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Chapter I

Contents

Part I

INTRODUCTION


CHAPTER I

Historical Note

Frank B. Berry, M.D.

EARLY OBSERVATIONS

Military surgery is as old as man himself, and battle wounds of the chest, and fatalities from them, are as old as military surgery. Homer described thoracic wounds vividly and with anatomic correctness. He also described how arrows rebounded harmlessly from the plated steel breastplates worn by soldiers during the Trojan War (1). It was not until World War II that U.S. Army Air Force crews began to have a comparable form of protection with the provision of flak suits. Later, in the Korean War, ground troops were provided with plastic body armor.

Hand-to-hand fighting determined the character of all wounds for another 2,500 years. Gunpowder was invented early in the 13th century, but cannon and gunshot were not employed effectively in the West until the Battle of Agincourt in 1415. Hieronymus Brunschwig (2) of Strasbourg, in 1497, was apparently the first surgeon to describe "Wound :s shot with a gonne." Like other surgeons of his time, he believed that the damage was caused by "the venym of the powder." This concept was dispelled by Paré some 40 years later.

Theodoric (3) was probably the first to describe the principles of debridement, in the latter half of the 13th century. He used the Latin word "abradantur" (abradere, to scrape off, to shave) and emphasized that the edges of the wound should be thoroughly trimmed, that all fuzz and hair should be removed, and that above all the wound must be thoroughly cleaned. Debridement was described with clarity and vision by Thomas Gale in 1586, and it is ironic that its principles and technique had to be learned over again in World War II, more than three and a half centuries later.

Up to this time, no special attention had been paid to wounds of the chest, nor was any special attention paid to them in the next two centuries. John Hunter, who served as an Army surgeon in 1761, remarked that while little had been done for them, something probably could be accomplished for the good of the patient. His only contribution, however, was the tentative suggestion that hemothorax might be treated by allowing the fluid to run out of the wound.

Baron Dominique Larrey, during the Napoleonic Wars, devised the system of battlefield evacuation and triage-another lesson finally learned in full in World War II-and also made certain recommendations for the management of chest wounds. Because he had observed that results were poor in penetrating wounds in which the traumatic thoracic opening was larger than the glottis, he


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recommended, as had John Hunter, that the casualty be placed on the wounded side, to permit the blood to drain out of the chest cavity, and that the chest then be closed. He described several patients in whom dramatic improvement had occurred and recovery had followed when this plan was used. Closure of chest wounds had been mentioned by John de Vigo early in the 16th century, and Paré said that the practice was founded on reason and truth, though he recommended that the closure should not be effected for from 48 to 72 hours after the injury, to prevent an accumulation of blood. Larrey's bold translation of advice into practice represented the first really notable advance in the management of these wounds.

THE CRIMEAN WAR

Fraser (4), in the review of the literature reported in his small monograph on wounds of the chest in the Crimean War, found little information on these wounds as compared with wounds of the extremities and joints, which required "showy manual ability." The single treatise entirely devoted to penetrating wounds was by Mayer of St. Petersburg, and there were only 33 reports of such wounds in five British medical journals between 1825 and 1853. Fraser also commented on the small number of preparations of lung wounds in British hospital museums; there were only seven at the Royal College of Surgeons, three at St. Thomas' Hospital, two at St. George's Hospital, and one at University College. At Chatham there were none.

Fraser's monograph contains chapters on diagnosis, prognosis, and complications of wounds of the chest; wounds of the diaphragm with herniation are discussed under complications. The Crimean experience made the author doubt that many of the cases reported in the literature as recoveries were really wounds of the lung. He regarded most of them, like most of the cases reported from Guy's Hospital (table 1), as wounds in which the lungs had escaped damage and only the pleura was involved. He shared the general opinion of others who wrote on the subject that most deep wounds of the lung were fatal.

"Paracentesis thoracis" was recommended for injuries in which blood or serum accumulated without a free mode of exit and in which movement of the lung was impeded. It was recommended that it be performed without delay.

Fraser considered that there might be more danger in attempting to remove a foreign body than in permitting it to remain in situ, "seeing the lengthened periods during which bullets may remain innocuous in the human body," because in the attempt at removal a relatively minor wound might be converted into a penetrating wound. He granted that there were cases in which the presence of the foreign body might be productive of "serious mischief and danger," and he also advised the removal of some objects if "for no other motive than great peace of mind which this event invariably induced in the patient."

Venesection was routine at this time, but Fraser termed it "this murderous act." He described a patient who recovered, after being bled 100 ounces in a month, "at the expense of an empyema and thanks to an iron frame."


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TABLE 1.-Number of chest wounds on the occasions named, and from the authorities quoted, with the percentage of deaths to wounded, 1859

Action or authority

Wounded

Deaths

Number

Number

Percent

The Director-General's records prior to Crimean War

39

27

70.0

Crimea

474

135

28.5

Simpheropol (Russians)

200

197

98.05

Toulouse

106

50

50.0

Quebec

26

2

7.07

Carlist War

29

27

100.0

Paris, 1830

120

10

50.0

Paris, 1848

9

4

44.0

Paris, 1850

11

5

45.5

Battle of Kilet

21

11

50.0

Battle of Idstead

97

17

17.0

Battle of Canton

4

4

100.0

M. Meniere

20

20

100.0

M. Legonest

6

3

50.0

Guy's Hospital Reports

272

9

12.5

Danish War (Report of Chief Surgeon Schytz. Total wounded, 227)

10

2

20.0

Dr. Kidd

36

24

66.0

Total

1,180

547

 


1 De Lambale and Baudeus.
2 Of this number, the lung was really wounded in two cases only.
Source: Fraser, Patrick: A Treatise Upon Penetrating Wounds of the Chest. London: John Churchill, 1859.

According to Fraser, 474 of the 12,094 wounds recorded in the Crimean War (3.9 percent) involved the chest, and 135 of these (28.5 percent) were fatal (table 1). Included in the chest wounds were 164 of the lung (1.35 percent of the total number of wounds), of which 130 (79.26 percent) were fatal. The case fatality rate for wounds of the lung in the French Army was reported as 91.6 percent.

THE CIVIL WAR

Of a total of 253,142 wounds recorded in the Civil War, 20,607 (8.1 percent) involved the chest, and 8,715 of these (42.3 percent) were penetrating wounds (5). The overall case fatality rate for chest wounds was 27.8 percent and for penetrating chest wounds 62.6 percent. A number of cases were reported in which complete recovery followed gunshot wounds of both lungs. A number of recoveries were also reported after penetrating gunshot fractures of the sternum, apparently because the causative missiles were of low velocity.

In 1863, Assistant Surgeon Benjamin Howard recommended to Brig. Gen. William A. Hammond, The Surgeon General, that penetrating wounds of the chest in which suppuration had not occurred should be managed by removal of all foreign bodies; control of bleeding; paring of the edges of the wound; closure by metallic sutures; and the application of an airtight dressing, so


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that the wound would be hermetically sealed. In this recommendation, the implications of the physiology of chest wounds, their mechanics, and the principles of wound suppuration and wound healing were all overlooked. Because of failure to realize that sealing the wound hermetically was only part of the problem, infection was common, and a high case fatality rate was inevitably associated with this type of treatment.

