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An Analysis of 2,811 Chest Casualties of the Korean Conflict

Medical Science Publication No. 4, Volume 1

THURSDAY AFTERNOON SESSION
22 April 1954

MODERATOR
COLONEL JOHN M. SALYER, MC


AN ANALYSIS OF 2,811 CHEST CASUALTIES OF THE KOREAN CONFLICT*

MAJOR A. R. VALLE, MC

In this paper we present an anlaysis of the 2,811 chest casualties of the Korean conflict who were treated at Tokyo Army Hospital between the beginning of the war and March 1953. A previous report covering 1,535 of these casualties has been published (21). However, this paper adds more than 1,000 cases and contains data which were not available at the time of the previous reports. Some conclusions are reported because additional experiences only served to bear out their validity.

Tokyo Army Hospital was the center for treatment of thoracic casualties. Approximately 85 percent of our patients were United States military personnel and 15 percent were members of forces contributed to the Korean effort by other United Nations.

During the first few months of the conflict, definitive treatment could not be administered overseas because casualties could be hospitalized in the theater only 30 days. However, as the bed capacity increased, the period of hospitalization was increased to 120 days, making definitive treatment possible.

In this series we have included only those patients who suffered injuries to the intrathoracic viscera and do not include those with only superficial wounds of the chest. Of these wounds, 1,968 or 70 percent were of the penetrating type, 787 or 28 percent were of the perforating type and 56 or 2 percent were results of crushing injuries.

Hemothorax

The most frequent complication of intrathoracic wounds is hemothorax with or without associated pneumothorax. This intrapleural blood may remain fluid or may coagulate and begin to organize. In this series 1,744 patients or 62 percent either had hemothoraces on admission or developed them within the first 2 weeks after admission. Of this number 74 percent or 1,291 remained sterile and 26 percent or 453 became infected.


*Presented 8 December 1953, to the Military Medicine Refresher Course, and 22 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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We treated hemothorax by simple thoracentesis without air replacement. Following removal of the fluid, 300,000 units of crystalline penicillin and 1 gram of streptomycin were instilled. The procedure is repeated every 24 hours, or more often if thought indicated, until no fluid can be obtained and the chest appears normal to physical and x-ray examinations. Specimens of the fluid removed were sent to the laboratory for culture, antibiotic sensitivity tests and other studies as indicated. If infection was present, the antibiotic of choice was administered systemically and intrapleurally, depending upon the manner in which the drug could be administered. Penicillin, streptomycin, terramycin, aureomycin and chloromycetin were utilized.

Eighty percent or 1,395 patients completely recovered after being treated by thoracenteses and antibiotics only. Sixty-eight percent were returned to duty and the remainder were evacuated to the Zone of Interior because of other wounds although they were recovered as far as their chests were concerned.

Many patients had clotted hemothoraces on admission to the hospital or within 2 days of being wounded. From a review of those patients' records, it would seem that the hemothorax clotted within a few hours of wounding, because at no time was any fluid obtained by aspiration. In other patients the hemothorax coagulated gradually, taking from 3 to 4 days to 2 weeks.

Decortication is the established method of treatment for those patients with significant clotted or organized hemothoraces (3-5, 7-13, 15, 16, 19). A total of 254 decortications were performed on patients with both infected and noninfected organized hemothoraces. Of these 76 percent were infected and 24 percent were noninfected. Ninety-one percent were considered as having good results, 4 percent as having fair results and 5 percent as having poor results.

It is noteworthy that 92 percent of the patients who needed decortication had closed intercostal drainage tubes inserted in Korea (23). We feel that closed intercostal drainage has many disadvantages as an early treatment for hemothorax. It increases the hazards of evacuation since the tubes were often found improperly clamped off and fluid from the bottles was sucked back into the chest. Furthermore, in hemothorax, closed drainage usually loses its value within 24 to 36 hours because of occlusion of the tube by fibrin and clots and by pleural adhesions about the intrathoracic portion of the tube (21-23).

After performing decortications at intervals of 1 to 8 weeks following injury, it was decided that the optimum time for such operation is within 3 to 5 weeks of injury. From a review of the reports published by surgeons who had experience in treating chest casualties during World War II, it would seem that there is general agreement


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upon this interval (10-12). In those operations performed early, the bleeding was much more severe, there was more edema and foreign bodies, if present, were more difficult to locate.

