in hemothorax, 263

in myocardial contusions, 68

Pulse pressure, in right heart failure, 162

Pulsion diverticula, of esophagus, 439

Purulent pericarditis, 95

Pylorospasm, 28

Quadruple ligation, in arteriovenous fistulas,

46

Quiet heart, in cardiac tamponade, 60

Radiopaque marking, of drainage tubes, 327n

Rapido River, 502

Rales:

appearance of, after atelectasis, 164

in blast injuries, 40

in wet lung, 213, 214-215

Rationale, of—

deeortication. 279-280

in nontraumatic empyema, 300-301

lobeetomy, in hronchiectasis, 410, 417-

418, 421

Ray fungus, 431

Reactions—

from procaine hydroehloride, 221

of chest, to trauma, 208

Rebound tenderness, 109

Reconditioning, in—

oversea theaters, 399

Zone of Interior, 400

Reconstructive surgery, in /one of Interior,

399

Records:

deficiencies of, 530, 539

in thoracoabdominal wounds, 129

Rectum, perforation of, 128

Rectus incision, in thoracoabdominal

wounds, 538

Recuperative capacity, of lung, 17,177

Recurrent bronchial obstruction, in wet lung,

22S

Recurrent hronchiectasis, 417

Recurrent bronchopleural fistula, 171

Recurrent diaphragmatic hernia, 190

Recurrent empyema, after—

deeortication, 300, 303, 306, 307, 309

repair of diaphragmatic hernia, 190

secondary deeortication, 310

Recurrent laryngeal nerve, paralysis of. 542
!X

Recurrent lung abscess. ITS

Recurrent spontaneous nontuborculous pneumothorax. 432

Recurrent wound disruption, 174

Redebridement. in wound disruption. 174

Reexpansion of lung:

after decortication. 286. 410

after spontaneous nontuberculous pneumothorax, 432

by physical (herapy, 407

failure of. 532

in hemothorax. 507

Referred pain, relief of. by nerve block. 22.".

Reflex arc. interruption of. by intercostal

nerve block.210-221

Reflex bronchial spasm—

after trauma. 20!)

in vet lung". 222

of coronary vessels. 06

Reflex stimuli, in wet lung. 215

Regional anatomy, effect of, in sucking

wounds. 5

Regional distribution of pulmonary damage, in thoracoabdominal wounds. 103

Regional incidence of ecchymotic mask. 31

Regression in bronchiectasis. after penicillin

therapy. 417

Regurgitalion, in wounds of esophagus. 28

Rehabilitation, in Zone of Interior, 3'.)!). 541

Rejections, for bronehieetasis. 410

Relaxing incisions, in closure of sucking

wounds, 10

Release of adhesions—

atdeeortication. 290

in infolded lung, 1,85-1 SO

Relief of pain, in—

blast injuries, 42

compound fractures, of ribs, 11, 12

crushing injuries, 30

(horacoabdominal wounds. 112

wet lung. 210

Remedial exercises—

after decortication. 300

after lobecfomy, 418

in chronic empyema, 551

in infolded lung, 185

in fhoraeospinal wounds, 47

in uninfected organizing hemothorax, 281

Remiremont, 508

Removal of foreign bodies, 180, 240n, 543

at decortication, 282

from heart and great vessels, 40-100, 353-

305

Removal of foreign bodies—Continued

in ilxed hospitals, on followed-up casualties, 440

in hematoma of lung. 106

in sucking wounds. 10

in thoracoabdominal wounds. 137

in Zone of Interior, on followed-up casualties, 450

statistics of, 320

Renal complications, in bronehieetasis, 418

Renal failure, as cause of death. 53,4

in thoracoabdominal wounds, 140

Renal pelvis, concomitant wounds of. 541

Repair, of—

chest wall defects, techniques of, 412

diaphragm. 12.8, 53s, 540

esophagus. 28

lacerations, of lung. 402

Replacement therapy :

after decortication. 208

after thoracoabdominal surgery, 120

at operation, 113

before decort ication, 288

excess of, 213

in blast injuries, 41—12

in cardiac tamponade, 80

in thoracoabdominal wounds, 112

injudicious use of, 533

Src a'lxo special agents.

Research and Kxperiments Department,

Ministry of Home Security, 34

Resection—

for carcinoma of esophagus, 434

for intestinal wounds, IIS

for pulmonary hematoma, 520

for pulmonary lacerations, 526

for splenization, IS

of clavicle (sternum), in mediastinal

wounds, 20

of esophagus, 28

of joint, in costochondral separations, 11

of small intestines, 118

Residual empyema. after decortication. 406

Residual symptoms, 145, 202-204, 523-527

Resolution, in—

organizing hemothorax, 230, 240, 250-200,

280-287

pulmonary hematoma, 100, 400. 520

pulmonary wounds, 17

Respiration:

depression of, because of pain, 211

in hemorrhage, 154

in hemothorax. 263
INDEX 601

Respiration—Continued Retrobulbar hemorrhage, in ecchymotic

in wet lung, 207n. 213, 232 mask, 31

influence of. in thoracoabdominal wounds, Retroperitoneal contamination, as cause of

100-108 death, in thoracoabdominal wounds, 140

physiology of, 5-S Retroperitoneal drainage, 137-138

voluntary restriction of, 148, 263 Retroperitoneal hematoma, 538

Respiratory causes of death, 533 Retroperitoneal hemorrhage, 131

Respiratory crippling, in organizing hemo- Retroperitoneal infection, from missed eecal

fhorax, 240 perforation, 530

Respiratory disturbances, in— Return to duty, 204, 300, 400

blast injuries, 41 after blast injuries, 474

cardiac wounds, 52 after decortication, 303, 306, 307-308, 507

Respiratory embarrassment: after excision of tuberculoma, 426

causes of, 112 after lobectomy. 400, 424

from acute gastric dilatation, 157 after mediastinal wounds. 548

Respiratory function, in chronic empyema, after surgery, for retained foreign bodies,