Pneumothorax is mentioned in the Civil War history a number of times but apparently seldom reached an alarming stage. Tension pneumothorax is mentioned only a half dozen times.

Hemothorax, either alone or in combination with pneumothorax, was recognized as a dangerous complication, particularly because of the extreme dyspnea often associated with it. Early in the war, it was believed that the surest way to arrest bleeding was by bleeding the casualty further. In the Confederate Manual used during the war, however, venesection was described as a time-honored absurdity, and it is doubtful that it was ever practiced by any Confederate surgeon. The routine plan, when hemothorax was present, was to try to identify the bleeding point, control it, and then employ such general measures as cold acidulated drinks together with the administration of digitalis or opium. It was recognized that if the hemothorax was not absorbed, empyema would result.

Thoracentesis was used to relieve the effects of effusions resulting from acute and chronic pleurisy or from "traumatic pneumonia" (a term used to indicate infected hematoma, atelectasis, lung abscess, and other infectious sequelae). This method was not used, as in World War II, to evacuate hemothoraces and promote rapid expansion of the lung.

Operation was sometimes necessary to control bleeding from the great vessels. The usual procedure was to ligate only the proximal end of the vessel, and it is not surprising that there were no recoveries in wounds of the axillary artery, though there were 5 survivals in 25 casualties with wounds of the subclavian artery.

Four recoveries were recorded in gunshot wounds of the heart. Patients with wounds of the pericardium sometimes languished for several weeks with suppurative processes, but, in one series of 51 cases, there were 22 recoveries. It was noted that extreme dyspnea might accompany a wound of the heart because of intrapericardial pressure, which could be relieved by paracentesis.

Wounds of the esophagus are not specifically mentioned in the Civil War history, but a disproportionate amount of space is given to descriptions of hernia of the lung. Such hernias, it was stated, were extremely uncommon among British casualties at Waterloo as well as in the Crimean War. One case, described in detail, was managed by the technique first described by Tolandus of Parma in 1449 (1) and used successfully by Whittemore (6) in 1929 on nine patients. This technique, which amounts to a two-stage lobectomy, consists of creation of a hernia of the lung, followed by excision of the protrusion after adhesions have formed.


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WORLD WAR I

General Considerations

It is difficult for a modern surgeon to visualize the status of surgery at the end of the Civil War. Techniques of anesthesia were limited. Antisepsis and asepsis were still undreamed of. Medical schools were poorly organized and administered. Programs of interne and residency training did not exist. Channels for dissemination of medical information were few. Within the Army Medical Department, both order and system were lacking.

It is not surprising, therefore, that in the Franco-Prussian War, which broke out in 1870, 5 years after the end of the Civil War, few advances were made in the management of wounds. When World War I broke out in 1914, enormous strides had been made in medicine and surgery, based on Pasteur's work in bacteriology and Lister's work on antisepsis, out of which the modern concept of aseptic surgery developed (7). During the last quarter of the 19th century, Osler (8) wrote in 1902, physicians had become better trained and equipped and disease was "understood more thoroughly, studied more carefully, and treated more skillfully." "The average sum of human suffering," he went on, "has been reduced in a way to make the angels rejoice."

The medical officers of World War I had reason to be thankful for these advances, for the wounds they were called upon to treat were far more dreadful than those of any earlier war (1). In 1892, the high-powered rifle had replaced the old muzzle loader, and, at about the same time, bullets were developed with thin steel, nickel, or copper jackets. Until World War I, the preponderance of wounds had been caused by bullets and low-velocity missiles. The United States was therefore completely unprepared for the extravagant use of artillery, high explosives, and high-velocity missiles that was manifest soon after the outbreak of the war in 1914. In World War I, about 70 percent of all wounds were caused by high-velocity missiles and high explosives, and their management created new and serious problems.

According to Hoche (9), in the 11 million wounds sustained in the armies of the United States, Great Britain, France, and Germany in World War I, there were 660,000 wounds of the chest (6 percent), of which 56 percent were fatal. Hoche's collected figures also show that of 12,350 soldiers killed in action, 20 percent had chest wounds.

The U.S. statistics for chest injuries in World War I are open to some doubt (10). In a total of 174,296 injured, 4,595 (2.6 percent) had wounds of the thorax; the case fatality rate was 24.05 percent. The British incidence of chest wounds was 3.8 percent (11). Both these proportions are entirely at variance with the incidence of wounds of the thorax in other recorded wars. In the U.S. statistics, it is possible that some wounds of the thorax are included with wounds of the neck and the back, which are listed separately.

In other recorded wars, including World War II, the incidence of chest wounds was about 1:12 (8 percent). In 55,000 wounded in the Seventh U.S. Army in World War II, the incidence of chest wounds was 7.8 percent and the


8

case fatality rate was 5.4 percent (p. 61). The figures for the Fifth U.S. Army are substantially on the same order. The figures for both armies are for the campaigns of 1944 and 1945, during which the case fatality rate was lower than it was in the early years of the war.

There were no chest centers in the U.S. Army during World War I. Patients with suppurative pleuritis were segregated in a few hospitals, but they were usually cared for in the so-called septic surgery sections. With this possible exception, all chest surgery was performed by general surgeons. At the time, there were only a few surgeons who were qualified in this specialty or who had any interest in limiting their surgical activities to it.

The Allied Experience 1914-17

When the United States entered the war in April 1917, effective methods of treating almost all types of wounds had been established by surgeons of the Allied armies. Among the exceptions were wounds of the chest, about which, as Yates (7) pointed out, there were still irreconcilable differences. These differences were caused, he continued, by the failure of many surgeons to understand the interdependence of the functions of the circulatory and respiratory systems; to appreciate the contributions of these functions to the powers of resistance, defense, and repair; and to understand further that these powers must be conserved and developed if immediate recovery were to be facilitated and the extent and duration of subsequent disability were to be reduced. Nonetheless, in spite of this confusion, U.S. surgeons had the general experience of their Allies to build upon when they first encountered wounds of the chest.

The British experience-Before 1916, according to Gask (11, 12), British surgeons practiced a policy of noninterference in chest wounds for three reasons:

1. The experience in the South African War, in which, because the ground was dry and wounds were chiefly caused by rifle bullets, this policy was generally successful.

2. The belief that it would be fatal to open the chest cavity without the aid of some form of pressure chamber.

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

Experience showed that all of these assumptions were wrong, and by the time the United States entered the war, British surgeons were doing a considerable amount of intrathoracic surgery. First, the need for wound excision (debridement.) had been recognized. Later, the need for thoracotomy, at least in some cases, became evident. Surgeons began to lose their fear of the open chest, and their successes further encouraged them to perform many bold and well-conceived operations previously considered impossible. The development of blood transfusion also made them bolder, especially in the management of thoracoabdominal wounds, the results of which, in some hands, showed a great deal of improvement.