In 18 cases we used streptokinase and streptodornase according to the procedure described by Tillett and Sherry (14-18). We obtained such poor results that their use was discontinued.

Foreign Bodies

It was the policy at Tokyo Army Hospital to remove only those foreign bodies which exceeded 1.5 cm. in greatest diameter, unless, of course, they were in such a location as to be regarded as dangerous to the patient, unless they caused some pathologic changes within the chest, or produced symptoms. Persistence or development of reaction about the missile indicated the need for exploration and removal (1, 2).

Three hundred and twenty-seven patients had retained foreign bodies which necessitated removal. Approximately 85 percent of these were shell fragments which varied in size from 1 to 9 cm. in diameter and the remaining 15 percent were bullets of various caliber. The incidence of infection when the foreign body was shell fragment was high, from 60 to 70 percent. When the foreign body was a bullet, the incidence of infection was about 10 percent.

Among the 327 patients operated upon at Tokyo Army Hospital solely for the removal of foreign bodies, the postoperative empyema incidence was only 2 percent. The majority of these patients returned to duty but a small number had to be returned to Zone of Interior because of other wounds.

We found that delaying operation for removal of foreign bodies for 2 to 3 weeks, if possible, decreases the amount of bleeding at operation and makes location of the foreign body easier. Also the patient is usually in much better condition to tolerate the thoracotomy procedure. In reviewing the records, we also found that the empyema incidence among some 150 patients who were operated upon in forward areas for removal of foreign bodies was 25 percent.

Mediastinal Injuries

One hundred and seventeen or slightly more than 4.2 percent of our patients suffered mediastinal wounds. The majority of these patients also had retained metallic foreign bodies. Approximately 65 percent of these patients developed infections which were drained through the pleural space.

We removed 32 foreign bodies from the mediastinum, 10 from the pericardium, and 16 from the myocardium. Three patients had


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foreign bodies in the intraventricular septum which we did not remove.

Forty-two patients developed pericardial effusions which were treated with pericardiocenteses and antibiotics. Pyogenic organisms were obtained from culture of the aspirated fluid in about 40 percent of the cases.

The following table shows the extent to which other structures in the mediastinum were injured.

Esophagus

9

Aorta

8

Thoracic duct

5

Vena cava

3

Trachea

5

The majority of these patients, with the exception of those with injuries to the heart and great vessels, were returned to duty in the theater.

Thoraco-abdominal Wounds

It was our experience that many patients with thoraco-abdominal wounds involving the upper abdomen could be handled adequately through the thoracotomy. The exposure is good and it obviates the necessity of an abdominal or thoraco-abdominal incision. It was our impression that those patients who needed extensive abdominal surgery made better progress when separate thoracotomies and laparotomies were done than when a thoraco-abdominal incision was made. Also, infection if it develops, is more localized when separate incisions are made.

Generally those patients who suffered injuries to the diaphragm and spleen in conjunction with their chest wound had these injuries repaired at thoracotomy. We repaired 186 injuries to the diaphragm and performed 8 splenectomies. The majority of these patients were returned to duty in the theater.

Patients with serious liver damage, multiple intestinal perforations with or without resection, colostomies, nephrectomies, etc., were evacuated to the Zone of Interior for definitive chest surgery. If necessary, the temporizing procedure of open drainage with rib resection was carried out so that they could be safely evacuated.

The following list gives the extent to which various abdominal organs were injured:

Liver

201

Spleen

82

Large intestine with colostomy

52

Small intestine

18

Stomach

48

Kidney

33


415

Approximately 18 percent of our patients suffered wounds involving both the chest and abdomen. Four deaths or slightly more than 25 percent of our mortality were in this group.

Other Injuries

A large number of our patients suffered nerve injuries and/or orthopedic injuries along with their chest wounds. Those patients whose injuries were so serious that there was little likelihood of their returning to duty in the theater usually received only palliative treatment such as thoracentesis or thoracotomy drainage with rib resection and were evacuated to the Zone of Interior.