237 305

Response to resuscitation, in wet lung. 207 after thoracentesis, 270

Responsibility, for cardiac fatalities, 08-90 after thoracoabdominal wounds, 476

Restlessness, in— of followed-up casualties, 450-451

blast injuries, 39 with foreign bodies in situ, 325

wet lung, 214 Revision, of thoraeotomy, 404

Restriction of respiration, as reaction to Ronchi, in wet lung. 214

pain. 112, 211 Riardo, 207

Results, of— Rib fractures, 11-16. 212, 413. 451

conservatism, in wounds of lung, 17 effect of, on cough reflex. 212

decortication, 301-303 in crushing injuries, 30

delayed decortication, 405-406 in sucking wounds, 11

early thoracentesis, 270-271 in thoracoabdominal wounds, 102

intercostal nerve block. 222-223 in wet lung, 232

lobectomy, in bronchiecfasis. 421-423 in wounds of chest wall. 3

para vertebral nerve block, 222-223 management of, at decortication, 280

removal, of foreign bodies, 340 wound disruption with, 173

rib resection drainage, in bemotbor icic Rib fragments :

empyema. 276-277 as cause of—

therapy, in wet lung. 232 broncbopleural fistula. 170

Resuscitation, 445, 525 subcutaneous emphysema. 157

failure of response to, 535 as secondary missiles, 64. 66

in wet lung, 210 cardiac wounds from. 40-50

improvements in. 530 excision of. at debridemenf. 183

in blast injuries, 41-42 in hronchopleural listulas. 171

in cardiac wounds, 52, 53, 80 role of, in infections. 240

in hemothorax, 274 Rib resection:

in myocardial contusions, 68 at decortication. 289-200

in sucking wounds. 526 avoidance of, at removal of foreign bodies,

in tension pneumothorax, 151

346 in thoracoabdominal wounds, 102, 111- 113,

130, 537

in wet lung. 207, 217, 223. 502

in osteochondritis. 540

in removal of foreign bodies, 304

thoracentesis in, 230, 267 in thoracoabdominal wounds, 125

Retraction, of— Rib resection drainage:

intercostal spaces, in organizing heino- antecedent to—

thorax. 2S1-2S2 decortication, 285

mediastinum, in infolded lung, 185 secondary decortication. 270

T4(i- <)41v—(>."> 41
602 INDEX

Rib resection drainage—Continued

in empyoina, 170, 274

in hemothoracic empyenia, 270-277

in infected hemothorax, 275, 20S

in posfdecortication empyema. 30(5

in recurrent empyenia, 308-310

in thoraeospinal wounds, 47

in unilocular basal einiiyema, 27G

in wounds of esophagus, 28

indications for, 285

Ribs :

elevation of, in cough mechanism, 241

fusion of, in empyema, 274

noninvolvement of, in hemothoracic empyema, 273

osteomyelitis of, 1 SO

simple fractures of, 11-12

use of, in plunionary herniorrhaphy, 109

Richter skin resistance technique, 203

Right heart failure. 161-1(52, 534

differentiation of. from wot lung, 246

in wet lung, 229

Right main stem bronchus :

catheter aspiration of. 227

wounds of, 23

Right-sided thoracoabdominal wounds, 424-

423, 128

complications of, 129

Rigidity of abdomen, 40.109

Rom:. Lt. Col. (I. P.. 40S

Robinson uroferal catheter. 224

Roentgenologic diagnosis, of mediastinal

wounds, 20

Roentgenologic examination—

after acute respiratory infections, 440-

447

after decortieation. 303

after lobectomy, 419

after separation from service, 022-523, 524

after thoracenfesis, 270

after thoracoabdominal surgery, 427

before decortieation, 28S

before induction, 410, 425-426, 437

for persistent symptoms, in followed-up

casualties, 203-204, 450

in actinomycosis, 432

in ateleetasis. 404

in blast: injuries. 44

in hronebiectasis, 440, 417—148

in bronchogenic cysts, 437

in bronchopleural fistula, 470. 543

in experimental blast injuries, 37

in cardiac tamponade, 02

Roentgenologic examination—Continued

in cardiac wounds, 54, 53-55. 5(5. 530

in chronic traumat ie hemothorax. 250

in compound fractures of ribs. 10

in diaphragmatic hernia, 186,191

in librothorax. 283

in hematoma of lung. 165. 160. 490

in hemothoracic empyema, 260, 270. 285

in hemothorax, 244, 203, 280

in infolded lung. 185

in lung abscess. 429

in mediastinal emphysema. 159

in mediastinal neoplasms. 430

in migratory foreign bodies, 394-392

in organizing hemothorax, 245, 250, 260,

265. 284-282

in oversea hospitals. 539

in pericardial cysts. 438

in pericardial wounds. 05

in pneumonitis (pneumonia), 179

in spinal injuries. 46

in subcutaneous emphysema, 457

in thoracoabdominal wounds, 10(5, 108, 110,

122. 138

in traeheoesophagoal wounds. 542

in tuboreuloma. 420

in tuberculosis. 424, 425

in vascular injuries. 45

in wet lung. 215-216. 223

in wounds, of—

esophagus, 26

lung. 17

in retained foreign bodies. 72. 89. 320. 327n.

332-335, 394, 545

Roentgenologic localization. of foreign

bodies, 123. 322-335, 408-409

Roentgenologic techniques, in cardiac

wounds. 53-55

Rome. Ga..491

ROSE, Jlaj. 1). L.. 203

Ross, .1. M.. 34

Rotation of heart, at operation. 91

Rupture, of—

alveoli, in blast injuries, 39

eardrums, in Idas! injuries, 41

subphrenic abscess, 430

traumatic aneurysm, of subelavian artery,

244

viscera, in crushing injuries, 30

Russo-Japanese War. 197

Sabotaged alcoholic beverages. 439

Saint L0. 357
INDEX 603

Saint-Raphael. 442

Salerno. 441, 442

Salting-out phenomenon, in hemothorax, 245

SAMSOX, Lt. Col. P. C, 18, 153. 279, 529

SAXCEK, Lt. Col. W. P., 23, 529

Satellite tuberculoma, 420

Sauerbruch grip, 91

SCADDIXG, .T. G., 310

Scapula :

fractures of, 12. 44-45, 413

in followed-up casualties, 451

osteomyelitis of, 179

Scapular region, wounds of. 108-109. 445

Scar tissue formation, about—

broneliopleural fistulas. 543

fractures. 180

Schede Ihoracoplasly, 275

SCHIFF, Capt. CA., 442

Screening, of inductees, 149, 41G

Screening techniques, in tuberculosis, 424

Secondary closure of wound, in chronic

parietal sinuses, 1S1

Secondary decortication, 308

after rib resection drainage, 277

in hemothoraeic empyeina. 276

statistics of, 310

Secondary drainage, in—

broneliopleural fistulas, 543

chronic empyema, 540, 551

lung abscess, 178

thoracoabdominal wounds, 476

Secondary hemorrhage, 244

after cardiac surgery, 93

after removal of retained foreign bodies.

349

after thoracentesis, 269

as cause of (loath, 536

from azygos vein, 530

in cardiac wounds. 92

in retained foreign bodies, 348

in wounds of liver, 119

Secondary intention, healing by. 450n

Secondary malignant neoplasms, 433

Secondary surgery, after primary thoracotomy, 553

Secondary wound closure, in chronic parietal

sinuses. 181

Secretory function, of tracheobronehial tree.