9

Sir Gordon Gordon-Taylor (13), however, began his account of chest surgery in World War II with the statement that it was strange that, in spite of the numerous chest injuries encountered, it was not until 27 July 1917 that a memorandum was issued to medical officers of the British Expeditionary Force calling attention to the value of dealing with open pneumothorax by immediate temporary closure of the chest wall by suture. His explanation of the delay was that experiences were disseminated much more slowly in World War I than in World War II.

Until the end of the war, empyema remained the principal anxiety of British surgeons and the principal cause of poor results. During the war, however, the disadvantages of expectant management in many cases of hemothorax, especially those in which clotting and infection were present, had become evident. In 1918, while on a surgical mission to the United States, Grey Turner (14) suggested the use of decortication in some cases of old hemothorax, in which, he pointed out, the lung was likely to be found imprisoned in a sort of sheath of organizing blood clots that extended to the diaphragm and interfered with its normal movement. It was most interesting, he continued, to see the lung during decortication reappear "from its coat of mail" and begin to reexpand normally. He "sighed" for anesthetic apparatus that would facilitate the operation by permitting a ready change from ordinary inhalation anesthesia to positive intrapulmonary pressure.

The war left the British, as it did the Americans, a large legacy of patients with chronic empyema, encysted hemothorax, and retained foreign bodies with chronic suppuration, as well as many chest cripples, with rigid and greatly deformed chests.

The French experience.-Before the United States entered World War I, Pierre Duval (15) of the French Army medical service had made some important observations on chest surgery:

The first of these observations concerned the concept, current at the outbreak of the war, that thoracic surgery should not be performed until the casualty had reacted from his initial shock. As a result of this policy, Duval pointed out, the chief causes of death in chest wounds at battalion aid stations were hemorrhage and mechanical asphyxia due to an open thorax. In 3,453 admissions to hospital units in Army areas, the death rate in the most forward units was 45 percent, against an overall rate of 20 percent.

Duval fully realized the difficulty of setting up clear-cut indications for immediate surgery in thoracic wounds, but he nonetheless urged that if signs of hemorrhage were persistent, the wound should be promptly opened and the damage sought for and repaired, whether it was in the chest wall or in the lung. Debridement of wounds of the soft parts and of the extremities was already being practiced with considerable success, and he saw no reason why a contaminated lung and pleura should not be similarly treated. In a series of 500 chest injuries with pneumothorax managed by the usual methods, there were 195 infections. In contrast, in 193 injuries which Duval had handled personally in the Battle of the Somme, there were only 34 infections in the 144


10

shell wounds and no infections at all in the 49 bullet wounds. His personal results proved his point that septic sequelae were far more numerous and more serious in wounds caused by high explosives than in bullet wounds, which either were immediately fatal or ran a relatively benign course.

Duval also advocated that all shell fragments and other retained foreign bodies should be promptly removed, under local infiltration with procaine hydrochloride, and that the chest then be tightly closed without drainage. As technique improved, he said, the general surgical principles and practices employed in gunshot wounds were being applied little by little to wounds of the lung. "Let us dare to hope," he concluded, "that those who follow in our steps may soon have many more numerous and more brilliant successes."

The U.S. Experience1

General principles and practices-Patients with uncomplicated chest wounds were not prone to shock unless there was considerable hemorrhage. According to Yates (7), it was often wise to defer transfusion-which was given in small amounts and to few casualties-until after the lung had been reinflated at operation.

All emphasis was placed upon the prevention and treatment of infection, particularly upon its treatment. With respiratory infection so prevalent and the grave type of pneumonia caused by the beta hemolytic streptococcus so frequent (p. 19), this was probably inevitable. Nonetheless, as one looks back now, it is somewhat perplexing that more attention was not directed toward the physiology and the spatial dynamics of the chest.

First aid was limited to hemostasis of the parietal wound, with temporary closure of an open thorax by strapping a firm, thick, broad pad over the wound by means of adhesive tape reinforced by a swathe. This method was preferred to initial suture of the wound, which often resulted in spreading subcutaneous emphysema.

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

1. Aspirating (sucking) wounds.
2. Large retained foreign bodies.
3. Severe bone injury.
4. Complicated lesions of the diaphragm.
5. Extensive hemorrhage and suspected infection, particularly anaerobic infection.

The arguments advanced for the various methods of management of chest wounds in World War I sound much like the discussions in World War II concerning the indications for thoracotomy and the advantages of formal thoracotomy at the site of election versus thoracotomy at the site of the wound.

1As a matter of convenience, special types of wounds and special complications of thoracic wounds, including empyema, are discussed under separate headings later in this chapter.


11

There were four possible methods of treatment, as Yates (7) pointed out in an analysis of a personal series of 104 injuries:

1. Simple debridement or excision of parietal wounds.-This method, combined with aspiration or suitable drainage of hemothorax, was a satisfactory routine method of treatment for wounds which were not too serious. Surgery was followed by systematic exercises to produce early and complete recovery.

2. Limited thoracotomy (the traumatic thoracotomy of World War II).- It consisted of debridement and exploration through the wound of entrance or exit, with little or no enlargement of the traumatic wound. Limited thoracotomy was indicated when the wound was small, the damage slight, and the lung readily inflated. At operation, accumulated blood and fluid were aspirated before closure. Local bleeding could usually be cared for through the same wound, and small wounds of the lung were closed. Missiles were removed whenever it was feasible. If they lay next to large blood vessels, they were always sought for and removed.

3. Thoracotomy of necessity (a term no longer used).-This operation was little more than a more extensive application of limited thoracotomy. It was used when debridement and limited thoracotomy revealed unexpected lesions that required immediate, more radical intervention. It was used upon casualties who were so severely wounded that both parietal and deep repair had to be managed through a single opening. Its advantages were (1) its greater rapidity and (2) the avoidance of an elective incision, so that the integrity of the parietes was not impaired by the trauma superimposed by such an incision upon the destruction wrought by the projectile. There were also disadvantages, including frequent failure to obtain sufficient exposure for satisfactory intrathoracic surgery, as well as the temptation to escape the risk of an increased surgical mortality by performing an operation less complete than was necessary to obtain complete recovery.

4. Thoracotomy of election.-The separate incision afforded sufficient exposure for a satisfactory examination of the pleural cavity and permitted repair of most visceral and diaphragmatic lesions. An elective incision healed well and imposed little disability.

Great importance was attached to prevention of soiling by final, thorough toilet of the pleural cavity and wound. When necessary, the lung was sutured into the defect in the parietal pleura. Blocking of the phrenic nerve with 1 percent cocaine was advised.

A firm and airtight parietal closure was considered imperative in all injuries.

The possibility of tension pneumothorax was recognized in World War I, as was the possibility of rapid collection of fluid with increase in the mediastinal pressure. The nature of acute hematomas of the lung was not, however, fully appreciated. The process was termed "splenization," and resection was the preferable treatment. This method was contrary to the usual practices in World War II, when the pathologic process was more clearly understood.


12

Generally speaking, when patients were seen early and operation could be performed within 8 hours, the case fatality rate was about 4 percent. When delay was over 24 hours, there was a 10-fold increase in the case fatality rate.