Bacteriology

Many kinds of bacteria were isolated on culture of the fluid aspirated from the chests of our patients. In the beginning, the infection was usually a mixed one, made up of various gram-negative rods and gram-positive cocci. However, as antibiotic treatment continued, the gram-negative bacilli, such as E. coli, E. freundii, Aerobacter aerogenes, Pseudomonas aeruginosa, various Proteus species, etc., were usually destroyed, leaving only the gram-positive cocci to be dealt with.

Hemolytic and nonhemolytic Streptococci were isolated in a number of cases but by far the most common and most persistent organism encountered was hemolytic, salt-resistant, mannite-fomenting (coagulase-positive) Staphylococcus. The Streptococci were easily controlled by antibiotics but usually the Staphylococcus became resistant to all antibiotics except chloromycetin in very high concentrations.

We found various types of proteolytic Clostridia in a number of our cases, which could account for the massive destruction of lung tissue found in these cases.

Morbidity

The prime factor in the treatment of chest casualties is the restoration of normal cardio-respiratory physiology as soon as practicable (3, 20). All such procedures as thoracentesis, decortication, removal of foreign bodies and irreparably damaged lung tissue, repair of the diaphragm and chest wall help restore normal function and decrease morbidity.

We feel that physiotherapy is an important adjunct in decreasing morbidity (6). If possible, it is started on the third postoperative day. The patients begin with breathing exercises and blow bottles and passive and active exercise of the shoulder and arm of the side operated upon.


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The period of hospitalization, in most instances, varied from 3 to 6 weeks. Following discharge from Tokyo Army Hospital, these patients who were considered candidates to return to duty in the theater were sent to Camp King. This camp was a convalescent and reconditioning center. It was operated under medical supervision and the amount of activity was gradually increased to combat peak. Those patients who could not stand the rigors of combat conditions were weeded out and sent to limited duty.

Approximately 80 percent of the chest casualties who had definitive treatment at Tokyo Army Hospital returned to duty in the theater. Also we know that a considerable number of patients who had to be evacuated eventually returned to duty but we have no data concerning these.

Mortality

It is assumed that the initial mortality in thoracic wounds must be high but we have no overall figures about the mortality of chest wounds in the Korean conflict. However, the delayed mortality appears to be lower than might be expected. Our overall mortality at Tokyo Army Hospital was 0.6 percent and that reported for the Yokasuka Naval Hospital was 1.9 percent (7).

We had 17 deaths in our series of 2,811 cases. Eight of these patients died as a result of serious wounding: 4 patients, of thoraco-abdominal wounds, 1 patient of pulmonary embolism, 1 patient of cardiac tamponade and 2 with serious nerve injuries. Nine of our deaths were due to homologous serum hepatitis. Many other patients, all of whom had received numerous transfusions of plasma and whole blood, developed jaundice but did not succumb.

More than 800 major operations, excluding thoracotomy drainages, were performed without a death, as follows:

Decortications

254

Lobectomies and partial resections

169

Pneumonectomies

5

Splenectomies

8

Thoracotomies for removal of foreign bodies, etc.

435

Many factors contributed to this low mortality. We had the benefit of the experience of the chest surgeons in the rather recent World War II; we had more and improved antibiotics; there was plasma and whole blood readily available for transfusion near the battle lines; the Mobile Army Surgical Hospitals could do major surgery if necessary just a few miles from the front lines; evacuation was very rapid. Lastly, but of great importance, the patients were healthy young men with an average age of 23 years.


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Late in the war protective vests were introduced which helped decrease the mortality of chest wounds. They are most effective in stopping low-velocity missiles and many soldiers who would have been instantly killed if not protected by the vest, are only wounded.

Conclusions

Our experience with 2,811 chest casualties indicates that, in general, the best early treatment for chest wounds is the most conservative one.

Thoracentesis is the most effective treatment for hemothorax. Approximately 80 percent of the patients with hemothorax were cured by thoracentesis and antibiotic treatment. We feel that closed intercostal drainage is seldom necessary and often dangerous. Ninety-two percent of those patients who required decortication had intercostal drainage tubes inserted in Korea.