208

Sedation, in pathogenesis of wet lung. 212-

213

Soginental lobectomy, 103, 170. 324

for tuberculoma, 425-426

in pulmonary hematoma. 490

in pulmonary lacerations. 462, 526

Selection of patients, for decortication, 2S1

SELT.OKS, T. H., 248

Sensorium, dulling of, by morphine, 219

Separation from service, for—

empyema, 243

tuberculosis, 424

Sepsis, in bronchiectasis. 410

Septic embolus. after lobectomy, 420

Septicemia, 280

Sequelae, of—

combat-incurred wounds, 399-413

retained foreign bodies, 32S

vascular injuries, 45

Sequestration, in—

compound fractures of ribs, 12

traumatic osteomyelitis, 179

Sequestrectomy, in osteomyelitis of scapula.

180

Serratus anterior, 44, 290

Serum albumin, in blast injuries. 42

Serum protein determinations, in thoracoabdominal wounds, 120

Seventh U.S. Army, 101, 442, 502

SIIEFTS. Lt. Col. L. 51., 22, 44, 47, 101. 124.

154. 155, 520

Shock:

after lobectomy, 420

antecedent to hemolhoracic empyema, 274

as cause of death, 533, 530

in thoracoabdominal wounds, 140

associated with wet lung, 207

classification of, 531

clinical picture of, 216

degrees of, 531

differentiation of right heart failure from.

162

effect of thoracentesis in, 267

effect of wet lung in. 210

front, in blast injuries. 37

in blast injuries, 39, 41—12

in cardiac wounds, 53

in crashing injuries. 30

in hemothorax, 535, 541

in pericardial wounds, 96

in sucking wounds. 9

in thoracoabdominal wounds, 108. 112. 122.

525, 537, 538, 539

in wet lung. 214, 219. 222, 229-230
m INDEX

Shock—Continued

incidence of, 531

pulmonary edema in. 21(!

relation of. to lower neiiliron nephrosis,

534

Shortages, of—

anesthetic equipment, 113

thoracic surgeons, in Pacific Ocean areas,

400

whole blood, 531

Shoulder girdle, fractures of, 44-45

Shoulder, immobilization of, in fractures of

scapula, 12

Shoulder pain, in thoracoabdominal wounds,

109

Sicilian campaign, 441

Sicily, 520. 531

Sigmoid, wounds of, 123

Signs. »SVf Clinical picture.

Silent resonant chest, 151

Silk sutures. ISO

in repair of diaphragm, ISO, 100

Simple fractures, of libs, 11-12

Simple homothorax, management of, 207-

271

Sinus formation, in infections of liver, US

Sinus of Yalsalva.3SS

Sinus tracts, management of, at decorfication, 295

Sinus (es), of chest wall. 145. 1S0-1S1, 400,

401.412-413,507.540

in World War I. 507

Sinusitis, associated with bronchiectasis,

41S

Site of entry of missile, in thoracoabdominal wounds. 102.103

Size (shape), as indication for removal of—

retained foreign bodies, 320. 320. 34S. 3S0,

305, 407. 40S. 545

infracardiac foreign bodies, 300-307

Size of wound :

as indication for forward thoraeotomy, 440

effect of, on sucking. 5

Skin, in repair of chest wall defects. 412

Skin resistance tests. 203

Skull fracture. 530

Small intestine:

evisceration of. 530

herniation of. into chest, 103

incidence of wounds of. 541

wounds of. 103. 110. US, 537

SXTDEK. Col. H. E., 113

SNYDKU. Lt. Col. J. H., 32.103

Soft tissues, wounds of, 533

Solid viscus (era), wounds of. 100,130

Somafovisceral reflex, in wet lung, 207-20S

South African War, 197

Southern France, landings in, 173, 442, 529

Spasm, of—

bronchioles, in blast injuries, 42

intercostal muscles, in blast injuries, 39

Special investigations, of forward surgery.

441-442

Spinal cord, wounds of. 140. 105, 533

Spinal injuries, 40-4S

Spine, fractures of. in followed-up casualties. 451

Spleen :

exploration of. 52S

herniation of. into chest. 103

incidence of wounds of. 541

wounds of. 103. 10S, 100, 115. US. 122,

130. 137, 537

Splenectomy. US, 123. 125. 127. 130. 53S

Splenic flexure, wounds of. 115. 110. 127-12S,

135

Splenization. IS

Splenomegaly. 534

Split-thickness skin grafts, in—

draining sinuses of chest wall. 413

repair of chest wall defects. 412

Spontaneous nontuberculous pneumothorax,

432

Spontaneous pneumothorax. 402

Spontaneous pulmonary hernia. 107

Spontaneous resorption in organizing hemothorax, 250

Spot films, in localization of foreign bodies.

330

Spur colostomy, 123

Sputum, in—

bronchiectasis. 417, 41S, 421

lung' abscess, 429

wet lung. 213-215

St. Louis. 443

Stab wound (s), 531

as cause of diaphragmatic hernia. 101

drainage in wounds of kidney. 53S

for exteriorization of colon. 53S

of heart. 40, S4-85

pulmonary hernia after, 107

Staged surgery, in chronic hemothorax. 275

Staphylococcic infection—

associated with actinomycosis. 431

in organizing hemothorax. 201. 202
INDEX 605

Staphyloeoeeie postpneumonic empyema. 430

Xtaitlnjlococciix aurciix empyeina. 313. 322

Stasis, in eeehymotic mask. 31

Stafen Island. 402

Statistics, 520-554

2d Auxiliary Surgical Group. 442-443, 529-

534

5tli Auxiliary Surgical Group, 534-539

actinomyeosis. 431

anatomic location of retained foreign

bodies, 353-355

aspiration in hemotliorax. 271

autotransfusion, 532

bacteriology of organizing hemotliorax.