According to Yates (7), the use of primary, and even of early, drainage of the pleural cavity after operation was generally condemned, because open methods were employed, and with them, collapse of the lung was inevitable. It was recognized, however, that proper drainage reduced the incidence of empyema; the official history simply states that some type of drainage tube was used, provided with some device to prevent the entrance of air, and that the earlier it was used, the better were the results. It was also pointed out that disastrous pleurisy could be limited if primary drainage were employed for large wounds with open pneumothorax, foreign bodies, and lacerations of the liver and diaphragm. The principle of closed underwater drainage was not as well established, even by the end of the war, as it has since become.

The possibility of postoperative accumulations of serum was realized in World War I, as was their frequency, and routine aspiration was used as necessary as a precaution against this complication. When aspiration was properly employed, the necessity for later open operation was considerably reduced.

Air replacement.-Air replacement as a means of collapsing the lung and thus controlling hemorrhage was first suggested by Chassaignac in a thesis written in 1835. In 1941, Berry (16) and Lambert, unaware of the early recommendation, suggested the procedure for uncontrolled bleeding in hemopneumothorax on the basis of their success with it in a personal case. They emphasized that the method had only a limited field of usefulness.

In World War I, artificial pneumothorax was extensively used in Italian military hospitals. The technique had been introduced by Forlanini in Italy and by J. B. Murphy in the United States for treatment of tuberculosis and other diseases of the lung and pleura, and Morelli (17), Forlanini's pupil, and Bastianelli (18) adapted it to wounds of the chest in which hemothorax was a feature. The routine was to aspirate the chest incompletely and replace the blood withdrawn by air, the amount of air to be injected being determined by readings of intrapleural pressure on a pneumothorax apparatus. If the apparatus was not available, the practice was to replace with air half of the volume of fluid removed. The procedure was repeated in 72 hours and carried out as necessary thereafter to achieve gradual clearing of the chest.

Air replacement was contraindicated in thoracoabdominal wounds. It was also not employed when the injected air would escape through parietal or pulmonary wounds or when it would be difficult to introduce it because of adhesions. Surgery was indicated in these circumstances.

Air replacement never won favor on the medical services of the other Allies, perhaps because, by the time the method had been popularized in Italy, other Allied surgeons were beginning to employ a more aggressive approach in wounds of the chest.


13

Anesthesia-The chief reason for the higher case fatality rate in thoracic surgery as compared with the rate in abdominal surgery was the disturbance of the normal intrapleural pressure relations which occurred when air entered through the incision into the chest. Fear of the consequences of an open pneumothorax was the chief reason for delay in the development of chest surgery (19).

The solution of the problem of anesthesia for chest surgery began when Meltzer and Auer (20) of the Rockefeller Institute introduced their simple method of insufflation intratracheal anesthesia as a substitute for the cumbersome and inconvenient techniques previously used for this purpose. By their method, it was now possible to administer an inhalation anesthetic at the same time that a surgical incision was made into the pleura.2

In spite of the simplicity of this method of avoiding collapse of the lung during thoracic surgery, it was employed only infrequently during World War I for three practical reasons:

1. The necessary equipment was seldom available.
2. Few anesthesiologists were familiar with the technique.
3. Few surgeons, as already mentioned, were qualified to undertake thoracic surgery.

Research studies in the American Expeditionary Forces-In the period between the Château-Thierry operation, in July and August 1918, until after the Armistice on 11 November 1918, a research unit composed of medical officers, nurses, and enlisted men was detailed to various field hospitals and mobile units in zones of active combat (7). Its personnel was appointed by the Chief Surgeon, American Expeditionary Forces, and its mission, specified by the Chief Surgical Consultant, American Expeditionary Forces, was in substance as follows:

1. To discover the physiologic interrelationship between the circulatory and respiratory mechanisms, in order to determine the functions which need protection to assure the largest opportunities for immediate and remote discoveries.

2. To develop the simplest effective surgical methods compatible with physiologic requirements.

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

4. To follow each fatality with an autopsy, to determine what should not be done.

5. To trace the results in casualties who recovered and thus discover the dependence of degrees of functional rehabilitation upon the methods employed, in order to develop better methods.

2This technique, naturally in a cruder form, had been suggested by the late Dr. Rudolph Matas as early as 1900 but had then attracted no attention.


14

6. To make a final report which would indicate how soldiers suffering from intrathoracic injuries could be more certainly protected against death and disability.

This was a comprehensive mission, and it was undertaken late in the war. In spite of these handicaps, a number of important observations were made:

1. A strong and active individual, with good vital capacity, could survive a wide partial opening in the chest even when it was produced suddenly.

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

3. The objective of management should be to protect and restore the function of the external respiration and to assure the integrity of both the circulatory and the respiratory units. This was obviously a difficult task.

4. When surgical procedures were necessary, the respiratory physiology must be understood, and every effort must be made to avoid leaving an open pneumothorax or a pyothorax. These two complications were the principal causes of postoperative disability and death.

5. Differential intrathoracic pressure was necessary for safety during surgery. It was best achieved by the use of a tight-fitting gas-oxygen apparatus such as had been recently developed by Gwathmey.

6. To lessen postoperative discomfort, injection of the phrenic nerve within the chest with 1 percent procaine hydrochloride should be part of each surgical procedure.

7. In the aftercare of the patient, breathing and body exercises should be emphasized, to restore parietal movement, pulmonary elasticity, and normal intrapleural relations.

Thus, as World War I drew to a close, many of the principles of management of thoracic wounds that were to prove basic in World War II were beginning to be developed and understood. In World War II, the emphasis upon chest exercises in the chest centers in the communications zone was regarded as a new and major contribution to thoracic surgery, but, as this record shows, the policy had been developed in World War I. The importance of these exercises had also been recognized in certain civilian centers long before the outbreak of the Second World War. Patients were ambulated early, and exercises were demonstrated to them, though the degree of regimentation possible in the Army, one of the factors which made these exercises so useful in wartime chest surgery, was naturally not achieved in civilian practice.

Postwar conference.-After the Armistice in November 1918, a group of senior Allied medical officers met in Paris for a general discussion of war wounds (7). The moderator of the symposium was Brig. Gen. John M. T. Finney, Chief Consultant in Surgery, American Expeditionary Forces. Among the points discussed relevant to thoracic wounds were the following:

1. Col. George Crile, MC, listed hemorrhage, shock, and wounds of the chest as among the conditions making casualties nontransportable. Maj. Gen. Sir Anthony A. Bowlby (British) added that "all completely smashed limbs should never be removed from the field ambulance"; that is, from the installa-


15

tion which corresponded to the U.S. Army field hospital in World War II. It should be noted that neither authority mentioned thoracoabdominal nor abdominal wounds as contraindications to transportation after wounding.

2. Colonel Crile inquired whether the experience in the Argonne had produced any new data, particularly in connection with shock and hemorrhage. Lt. Col. Walter B. Cannon, MC, mentioned the importance of placing blankets under, as well as over, patients, who lost heat by perspiration and because of their wet clothing and their contact with wet stretchers. He had seen patients in shock with four blankets over them and none under them. The discussion brings to mind similar errors at the front in World War II.