References

1. Blades, Brian: Recent Observations Concerning the Treatment of Chest Wounds. Surg. Clin. of North America 24: 1410, 1944.

2. Churchill, E. D.: Trends and Practice in Surgery in the Mediterranean Theater. J. Thoracic Surg. 13: 307, 1944.

3. Coleman, F.: Traumatic Hemothorax. Arch. Surg. 50: 14, 1947.

4. De Lorme, E.: Noveau Traitement des Empyemes Chroniques. Gas. d. Hop. 67: 94, 1894.

5. Fowler, R. G.: A Case of Thoracoplasty for Removal of a Large Cicatricial Fibrous Growth from the Interior of the Chest, The Result of an Old Empyema. M. Rec. 44: 839, 1893.

6. Markem, D. E.: A Review of the Activities of the Thoracic Center for the III and IV Hospital Group 160th General Hospital, European Theater of Operations, 10 June 1944 to 1 January 1945. J. Thoracic Surg. 15: 31, 1946.

7. King, J. D., Commander, USN, and Harris, H. Lt., USN: War Wounds of the Chest Among Marine and Naval Casualties in Korea. Surg., Gynec. & Obst. 97: 199-212, 1953.

8. Langston, H. T., and Tuttle, W. M.: The Pathology of Chronic Traumatic Hemothorax. J. Thoracic Surg. 16: 99, 1947.

9. Lush, R. W., Stevenson, C. R., Nicholson, J. C., and Nicholson, W. P. L.: Clotted Hemothorax. Lancet 2: 467, 1944.

10. Nicholson, W. P., and Scadding, J. G.: Penetrating Wounds of the Chest. Lancet 1: 299, 1944.

11. Samson, P. C., and Burford, T. H.: The Management of War Wounds of the Thorax in an Overseas Theater. Clinics 3: 1561, 1944-45.

12. Samson, P. C., Burford, T. H., Brewer, L. A., and Burbank, R.: The Management of War Wounds of the Chest in a Base Center. J. Thoracic Surg. 15: 1, 1946.

13. Samson, P. C., and Burford, T. H.: Total Pulmonary Decortication. J. Thoracic Surg. 16: 127, 1947.

14. Sherry, S., Tillet, W. S., and Rand, C. T.: The Use of Streptokinase-Streptodornase in the Treatment of Hemothorax. J. Thoracic Surg. 20: 393, 1950.


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15. Sommer. G. H. J., and Mills, W. O.: Hemathorax and Empyema in a Thoracic Center. J. Thoracic Surg. 16: 154, 1947.

16. Thomas, C., and Cleland, W. P.: Decortication in Clotted and Infected Hemothoraces. Lancet 1: 327, 1945.

17. Tillet, W. S., and Sherry, S.: The Effect in Patients of Streptococcal Fibrinolysin (Streptokinase) and Streptococcal Desoxyribonuclease on Fibrinous, Purulent and Sanguineous Pleural Exudations. J. Clin. Investigation 28: 173, 1949.

18. Tillet, W. S., Sherry, S., Christensen, L. R., Johnson, A., and Hazlehurst, O.: The Effect in Patients of Streptococcal Fibrinolysin (Streptokinase) and Streptococcal Desoxyribose Nuclease (Streptodornase). Tr. A. Am. Physicians 62: 93, 1949.

19. Tuttle, W. N., Langston, H. T., and Crowley, R. T.: The Treatment of Organizing Hemothorax by Pulmonary Decortication. J. Thoracic Surg. 16. 117, 1947.

20. Valle, A. R., Major, MC.: Emergency Treatment of Chest Injuries. The Surgeon's Circular Letter, FEC, Vol. VI, No. 5, May 1951.

21. Valle, A. R., Major, MC.: Management of War Wounds of the Chest. J. Thoracic Surg., Vol. 24, No. 5, November 1952.

22. Valle, A. R., Major, MC., and Watkins, D. R., Captain, MC: Experience and Treatment of Chest Wounds in a General Hospital. The Surgeon's Circular Letter, Symposium, FEC, September 1951.

23. Valle, A. R., Major, MC., and Watkins, D. R., Captain, MC: The Treatment of Intrathoracic Wounds. The Military Surgeon, Vol. III, No. 6, December 1952.