201-262

blast injuries, 32-33, 41

blood replacement, 531-532

broncbiectasis, 415-424

bronebogenie cysts. 437

bronchopleural fistulas. 171

bronclioseopy in tlioracoabdominal

wounds, 125

bronchospirometry in broncbiectasis. 421

carcinoma of—

esopbagus, 434-436

lung. 433

cardiac deaths, 534

cardiac lacerations, 69-70

cardiac tamponade, 59, 60, 61

cardiac wounds, 52, 94-99, 536

causes of death, 2d Auxiliary Surgical

Group, 533-534

chronology of deaths, 534

closfridial myositis, 534

complications of—

hepatic wounds, 129

tlioracoabdominal wounds. 129, 538

concomitant wounds, 533

contusions of heart, 65-67

deaths from blast injuries. 534

deaths in lixed hospitals. 527

debridement. 532, 533

decortication, 306-311

delayed decortication, 405-406

diaphragmatic hernia, 186-196

drainage in tlioracoabdominal wounds,

121

eccbymotic mask. 31, 32

empyema, 241-243, 549-551

followup studies, long term. 441-527

Statistics—Continued

foreign bodies, 327, 393-395, 407-408, 513,

544

in (aliout) great vessels, 380

in (about) heart, 94

in Mediterranean theater, 348-351

hemorrhage, 153-154, 536

as cause of death, 534

hemothoracic empyema. 240

hemotliorax, 239, 507. 536, 546-549

hernia of lung. 197

incision in tlioracoabdominal wounds. 537-

53S

infected hemotliorax. 207-308

initial wound surgery in forward hospitals, 535

intercostal nerve block, 532

intra-abdominal wounds, 110-111

intravenous migration of foreign bodies.

390-391

Kennedy General Hospital Thoracic Surgery Center. 539-554

lobectomy for—

broncbiectasis, 418. 419

pulmonary tuberculosis, 425

location of wounds, 531, 535

lung abscess, 175-177

malignant neoplasms, 433

mediastinal neoplasms, 436-438

mediastinal wounds, in f'ollowed-up casualties, 468

mediastinitis. 534

migratory foreign bodies, 78, 3S0-3S1, 388-

391, 392

myocardial contusions. 66-67, 68

negative explorations, 110-111

neurogenic tumors of mediastinum, 437-

438

organizing hemotliorax. 240. 307-308, 401

penetrating (perforating) cardiac wounds,

71-72

penetrating wounds, 534-535

perforating wounds. 534-535

pericardial wounds, 04-65

plasma replacement. 531-532

pneumonectomy for tuberculosis, 425

post mortem examinations. 534

postseparafion diseases, 524—525

postseparation followup. 522-525

preoperative bronclioseopy. 532

primary thoracotomy. 532, 533, 551-553

pulmonary complications, 165

pulmonary embolism, 534
606 INDEX

Statistics—Continued

pulmonary resection. 18-19

removal of foreign bodies, 329

replacement therapy—

at operation, 114

in thoracoabdominal wounds, 112

secondary decortication, 310

secondary hemorrhage, 214

shock, 531, 533

in thoracoabdominal wounds, 112

spinal injuries, 46

spontaneous nontuberculons Pneumothorax, 432

sucking wounds, 535

tension pneumothorax, 148, 532

thoracentesis, 532

thoracoabdominal wounds, 21. 101, 102,

117, 130-141, 534, 537-539. 541-542

time of death, in cardiac wounds, 97-98

timelag. 532, 535

wet lung, 502

wound disruption, 173-174

wounding agents, 531-535

wounds of—

chest wall, 451

esophagus, 24

great vessels, 85

heart. 49-50

lung. 18-19

Sec alto Incidence; Deaths; Case fatality

rates ; Mortality, etc.

Status of casualties, returned to Zone of Interior. 399-400, 404-405

STKAD, E. A., Jr., SO

Steering wheel injuries, of chest. 65

Stem bronchus, catheterization of, 227

Steps, of decortication, 291-294

Stereoscopy,332

Sternoclavicular disartieulation. 155

Sternoclavieular injuries, 12

Sternum:

division of, in—

cardiac surgery, 90

removal of migratory foreign bodies. 392

fractures of. 30. 212. 451, 540

resection of, in mediastinal wounds, 20

Stethoscopic findings, in wet lung, 214—215

Stomach:

evisceration of, 539

herniation of, into chest, 180,191,193

incarceration of, in diaphragmatic hernia,

193

Stomach—Continued

incidence of wounds of, 541

perforation of, 112

wounds of, 20, 103. 108. 115. 118, 123. 149,

537

Strain, as precipitating cause of diaphragmatic hernia. 191

Strapping, in —

rib fractures, 11,12

thoraeospinal wounds, 47

wet lung. 219

STHAI s. R., 380, 391. 3!)2

St reptococcic infection—

associated with actinomyeosis, 431

in organizing hemothorax, 261, 262

St reptococcic postpneumonic empyema. 430

Streptomycin, in actinomyeosis, 432

Stricture, of esophagus, 439, 542

Subphrenic abscess. US. 122. 540. 542

after thoracoabdominal operation, 129

in hepatic lacerations, 129

in thoracoabdominal wounds. 129, 130-131

Subphrenic space :

drainage of, 542

foreign bodies in, 394

infection of, 123

Subscapular abscess. 44

Subscapular damage, in compound fractures

of ribs. 16

Subscapular fractures. 44

Subscapularis. use of. in wound closure. Is3

Substernal pain, in wounds of esophagus, 25

Sucking wounds. 5-11. 112. 123. 234, 269. 326.

445, 513. 526, 530. 540

after wound disruption, 174

as indication for primary thoracotomy,

535,554

associated with thoracoabdominal wounds,

537

closure of, 112.174, 526

debridement of, 9, 10, 52. 535, 541

differential diagnosis of. 22

differentiation of, from wounds of esophagus. 25

emergency occlusion of. 0-10,174

hemothorax in, 401, 546

in followed-up casualties, 451

management of. 9-11, 541

nomenclature of, 5

of diaphragm, 116,136

pathophysiology of, 5-8

priority of management of, 541
INDEX 607

Sucking wounds—Continued

tension pneumothorax in, 14S

wet lung in, 217

wound disruption in, 173

wounding agents in, 535

Suction wave, in blast injuries, 38

Suicide, attempts at, 43!)

Sulfadiazine. in—

actinomycosis, 432

pneumonia, 171)

Suli'onamide therapy, 241, 412

after thoraeoabdominal surgery. 12<i

in actinomycosis, 431

in blast injuries, 42

in decortication. 307

in hemothoraeie einpyema. 310

in organizing hemothorax, 247

in pneumonia, 42S. 429

in prophylaxis of pneumonitis (pneumonia), 104, 170

in sucking wounds, 11

Superior vena cava :

exposure of, 375

laceration of, 85, 153

obstruction of, 20

Suppression of cough reflex, in wet lung, 217

Suppuration, in—

massive pulmonary gangrene, 178

organizing hemothorax, 250, 202-263

Suppurative pericarditis, 540

Suppurative pleuritis, in organizing hemothorax, 247, 203

Supraelavicular area, wounds of, 413

Suprasternal incision, in mediastinal emphysema. 20

Surgery Branch, Office of The Surgeon General, 400

Surgery:

in mediastinal emphysema, 150

timing of, in blast injuries, 42

Surgical approach, in—

thoracoabdominal wounds, 114-110, 537-

538

wounds of esophagus, 345

Surgical Consultants Division, Office of The

Surgeon General. 400, 407

Surgical risk—

in bronchiectasis. 421

in cardiac contusions, 08

in cardiac wounds, 08

in concomitant wounds, 533

Surgical risk—Cent inued

in empyema, 274-275

in World War I, 274

in mediastinal tumors, 43S-430

in myocardial contusions. 07

in pneumonectomy for tuberculosis, 435

in primary decortication, 270

in removal of parietal pleura, 280

in wet. lung. 207

of decortication, 287

of lobectomy for—

bronchiectasis, 420

lung abscess, 429

Surgical teams, 2d Auxiliary Surgical

Group, 520

Suture material, as cause of chronic parietal

sinuses. 180

Suture of lung, in sucking wounds. 10

Suture of wounds—

of lung, 17-18

in closure of diaghragm, 120, 180-180, 190,

542n

in pulmonary herniorrhaphy, 109

Suture techniques, in—

cardiac surgery, 91-93

draining sinuses of chest wall. 412-413

intracardiac surgery, 372-373, 374

SWAIX. E. H., 34

SWEKT. R. H., 2S

Sympathetic nerves, transmission of afferent

impulses by, 219

Sympathicoblasf oma, of mediastinum, 437

Symphysis, between—

costophrenic pulmonary fringe and diaphragmatic pleura, 184

costophrenic pulmonary fringe and mediastinum, 184

diaphragmatic surfaces and visceral

pleura, 207

pleura and peel in organizing hemothorax,

240, 258-250, 2S7

Symptom-free retained foreign bodies. 325

Symptoms—

after separation from service, 145. 202-

204,522-527

of pulmonary hernia, control of, 19S

See also Clinical picture.

Synpneumonic empyema, 28Gn

in World War I, 275n

Systolic murmurs, in cardiac wounds, 52

Systolic pressure, in myocardial contusions,

OS
«ÖS INDEX

Tachycardia, in— Technique (s)—Continued

cardiac contusions, 00 of hemostasis, 155

cardiac wounds. 52, 53 of intercostal catheter drainage, in bronintraeardiac foreign bodies. 350 choploural fistulas, 170

wot lung. 210 of intercostal nerve block, 211-222

Tacoma. 510 <if internal pneumonolysis, 407

Tacticle fremitus. in—

infolded lung. IS;"»

wef lung. 214

Tangential wound ( s), 04. 145

of lobectomy, 410

of localization, of foreign bodies. 332-340

of paravertebral nerve block. 221-222

of partial decortication. in World War I—

274

of pericardial repair. 05

of positive pressure oxygen therapy, 220

of pulmonary herniorrhaphy. 100

of pulmonary suture. 17

of removal, of—

in Hauchest. 10

Tantalum i>late(s), in—

cliest wall defects. 412

pulmonary hernia. 100

Ti: MED (War Department Technical Kulletin) —

No. 00. 22 July 1044—420-430

Xo. 147. .March 1045—85

foreign bodies, 340-34S

infracardiac foreign bodies, 370-375

mediastinal tumors, 43S

Technique! s) — migratory foreign bodies, 302-303

in left-sided fhoracoabdoniinal wounds. of repair, of—

124-125 chest wall defects. 412

in fhoracoabdoniinal wounds. 114-110. diaphragmatic hernia. 100

117-121 draining sinuses of chest wall, 412-413

of angiocardiography. 40S-400 of roentgenologic examination, in—

of aspiration, in pericardinl wounds, 04 foreign bodies. 332-335

of Herman localization, of retaiiu d foreign wet lung. 215

bodies. 40S of rotation of heart, at operation. 01

of bronchoscopic aspiration. 220 of surgery—

of carbon dioxide inhalation, 232 for empyema. in World War I—274

of cardiac surgery. SO-03 for parietal defects. 183

of catheter aspiration, in wet lung. 224— in chronic parietal sinuses. 1S0-1S1.

227 of thoracentesis, 200-270

of closure, of— of trachea 1 repair. 22

chest wall. 204 of wedge resection, 18

diaphragm. 110-120 8Vr (lino Incisions : Management.

sucking wounds. 10-11 Temperature—

wounds after disruption, 174 after decortication. 20S. 300

of colostomy, 12S

of decortication. 280-208. 540

of delayed decortication. 400

in atelecfasis, 104

in hematoma of lung. 100

in heniofhoraeie empyema, 200, 270, 283,

of diagnost ic pneumoperitoneum. 344 2SS

of drainage— in infected organizing hemothorax, 282

after decortication, 20S

in bile empyema. 120-130

in organizing hemothorax. 247

in wet lung, 214

in subphrenic abscess. 130 Tenderness in abdomen, in chest wounds. 100

in thoracoabdominal wounds, 1 20-121 Tension, effect of closure under, 11

in wounds, of liver, 110. 122-123 Tension pneumothorax, 145-152, 150, 532,

of esophageal repair, 27 530. 540

of exploratory thoracotomy. 402 after occlusion of sucking wounds. !.), 11,

of extra pleura 1 approach, in thoraeoab- 541

dominal wounds. 122 as cause of death, 534
INDEX 609

Tension pneuniot borax—Continued

as indication for primary tiioraeotomy,

0.35, 554

association of, with subcutaneous emphysema, 157

in bronchopieural fistulas, 140, 170, 171

in lacerations of lung, 462

in mediastinal wounds, 20

in thoracoabdominal wounds, 542

in wet lung, 217. 220-2.30

in wounds, of major bronchi, 21

incidence of, 148-149, 532

management of. 20, 151-155

of peritoneal origin, 103-10(5

pathogenesis of, 149

priority of management of, 541

Teratoid tumors, of mediastinum, 437

Teratoma, of mediastinum, 430, 437-43S, 4.39

Terrain, in—

Mediterranean theater, 442

Pacific Ocean areas, 399

Testing of diaphragm, 522

Theater holding policies, 400

Therapy, complications of, 541

Thickening of pleura, absence of, in—

early organizing hemothorax, 250-251

infected hemothorax, 250

Thoracentesis, 2G1. 203, 327. 507, 5.32, 536,

540, 553. 554

after operation, 554

after primary tiioraeotomy. 553

after thoracoabdominal surgery, 127

clotting of blood after, 239

hemorrhage after, 5.35

in bronchopieural fistulas, 170

in chronic hemothorax, 23S

in diagnosis of hematoma of lung, 166

in evacuation hospitals, 117

in field hospitals. 2.39

in hemothorax, 239, 549

in infected hemothorax. 275

in infolded lung, 185

in posfpneumonie empyema, 430-431

in resuscitation, 267

in thoracoabdominal wounds, 120, 122

in thoracospinal wounds, 47

in tracheobronchial wounds, 22

in uninfected organizing hemothorax, 281

inadequate use of, 240

indications for, 267

prevention of empyema by, 241

quantitative aspects of, 269

Thoracentesis—Continued

results of, 270-271

technique of, 269-270

wound disruption after omission of, 173

iS're (I'IKO Aspiration.