3. Colonel Crile inquired whether morphine was contraindicated in abdominal perforations and in thoracic injuries. Lt. Col. John L. Yates, MC, who was later to write the chapter on chest surgery in the World War I official Medical Department history, replied that in a series of 130 patients with chest injuries, he had seen only 2 upon whom morphine had apparently had a bad effect. He was inclined to think that the bad results in these and other cases could be attributed not to morphine per se but to too much morphine; he suspected that these patients had had earlier injections of morphine that had not been recorded on their cards. He saw no objection to the judicious use of morphine in chest injuries.

Again one is reminded of the World War II experience, in which bad effects arose from the overgenerous administration of morphine and its unnecessary use and not from the drug itself.

4. When votes were taken as to how casualties with through-and-through chest wounds tolerated transportation, the replies were: badly, 8, and well, 23. A variety of opinions were expressed: well after a week; poorly if the wounds were caused by shrapnel, but well if they were caused by rifle bullets; well if the patients had not been operated on and were not in shock; badly if the wounds were severe intrathoracic injuries or operation had been performed and healing had not yet occurred.

5. A vote on the comparative status of wounds observed in base hospitals after treatment by various measures favored the following techniques: simple dry gauze, 13; the Carrel-Dakin technique, 12; petrolatum-impregnated gauze, 5. Dichloramine-T, some protective agent, BIPP (bismuth, iodine, and petrolatum paste), flavine, and rubber tubes secured a scattering of votes. Nearly all observers emphasized the risk of packing the wound tightly; lightly placed surface dressings were considered all that was necessary.

6. When the criteria for secondary wound closure (the delayed primary wound closure of World War II) were discussed, all present voted for bacteriologic control plus clinical judgment when both were practical. When they were note, the vote for clinical judgment alone was 10 and for bacteriologic control alone, 5. The optimum period for closure was considered to vary from 3 or 4 days to 10 or 12 days after wounding. Again the discussion is reminiscent of the lessons that had to be relearned in World War II.


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7. Indications for thoracic surgery in the forward area were listed as a second chest wound; serious hemorrhage; large effusions; indriven bone fragments; large foreign bodies; a collapsed lung on the same side as the wound; considerable comminution of the ribs; infection; hemothorax with tension; pneumothorax with tension; foreign bodies in the heart, pericardium, or mediastinum; bilateral chest injuries; and anaerobic infection accompanying hemothorax.

8. Indications for operation in the base were listed as empyema; lung abscess; secondary hemorrhage; sinuses caused by foreign bodies; pus pockets; hemothorax with symptoms, which was to be treated by repeated aspirations as necessary; infected hemothorax, for which the treatment was radical thoracotomy.

9. All present voted for thoracic surgery under local infiltration when this technique was possible. When it was not, 18 preferred gas-oxygen anesthesia; 9, ether; 2, chloroform; 3, morphine and atropine; and 1, warm ether.

The symposium closed with a discussion of various techniques of thoracic surgery.

Conclusions from the World War I experience.-Colonel Yates (7), in a detailed analysis of a personally managed series of 104 chest wounds, listed the errors which had been made in them, including failure to appreciate the inherent seriousness of the wound; inadequate preoperative preparation; and a number of unwise surgical procedures. When these cases were analyzed according to the first operation performed, Colonel Yates arrived at the following conclusions:

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

2. Limited thoracotomy (p. 11) is applicable to the treatment of less seriously wounded casualties if deep repair can be effected through slight enlargement of the wounds of entrance and exit and if the bulk of a hemothorax can be aspirated by large cannulas introduced through a defect in the parietal pleura.

3. Thoracotomy of necessity, which is a more extensive application of limited thoracotomy, should be used when immediate deep repair is required and when there are reasons for using the parietal wound to secure closure.

4. Thoracotomy of election will find wider application in the future as a primary procedure. If two-stage procedures are practical, it is the preferred secondary procedure. "Indeed," Colonel Yates concluded, "with the development of simple and effective methods of primary drainage, thoracotomy of election may prove to be the safest treatment of massive pneumothorax unless the patient's condition be poor."

At the conclusion of his chapter on thoracic wounds in the official history of the U.S. Army Medical Department in World War I, Colonel Yates made some general observations reminiscent of the observations made by Col. Edward


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D. Churchill, MC, Chief Consultant in Surgery in the North African (later Mediterranean) theater in World War II. These observations were embodied in the circular letters issued by the Office of the Surgeon, Headquarters, North African theater and later embodied in War Department Technical Bulletin 147, issued from the Office of The Surgeon General in March 1945 (p. 201).

Success was possible in the management of thoracic wounds, wrote Colonel Yates, if personnel competent to furnish treatment and materials essential for treatment were so organized and disposed that the wounded could be well and properly served. From a medical standpoint, service to the wounded man was all-important. From a military standpoint, service to the fighting man was most important. The exaggerated individualism of civilian surgeons, Colonel Yates continued, led them to misunderstand, or to fail to appreciate, the responsibilities of their colleagues in the Regular service to Army organization and administration. Similarly, medical officers of the Regular service apparently underrated the personal aspirations of physicians and nurses to provide their patients with the best possible care. On both sides, there was lack of preparation to fulfill their obligations, and neither side hesitated, justly or unjustly, to hold the other side responsible for its own deficiencies.

Colonel Yates concluded:

An Army must be an autocratic organization, but many evils peculiar to autocracies can be minimized. This can be accomplished effectively so far as the Medical Corps of the U.S. Army is concerned by developing cooperation in advance. Civil surgeons can and should prepare themselves not merely to give professional services but to give them under the restrictions of military methods, the worst attribute of which is inflexibility. Similarly, the officers of the Regular Medical Corps, kept directly in contact with progress and changing requirements of surgical practice, will find more liberal interpretation of regulations, which are fixed products of past experiences and often are literally opposed to immediate necessities. National security should be enough of an incentive to produce the necessary personal adaptation and coordination of effort.

As experiences in a later war were to prove, there is no category of wounds to which these generalizations are more applicable than wounds of the thorax.

EMPYEMA IN WORLD WAR I

In World War I, the U.S. experience with thoracic conditions was concentrated chiefly upon the treatment of infection, and, more specifically, upon the treatment of the infected pleura (21). This was partly because of the numerous epidemics of measles and pneumonia that occurred in camps after this country entered the war and partly because of the worldwide epidemic of influenza and pneumonia in 1918 and 1919.

In the voluminous literature on empyema that appeared after World War I, very little attempt was made to separate posttraumatic organizing hemothorax and subsequent hemothoracic empyema from metapneumonic or synpneumonic empyema, in spite of the significant differences between the two groups of cases. The explanation, advanced by both British and U.S. surgeons


18

in World War II, is probably that the influenzal empyemas so overshadowed the traumatic variety in both numbers and importance that the separate identity of the posttraumatic variety was not realized. It is remarkable, nonetheless, that these differences were not more clearly appreciated by the military surgeons who had observed the large numbers of empyemas during World War I.

The Empyema Commission

During the second half of 1917, pneumonia, in part primary and in part secondary to measles, was causing approximately 65 percent of all deaths in the U.S. Army. The Surgeon General, in an attempt to find some means to combat this terrible loss of life, appointed a commission to study pneumonia in its clinical, pathologic, and bacteriologic aspects. One of the far-reaching results of the work of this commission was the determination that the beta hemolytic streptococcus was playing the principal role in many cases of pneumonia and was giving rise to an entity which the commission termed interstitial bronchopneumonia.

Because empyema constituted such an important complication of pneumonia, especially when the pneumonia was of the hemolytic streptococcic variety, The Surgeon General, in the early spring of 1918, created another commission to take up research work where the first research commission (p. 13) had left off. This commission, later known as the Empyema Commission, carried out its work at Camp Lee, Va. It had two groups of members. The continuous members were Maj. Edward K. Dunham, MRC; Maj. Evarts A. Graham, MRC; Maj. James F. Mitchell, MRC; Capt. Alexis V. Moschcowitz, MRC; Maj. Ralph A. Kinsella, MRC; Capt. Richard D. Bell, MRC; and Lt. Franklin A. Stevens, MRC. The temporary members were Capt. William L. Towers, SC; Capt. Clifford C. Hartman, MRC; Lt. Frederick D. Zeman, MRC; Lt. Milton B. Cohen, MRC; Miss Maude H. Hays, dietitian; Miss Bessie E. Stocking, artist; and Miss E. Pauline Jacobs, secretary.

When the Commission began its work, there were two major problems to be solved. The first, as already mentioned, was the development of empyema as a sequel to the pneumonia that was itself a sequel of measles, meningitis, and influenza. The second problem, which was extremely acute, was the prohibitively high case fatality rate associated with the standard routine of early operation as soon as empyema was diagnosed.

Immediate problems.-The management of empyema had been a subject of discussion for many years before World War I. Arguments were heated and acrimonious, with the protagonists of one method or another holding firmly to their opinions. One group defended early operation. Another group held out just as stoutly for repeated aspiration or aspiration and pneumothorax. Roe (22), in England, for instance, recommended paracentesis thoracis as a curative measure in both empyema and "inflammatory hydrothorax." In


19

the United States, Bowditch (23) of Boston, in 1852, had urged that pleuritic effusions be managed by repeated aspiration.

When the United States entered World War I, early operation was routine in empyema that developed after the stage of resolution of pneumonia had begun. The infection was usually pneumococcic in origin, and the pathologic process found at operation was characterized by walled-off cavities of varying sizes filled with thick pus. The surgeons of World War I, who were chiefly conversant with this type of empyema, had either forgotten that beta hemolytic streptococcic empyema also exists or had failed to recognize the differences between it and the pneumococcic type. The differences were considerable. The hemolytic streptococcic type developed very early, sometimes concomitantly with the pneumonia itself. It was characterized by the presence of large quantities of thin, purulent fluid, which accumulated rapidly. Most important, the walled-off cavities that were characteristic of pneumococcic empyema were completely absent; in the early stages of the beta hemolytic streptococcic variety of empyema, there was no attempt at walling off at all.

One reason that empyema was so dreaded by most surgeons was their lack of understanding of the pathologic process and its correction. As a result, drains were incorrectly placed. Drainage tracts were permitted to close too soon. Some surgeons followed the example of Mozingo (24), who believed, as was later proved false, that a cavity could be sterilized and then left alone with its residual pneumothorax.

For all of these reasons, empyema was often allowed to become chronic, and patients drifted from one clinic to another. No thought was given to physiotherapy or to early ambulation and active exercise, to help the lung reexpand and prevent a shrunken, deformed, and stiff chest. When the errors and misunderstandings associated with empyema in civilian practice were carried over into wartime practice, the results of management were intolerably bad.

Physiologic Concepts in World War I

Early in World War I, the physiologic concepts of the respiratory mechanism were surprisingly erroneous (19). The prevailing belief was that the mediastinal pleura constituted a more or less rigid partition between the two pleural spaces, so that the result of an open pneumothorax would be the collapse of the lung of the affected side, without any effect at all on the opposite, uninvolved side.

More important than the error of this concept was the significance read into it, that the former fear of a pneumothorax associated with intrathoracic surgery was groundless, since the worst that could happen would be the temporary collapse of a single lung. Many experienced surgeons removed shell fragments from the lung without any special equipment for combating the effects of pneumothorax, and in their astonishment over the survival of their


20

patients, they drew extravagant and unwarranted conclusions from their results. One of these conclusions was that no special protection was necessary against the effects of pneumothorax. Duval of the French Army and Moynihan of the British Army, both highly experienced and capable surgeons, said Graham, helped to create the dangerous impression that operations on the chest could be performed quite as safely as abdominal operations, without heed to any possible complications from pneumothorax. Duval (15) stated unequivocally that it was quite as safe to handle the lung and operate on it at thoracotomy as it was to handle a coil of intestine and operate on it at laparotomy. Surgery of the lung, he remarked, "does not require any of those pressure chambers which the genius of the Germans invented and their persuasion made us think necessary."

As Graham (19) pointed out in his 1957 review of the development of thoracic surgery, an accurate knowledge of the effects of pneumothorax was considerably more than an academic matter. It was a requirement of fundamental importance. The full development of chest surgery, including the management of empyema, was impossible until this knowledge was available and fully utilized. It was the comprehension of the importance of respiratory physiology that so sharply differentiated the practices and results of chest surgery in World War I and World War II (p. 198).

Work of the Empyema Commission

The experimental work on dogs carried out at Camp Lee, under the direction of Major Graham and Captain Bell, included studies on the comparative physiology of animals and humans; studies on pneumonia and empyema in both species; and studies on normal and diseased animals when the intact chest and the open chest were filled with sterile fluids and infected fluids.

Changes of concept.-As the result of these studies, the following conclusions on pneumothorax were possible:

1. In a normal chest, in which there is no thickening of the mediastinal pleura, alteration of the pressure in one pleural space produces almost the same alteration in the contralateral space. It could be concluded, therefore, that an open pneumothorax on one side affects the other side also, though not quite to an equal degree.

2. The lethality of an open pneumothorax depends upon its size and the vital capacity of the patient, just as the research unit operating in Europe had also demonstrated (p. 14). A unilateral pneumothorax would be fatal if the opening were beyond the size which the vital capacity of the patient could withstand. If his vital capacity were high, a much larger opening could be withstood than if it were low. If the vital capacity were so greatly reduced that its level approached that of the vital air requirement, then a very small, unilateral opening could be fatal.

Practical application.-The conclusions derived from the experimental work of the Empyema Commission had immediate practical applications. At


21

this time, an epidemic of acute streptococcic empyema was raging in U.S. Army camps. The usual method of treating it was to resect a rib and establish open drainage of the involved pleural space as soon as the diagnosis was made. The case fatality rate averaged 30.2 percent and was as high as 90 percent in some series. The principal cause of death, the studies of the Commission showed, was open pneumothorax, created by surgical means during the period of acute pneumonia. Operation was being done on patients whose vital capacity was already seriously lowered by their pneumonic disease. It was still further lowered, sometimes to the lethal level, by the establishment of an open pneumothorax.