Thoracic aorta, foreign bodies in, 354

Thoracic approach, in thoracoabdominal

wounds, 114

Thoracic component, of thoracoabdominal

wounds, 139

management of, 117

Thoracic ducts, wounds of, 103, 525

Thoracic surgeons:

assignments of. 102, 400

shortages of, in Pacific Ocean areas, 400

Thoracic surgery, development of. between

World Wars, 392

Thoracic surgery centers:

at Kennedy General Hospital. 189

chronic empyema in, 430

deaths in.530

decortication in, 2,87

foreign bodies in, 348

in Mediterranean theater, 399. 441, 449

in United Kingdom Base, 399

lung abscesses in, 429

management of—

intracardiac foreign bodies in. 88

postpneumonie empyema in. 301

removal of migratory foreign bodies in,

88

surgery for tuberculosis in, 424-425

Thoracic Surgical Team Xo. 4. 2d Auxiliary

Surgical Group, 442. 446

Thoracic surgical teams, of 2d Auxiliary

Surgical Group, 529

Thoracic symptoms, in thoracoabdominal

wounds, 109

Thoracoabdominal woundl.s). 101-141. 525.

520, 529n, 534, 540

acute gastric dilatation in, 157

anatomic considerations in, 139

anesthesia in. 113-114

as indication for forward surgery. 102

associated with—

cardiac wounds, 97, 98, 99

myocardial contusions, 68

wounds of auricle, 89

blast injuries in, 33

cardiac contusions in. 68

cardiac injuries in, 50. 52

case fatality rates in. 138-139. 529, 537

complications of, 128, 129-133. 5.38
INDEX

Thoracoabdominal wound (s)—Continued

concomitant wounds with, 140-141

definition of, 101

diagnosis of, 106-110

disruption of chest wounds in. 173

drainage in, 120-121

empyema in, 242-243

exploration in, 110-111

factors of mortality in, 138-141

following studies in, 445, 440, 451, 470-490

incidence of, 101

infectious pulmonary complications with,

170

influence of respiration in, 10G-10S

in Zone of Interior hospitals, 541-542

lethality of, 101, 102

management of, 101-102.106

mortality of, in foil owed-up casualties,

450

nomenclature of, 101

pathologic process in, 102-106

postoperative management of, 125-127

preoperative preparation in, 111-113

priority of surgery in, 62

resuscitation in, 111-113

statistics of, 21, 101, 102, 117, 136-141, 534,

537-539

surgical approach in, 114-116

technique in, 114-116,117-121

tension Pneumothorax in, 14S

time of death in, 140

transthoracic approach in, 137-138

wet lung with, 211. 216

See a'ho special organs.

Thoracolaparotomy, 117

wet lung after, 502

Thoraeoplasfy, 44, 406. 407

in chronic empyema, 551

Thoracospinal wounds, 46-48

Xhoracotomy:

bronehoscopy before, 228-229

for removal of clot in hemothorax, 278

hemorrhage as indication for, 269

in bronchopleural fistula. 171

in clotted hemothorax. 239

in compound fractures of ribs, 16

in forward hospitals, foreign bodies as

indications for, 32S

in thoracoabdominal wounds, 116-117, 537-

538

intercoastal nerve block at, 222, 223

on unnecessary indications, 313

revision of, 404

Sec also special types.

Thrombophlebitis, after removal of retained

foreign bodies, 349

Thromboplastin, 24S

Thrombosis—

after cardiac surgery, 91-92. 93

as cause of death in intracardiac foreign

bodies, 356

in cardiac contusions, 66

in cardiac wounds. 63

of coronary artery, 6S, 9S

of pulmonary artery, 534

Thrombus, in heart, 378

Through-and-through wounds, of heart, 93

Thyoma. of mediastinum. 436, 438

Thyroid adenoma, 438

Tidal aii-:

relation of. to vital capacity. 5

requirements, 8

Tidal respiration, decrease of. as response to

pain, 211

Timelag. 111-112,113, 532. 535

effect of, on wound infection. 451

in deeorlieation, 309

in mountain fighting, 213

in Pacific Ocean areas, 400

in secondary decortication. 285. 310

in thoracoabdominal wounds, 137

Timing, of—

aspiration, in wet lung, 223

closure, of colostomy, 128

decortication. 129. 249-251. 259-260. 280-

287, 309. 315. 317, 322, 400-107, 549

drainage, in empyema, 549-551

removal, of—

drains, after thoracoabdominal surgery,

127

intracardiac foreign bodies. 72. 326. 328-

332, 349-351

secondary decortication, 310

surgery—

in blast injuries. 42

in cardiac contusions. 68

in cardiac wounds, 67, 72, 88-89

in myocardial contusions. OS

in fhoraeoabdoniinal wounds, 102, Hill 2, 113, 122

overseas, 507

Tissue necrosis, in hemothorax, 273

Topical anesthesia, in bronehoscopic aspiration. 229

Total empyema, 273

after open thoracotomy, 551
INDEX Gil

Total gastrectomy, 434

Total pulmonary atelectasis, 105

Tourniquet, use of, in right heart failure, 302

Toxieity, in—

liemothoraeic empyoma, 200, 2T4. 283. 285

infected organizing hemothorax, 282

Trachea:

attachment of bronchogenic cysts to, 437

carbon dioxide in air from, in sucking

wounds, 8

malignant neoplasms of, 433

wounds of, 10. 20. 21-24. 145, 408, 525, 534,

540, 542

Tracheal deviation, in atelectasis. 104

Tracheal obstruction, as cause of death, 533

Tracheal rattle, in wet lung. 214

Traeheobronchial aspiration, 313, 125, 104,

228, 400, 532. 533

in thoraeospinal wounds, 47

Traeheobronchial obstruction. Sec Wet

lung.

Traeheobronchial suction, in wound disruption, 174

Traeheobronchial tree, involuntary evacuation of, 208-200

Traeheobronchial wounds, management of,

22

Tracheobronchitis. 105

after untreated wet lung. 210

Tracheoesophageal fistula, 28

Tracheoesophageal wounds, 542

Tracheotomy, in—

flail chest, 10

mediastiii.il emphysema, 150

tension pneumothorax, 140

tracheoesophageal wounds. 542

Traction diverticula of esophagus, 430

Traction :

effect of, in wounds of chest, 45

in flail chest. 10

Traction management of fractures, after decortication, 300, 300

Traffic accidents, 11, 101

Transdiaphragmatic approach, in thoracoabdominal wounds, 114-110. 121-122, 123-

125

Transfusion. Sec Blood replacement.

Transpleural pneumonotomy, 303-304

removal of foreign bodies in, 304

technique of cardiac surgery in, 00

Transportability:

after primary thoracotomy, 553

clarification of, 530

in compound fractures of ribs, 12

in sucking wounds, 0

in thoraeoabdominal wounds. 101-102, 111,

113, 440

in wet lung, 501-502

Transportation, closed intercostal drainage

during, 404

Transthoracic approach, 135. 130

in diaphragmatic hernia, 100

in thoraeoabdominal wounds, 123-124,

137-138, 537-53S, 541-542

Transudates :

excessive production of, after wounding,

200

in organizing hemothorax, 247

in wet lung. 200, 215, 227. 220

in wounds of chest wall, 3—1

Transverse colectomy, 434

Transverse colon, wounds of, 110

Trauma :

as cause of atelectasis. 103

effect of degree of, in organizing hemothorax, 246

Traumatic amputation (s). 43, 141. 533

Traumatic aneurysm. of subclavian artery,

244

Traumatic colostomy, 131-132

Traumatic osteomyelitis, 145, 170-180

in Zone of Interior, 401

Traumatic pleuritis, 3—1

Traumatic pulmonary hernia, 107-202

Traumatic thoracotomy, 181-183, 445-440.

525, 532

exploration through, in thoraeoabdominal

wounds, 110

in followed-up casualties, 445^140

in mediastinal wounds, 408

in sucking wounds, 10, 520

in thoraeoabdominal wounds. 110-117, 121

in wounds, of major bronchi, 21

removal of foreign bodies through, 513

Treitz, ligament of, 123

Triage:

improvements in, 530

of sucking wounds, in clearing stations, 0

Triangular ligament. 125

TKIBRY. Capt. W. W.. 32. 38. 50

Tricuspid valve, wounds of, 530

TEOPEA, Maj. F. Jr., 32,103

Tuberculomas, 425-420, 438
m INDEX

Tuberculosis. 424-4-!*

after ateleetasis, 165

after combat wounds, 165n

after separation from service, 524

complicating combat-incurred wounds,

420-428

pbrenieeetomy for, 537

Pneumothorax in, 341

Tuberculous enipyema, decorfication in, 301

Tunisian campaign. r>2!), 530

Tuiixrcii. (J. (.}., 360

Ti-rn.K. Maj. YV M.. 306-307

Tympanum, perforation of, in blast injuries.

473. 526

Fleer, of esophagus. 43!)

Unhealed wounds, management of, at decortication. 2S0

Uninfected organizing hemothorax, as indication for deeortication. 2S1-2S2

United Kingdom Rase, 155

I'nited States. Xcc Zone of Interior.

Vnunited fractures, as cause of chronic parietal sinuses. ISO

Upper respiratory infections, antecedent to—

atelectasis. 163

wounding, 533

1'iiisAX. .7. A..43S

Urinalysis. in—

diagnoslie routine, 10!)

low thoracic wounds, 541

Vagal irritation, in wounds of esophagus, 28

Vagosympathetic imbalance, 66

Yagovagal reflex. 126, 534

as cause of death, in thoracoabdominal

wounds, 140

Valley Forge General Hospital. 475

Vancouver. 405

Varices. of esophagus. 430

Vascular occlusion, by migratory foreign

bodies, 302

Vascular wound fs), 45-46, 85

World Wars, 302

Vascular wound (s), 45-46, S5

associated with abdominal wounds. 537-

53S

effects of. in wet lung. 211

fistula formation after, 277

V-E Day, 442

Velocity of shock front, in blast injuries, 37

Vena cava :

foreign bodies adjacent to, 304

migration of foreign bodies in, 391

mural thrombi in, SO

wounds of, 137, 534

Venafro, 474

Venesection, in—

blast injuries, 41

right heart failure. 162

Venous pressure, in—

cardiac tamponade, 50-60

pericardial wounds. 65

Ventricle(s) :

control of hemorrhage from. 92-03

contusion of, 66-67, 68, 69-70

exposure in wounds of, 90

foreign bodies embolic to. 388—389

foreign bodies in, 88. 353. 354

lacerations of, 69-70

migration of foreign bodies to, 300-301,

393

removal of foreign bodies from. 370-373

stab wounds of. 84-85

wounds of. 58. 71-72. 9S-00, 536

Ventricular failure, in cardiac tamponade,

63

Ventricular fibrillation, 378-370

Ventricular tachycardia. 378-370

Vertebrae, fractures of. 46

Vertebral column, foreign bodies in, 304

Veterans' Administration, 101. 327n, 424,

443. 507. 524. 527

Veterans' Administration Regional Office,

Los Angeles, 443

Violet (de Lyon), 2S6

Viscera, rupture of. in crushing injuries. 30

Visceral pleura :

in organizing hemothorax. 250-251, 256,

258

management of. at—

deeortication. 297

delayed deeortication, 40G

removal of peel from, 2SS

Visual-radiopaque localization, of retained

foreign bodies, 408

Vital capacity—

after chest wounds, 203

in flail chest, 12

in sucking wounds, 5-8

Vitamin C content, of blood, 41S
INDEX 613

l.Ti

Vitamin therapy—

after tlioracoabdominal surgery, 120

before lobectomy, 418

in chronic empyema, 551

Vittel. 480, 40:-!

Yosges Mountains. 442

Yomitus. aspiration of. 534

Vulnerability of abdominal viscera, 537

Walter Reed General Hospital, 197, 109, 202,

204, 400. 401, 405. 407, 408, 410, 424, 428,

432, 405, 499. 523

Wandering pacemaker, 379

Wangensteen decompression, 13:

WAXOF.XSTEF.N, O.. 117n

WAIUUJKG. K., 06

WAHREN, .T. V.. 89

WARREN. Al. F., 101. 209

Washington, D.C.. 405, 400

Water-seal decompression, in—

tension pneumothorax, 151, 530

traeheobronchial wounds, 22

Water-seal drainage—

after deeortieation. 303

after lobectomy. 419

after primary thoracotomy, 549, 553, 554

after removal of foreign bodies, 347

in bronchopleural fistulas, 170,171

in clotted hemothorax, 239, 205

in diaphragmatic hernia, ]96

in hemothorax. 239

in postdecorficafion empyema, 300

in sucking wounds. 11, 541

in tlioracoabdominal wounds, 120-121

in wounds of—

esophagus, 28

liver. 122

,S7r «/.so Closed drainage.