The policy recommended by the Commission was:

1. Careful avoidance of open pneumothorax during the active period of the pneumonic disease.
2. Early sterilization and obliteration of the empyema cavity.
3. Maintenance of the patient's nutritional status.

By this policy, simple aspiration every 3 or 4 days was substituted for surgery during the acute pneumonic stage, or closed drainage was instituted. The object of treatment was to prevent fluid accumulations from becoming large enough to cause dyspnea. Even before the Commission had advocated this policy, it had become evident in some civilian hospitals that these patients did better under repeated aspiration or with closed techniques of drainage than by early, open drainage, but it was not until the work of the Commission was published that the rationale of the improved results became clear.

When the purulent exudate had become thick, when recovery from acute pneumonia had occurred, and when the empyema could be presumed to be localized, open drainage, usually with rib resection, could safely be performed. As a rule, these criteria could be met in about 10 days. By delaying the institution of open drainage until the pus had become thick, the surgeon made his opening into an abscess cavity instead of into the free pleural cavity. By the delay, the harmful effects of open pneumothorax were avoided in patients who, because of their extensive pneumonic process, were already dyspneic and often cyanotic. If a little air entered the pleural cavity when deferred surgery was instituted, it did little harm then because, with the clearing of the pneumonic process, the vital capacity had increased. Furthermore, the mediastinal pleura had become stabilized as the result of edema and inflammatory induration, and it was therefore less likely to be crowded over into the contralateral pleural cavity and to compress the lung on that side.

When the new plan of management became generally effective, results promptly improved. At Camp Lee, for example, the case fatality rate fell from 40 percent to 4.3 percent. At Fort Riley, Kans., Maj. William J. Stone, MC, chief of the medical service and in charge of the pneumonia wards, reported convincing comparative figures: In a series of 85 patients with empyema treated by the old plan of early, open operation, the case fatality rate was 61.2 percent. In a second series of 96 patients treated by early aspiration and late surgery,


22

the case fatality rate was 15.6 percent. In a third, later series treated by the same methods, the case fatality rate was 9.5 percent.3

Chronic Empyema

There is no doubt that the majority of cases of chronic empyema that were the residua of World War I were the result of ill-timed and poorly planned early management. Col. William L. Keller, MC (25), reporting on a large series of patients observed after the war, found that 75 percent had "accessory" pockets of infection; 15 percent had foreign bodies in situ, including drainage tubes and bismuth paste; and 90 percent had osteomyelitis of the ribs. Beta hemolytic streptococcus had been the infecting agent in this series, and in most cases, drainage had been instituted too early, before localization had occurred. Many patients therefore developed total empyemas, the majority of which were inadequately drained, and, as a result, residual pockets of infection formed and persisted.

Three types of operations had been developed to deal with these chronic empyemas:

1. In 1879, Estländer (26) recommended removal of the ribs overlying the pleural cavity. This operation was essentially a limited extrapleural thoracoplasty.

2. In 1890, Schede (27) went one step further and recommended the removal of the tough, edematous fibrous pleura overlying the pleural cavity along with the ribs.

3. In 1893, Fowler (28) in the United States and Delorme (29) at the Val-de-Grâce Hôpital in Paris recommended that chronic empyema be managed by decortication. This operation, which became the preferred surgical treatment for organizing hemothorax and hemothoracic empyema, is discussed in detail elsewhere (p 24).

Tuffier's (30) personal statistics for these operations in World War I were as follows:

1. When the Estländer operation was used, the case fatality rate was 18 percent; 50 percent of the patients were classified as cured and 32 percent required additional surgery.

2. When the Schede operation was used, the case fatality rate was 28 percent and 50 percent of the patients were cured. The remainder were not followed.

3Dr Berry writes of these matters from personal experience. In April 1918, just after he had entered the Army, he was assigned to the hospital at Fort Riley. Here he worked under Major Stone and also served as assistant to Maj. George Draper, MC, of New York City. Major Draper was then studying the bacteriology and epidemiology of pneumonia and meningococcic cerebrospinal meningitis both at the Fort Riley Hospital and among the troops of the 89th Division in training at nearby Camp Funston. Dr. (then Lieutenant) Berry's work was done in the laboratory under the immediate tutelage of Dr. Edward C. Rosenow, one of the most distinguished bacteriologists of the time, who had been asked by the Army to work as a civilian on the problem of hemolytic streptococcus in milk and other dairy supplies and food, as well as among human carriers.- J. B. C., Jr.


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3. When the Delorme operation was used, the case fatality rate was 15 percent and 48 percent of the patients were cured. The remainder were not followed.

Both the Estländer and the Schede operations had many disadvantages. They left considerable deformity. They were attended with considerable risk. The chest was always infected. The postoperative course was long and trying. The surgery necessary required patience, tact, and a profound knowledge of surgical principles as well as a clear understanding of respiratory physiology. Colonel Keller (25), at Walter Reed General Hospital, Washington, D.C., made outstanding contributions to the courageous and successful treatment of many of the empyema casualties of World War I.

Hemothoracic Empyema

In World War I, aspiration was favored as the initial treatment of hemothorax; it led to early recovery and return to duty. The bad results of organized hemothorax were realized, as was the fact that infection could be anticipated in 25 percent or more of all such cases. As the war progressed, therefore, there was growing agreement that in cases of massive clotting, thoracotomy, with mechanical cleansing of the pleura and tight wound closure, was the procedure of choice. It was carried out by three methods:

1. Mere debridement of the wounds of exit and entrance.

2. Formal thoracotomy at the site of election, with the repair of wounds of entrance and exit.

3. Removal of foreign bodies, with resection and suture of the lung according to the indications.

Also as the war progressed, postoperative airtight drainage came to be considered better than repeated aspiration, and early ambulation and activity were recommended. Thus at the end of World War I, there existed the prototype of the methods of treatment of hemothorax and organizing hemothorax used with such brilliant results in World War II.

Many observers in World War I recognized that the late results of an inadequately treated or neglected hemothorax could be extremely serious. They included pulmonary compression, thickening of the pleura, immobility of the diaphragm, poor pulmonary expansion, shoulder drop, scoliosis, and dyspnea (which might be incapacitating).

The dangerous possibilities of secondary infection of hemothoraces were also recognized. Soltau (31) reported the presence of gas-producing organisms in 48 percent of infected cases and of streptococci in 40 percent. The seriousness of these observations is apparent when it is recollected that 75 percent or more of wounds of the chest were associated with hemothoraces.

Hemothorax associated with thoracic injuries provided all the conditions favorable for pleural infection. They included lacerated tissue, the unyielding costal parietes, exudation that was more rapid than compensatory absorption


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(with resulting increase in the hemothorax), and the presence of retained foreign bodies and of bacteria. The presence of blood in any amount was irritating and could lead to a serofibrinous serositis. With the development of hemothorax, the blood was defibrinated by the physiologic movements of the chest, and the fibrinous exudate spread over the entire pleural lining. Infection readily followed.