WATSON. W. L., 438

Wedge resection of lung. 18. 280. 347. 52

for tuherculoma, 420

Wet lung. 207-230. 328. 513, 525

after tlioracoabdominal surgery, 125, 120

antecedent to—

acute massive atelectasis, 210-211

atelectasis, 103

pneumonitis (pneumonia), 179

as cause of death, 533

atrophine administration in, 231

bronchoscopic aspiration in, 227-229

carbon dioxide inhalations in, 232

case fatality rates in, 232

catheter aspiration in, 223-227

AVef lung—Continued

chest pain in, 232

clinical picture of, 213-215

concept of, 207-208, 501

diagnosis of, 215-210

differential diagnosis of, 210

effect of—

anesthesia on. 212-213

sedation on. 212-213

etiology of, 211-213

followup studies on, 501-506

improvements in care of, 530

in atelectasis, 104-105

in cardiac contusion, 68

in compound fractures of ribs, 12

in contusion of chest wall. 4

In crushing injuries, 30

in pulmonary hematoma, 496

in tlioracoabdominal wounds, 109.112. 53S

in wounds of chest wall. 3

incidence of. 211. 501. 502

intercostal nerve block in. 115-110

management of. 179, 217-232. 501-502, 532

nomenclature of, 208

pathogenesis of, 20S-211

pathophysiology of, 208-211, 217

pulmonary edema in, 32

role of. in hemothorax, 248-249

wound disruption in, 173

White clot, in organizing hemothorax. 248.

249. 253, 255

Wire sutures, 180, 183

Wiring of fractures, of clavicle, 11

WOOD, P., 04

World War I:

atelectasis in, 208

chest cripples in, 283, 303. 313, 315, 400,

404, 507, 524

chest wall defects in. 412

chronic empyema in, 240, 301

concept of splenization in, 18

ecchymotic mask in. 31

empyema in, 273-275, 275n, 280-281

incidence of retained foreign bodies after,

325

infectious pulmonary complications in, 178

investigation of empyema in, 280

laparotomy incision in, 117

management of empyema in, 274

massive atelectasis in, 502

migratory foreign bodies in. 7Sn

pulmonary hernia in, 197

pulmonary tuberculosis in, 424
614: INDEX

World War I—Continued

sequelae of chest wounds in, 525

status of soldiers in, 149

studies of sucking wounds in. 5-S

traumatic osteomyelitis in, 179

wound infection in, 412

wounds of heart in, 49, 53

Wound closure, after—

decortication, 29S

removal of foreign bodies, 347

Wound disruption, 145,173-174

after thoraeoabdominal operation,

538

in wounds of liver, 119

management of, 174

Wound infection:

after decortication, 300, 307

after removal of foreign bodies, 349

followup studies on, 451

in thoraeoabdominal wounds, 538

in wounds of colon, 115

incidence of, 412

prevention of, by penicillin, 284

with acid-fast bacilli, 427-428

Wound(s) :

classification of, 3-48

of abdomen, 141,105, 529, 533

of aorta, 534

of brachial plexus, 46, 413

of brain, 140

of bronchus, 149, 532

of cardiac chambers, 71-72

of cecum, 539

of chest wall, 3-4, 23S, 329

of colon. 103, 110, 118, 123, 53S, 541

of coronary artery. 536

of costal cartilages, 412

of descending colon. 110, 127-12S

of diaphragm, 101-141, 140. 293

followup studies on, 446

of duodenum. 121. 123. 538

of entry, in Ihoracoabdominal wounds

of esophagogastric junction, 125

of esophagus, 103 149. 525, 526, 532,

540. 542

of gallbladder. 103. 121

of great vessels, 525, 532

of head. 103, 573

of heart (pericardium). 20, 49-100,

353-305, 525, 532. 534, 540

of hepatic flexure, 123

of hollow viscera. 109. 115, 130. 140

of ileum. 123

Wound ( s)—Continued

of inferior vena cava, 530

of innominate artery, 244

of internal mammary vessels, 244

of kidney, 103. 109, 115, 118. 121. 137, 541

of larynx, 145

of liver, 103, 109. 115, 121-123, 128, 137,

538. 539. 541

of lung. 243-244, 248

of mediastinum, 139, 140, 525, 526. 532

followup studies on, 408-473

129, of myocardium. 04, 05, 97

of pancreas, 118, 538

of portal vein. 137

of pulmonary artery, 269

of sigmoid. 123

of small intestine. 103. 110,11,8, 537, 541

of soft tissues, 533

of solid viscera. 109. 130

of spinal cord, 140, 165, 533

of spleen. 103, 108, 109, 115. 118, 122, 130.

137, 541

of splenic flexure. 115

of stomach, 20. 103, 108, 115, 118, 123, 149,

537

of subclavian artery, 244

of thoracic duct. 103, 525

of trachea. 145, 525. 534, 540. 542

of vena cava, .137, 534

of ventricles, 97

Sec also specific varieties and areas.

Wounding agents, 240. 325-320. 401. 531. 535.

530

effects of, in wet lung, 211

in blast injuries, 33

in cardiac wounds, 40-50, 58

in defects of chest wall. 181.

in diaphragmatic hernia. 191

in followup studies. 445

in hemothorax. 273

in migratory foreign bodies, 381

537 in tension pneuniothorax. 149

in thoraeoabdominal wounds, 136, 537-538

534. pressure effect of, in atelectasis, 163

role of, in organizing hemothorax, 246

Wroughton. 383

WYLKV, Maj. R. H., 22

244. Yugoslavia, 241

Zone of Interior, 85, 130

absence of wet lung in. 502

cardiac surgery in.S8-S0
INDEX 615

Zone of Interior—Continued

chronic parietal sinuses in, ISO

closure of eolostomy in, 128

deeortication in, 2S7, 54!)

deferred lobectomy in, 10

diaphragmatic hernia in, ISO, 180-190

disposition in, 400

enipyema in, 242, 551

evacuation to, after—

deeortication, 30G, 308, 300

rib resection drainage, 308

evaluation of oversea surgery in, 539-554

foreign bodies in, 78, 88, 513, 543-540

liemothoraeie enipyema in, 507

Zone of Interior—Continued

hemotliorax in, 540

lung abscess in, 175

malignant neoplasms in, 433

pulmonary hematoma in, 490

pulmonary lacerations in. 402

reparative surgery in, in followed-up

casualties, 450

residual symptoms in, 202

status of returned casualties in, 390, 400

thoracoabdominal wounds in, 541-542

vascular surgery in. 40

wound sequelae in. 300-413

ZUCKKKMAX, S., 34, 37, 38

U.S. GOVERNMENT PRINTING OFFICEM96E