When an acute pyothorax was added to the burden of recent wounds and exposure, it became an extremely serious complication, particularly when, as often happened, the casualty could not receive the personal, individual attention he could have received in civilian life. Chronic pyothorax, even when it was treated as superbly as it was by Colonel Keller, inevitably caused material disability.

DECORTICATION IN EMPYEMA

Development of Operation

Numerous observers, beginning with Laennec, had noted that in chronic empyema, the lung beneath the thickened membrane was often normal and that its reexpansion was often prevented not by pulmonary disease but by a false membrane deposited on the pleural surface.

Delorme (29), in 1893, was the first to make practical application of this observation in a "tuberculous" abscess of the chest wall with intrapleural extension. The operation consisted of the removal of two ribs and of the thickened membrane overlying the parietal pleura and the lung. The next year, at autopsy, he removed a leatherlike membrane from the lung of a patient who had had tuberculous pleurisy for 6 months and had died after rib resection. When the membrane was removed, the underlying lung was found healthy and expansile.

Delorme's first decortication for empyema was performed in January 1894 (32), on a patient who had been ill for 4½ years. The case was apparently highly favorable because, as he described the operation, as soon as the peel was split, the lung began to burst forth, much as the pulp of an orange appears when it is peeled, and full pulmonary reexpansion occurred. The end results were excellent. Two years after he had performed the operation, Delorme applied the term "decortication" to it (33).

Although Delorme devised the operation of decortication, he was not the first to employ it on the indication of empyema. This distinction belongs to Fowler (28), who performed the operation in 1893, in line with his contention that the fibrous investment of the pleura in chronic suppurative disease must be removed before pulmonary expansion could be achieved. His patient, a 35-year-old woman, had been ill with empyema since January 1891; five thoracenteses and open drainage had all been unsuccessful. The mass of cicatricial tissue which he dissected free from the thoracic wall, diaphragm, pericardium,


25

and lung occupied three-fifths of the right pleural cavity. Within 28 days, the lung had completely reexpanded, and the good results led Fowler to suggest the possibilities of this method for other instances of old empyema that had resisted the means ordinarily employed for their cure.

Delorme clearly described the pathologic process in chronic empyema as a "shell" or "false membrane," and neither he nor Fowler mentioned the removal of thickened pleura in their reports. It is odd, therefore, that the totally erroneous idea soon developed that decortication was the removal of thickened pleura. This incorrect concept persisted in many quarters until World War II. The term "pleurectomy" was, in fact, employed by C. H. Mayo and Beckman (34) in 1914 and by Newton (35) in 1916. On the other hand, Dowd (36), in 1909, stated that the firm exudate in empyema became so incorporated with the pleura that the resulting membrane resembled a thickened pleura, and the pathologic process was also correctly conceived of by Lilienthal (37) and by Spencer (38) in 1915, by Grey Turner (14) in 1919, by Moynihan (39) in 1920, and by Graham (40) in 1924.

Indications and Results

In spite of the unquestioned soundness of the concept of decortication, the operation never became widely popular until World War II. Its dangers, which were real enough, were overemphasized, and although some surgeons advocated it on strict indications, others would have nothing to do with it.

Delorme (41), in 1912, had pointed out that patients with posttraumatic empyema were particularly favorable candidates for decortication. Grey Turner (14), in a postwar discussion of chest wounds, described empyema following hemothorax as more serious than the empyema seen in civilian practice, and for this reason he considered drastic measures such as decortication more justified in its management. Moynihan (39), among others, emphasized the importance of freeing the lung from constricting adhesions when thoracotomy was performed for the removal of missiles; he thought, in fact, that many times liberation of the lung was more important than the removal of the foreign body.

Decortication was mentioned in the report of the Empyema Commission in World War I (21), but the members had no great enthusiasm for it. Their remarks, in substance, were as follows:

This operation, like the Estländer and Schede operations for empyema, carries a high mortality rate, and the patient who submits to the serious risk which it entails has little assurance of complete relief. Extensive decortication is usually attended by serious hemorrhage. In many instances, a complete operation is impossible because the fibrous tissue on the surface of the lung is only part of a more general fibrosis of the whole lung, and projections of scar tissue extend from the surface deep into the lung substance. Colonel Keller (25), in 1922, made much the same point. He considered decortication suitable


26

for some patients, but he qualified the recommendation with the sound warning that nothing could effect reexpansion of a lung which had become fibrotic.

The Empyema Commission recognized the benefits of chemical decortication with Dakin's solution in some cases of empyema, and Gurd, in a discussion of the operation at the 1946 meeting of the American Association for Thoracic Surgery (42), recalled that this technique had been used successfully by British surgeons in World War I when hemothoraces could not be evacuated by aspiration. Gurd also mentioned that during World War I, he and some of his associates made it a practice, when they were operating for empyema, to remove a fragment of rib sufficiently large for the hand to be introduced into the chest, so that what amounted to a very early decortication could be carried out with sponges.

It was entirely logical that decortication should not have attained wide popularity when it was first introduced:

1. The operation was usually performed only on poor risk patients, who had been ill for months or years.

2. The long duration of hemoorganization or suppuration had usually resulted in enormous thickening and organization of the visceral pleura, while formation of fibrous synechiae between the constricting membrane and the pleura had resulted in such a degree of cellular intimacy between the pleura and the investing layer of organized exudate that the operation was almost doomed to failure when it was undertaken. In addition, the lung had frequently become fibrotic.

3. If a complete operation was attempted in the face of these conditions, dangerous hemorrhage could result, or bronchopleural fistulas might follow. Complete operations were therefore not the rule. Usually, only the outer surface of the lung and the fissures were liberated. No attempt at visceroparietal, mediastinal, or pericardial separation was made. A compromise operation was sometimes employed, consisting of deep crosshatching over the thickened visceral pleura, sometimes with liberation of the lung along with the circumference of the cavity, the patch of thickened pleura over the cavity being left intact. This operation was sometimes combined either with a thoracoplasty or with a Schede type of operation, with removal of the overlying parietal pleura.

4. Anesthesia for chest surgery was entirely inadequate.

5. Blood transfusions were seldom employed.

6. Chemotherapy and antibiotic therapy were not available, and surgery in the presence of fresh suppuration was therefore particularly hazardous.

As a result of these unfavorable conditions, the case fatality rate in decortication was high. The statistics which Violet (43) collected in 1904 covered 160 operations. Although 41.9 percent of the patients were entirely well and 12.5 percent improved, the case fatality rate was 12.5 percent. In 1915,


27

Lilienthal (37) reported 23 decortications on patients ranging in age from 16 months to 53 years. There were 18 cures, but there were also 4 deaths.

Hedblom (44), in 1920, reported on 30 of 150 patients with empyema treated by decortication, with 1 hospital death; 3 later deaths from other causes; 15 primary cures; and 5 additional cures after secondary operations. At the time of the report, three patients had persistent sinuses, and three were still under treatment.

By far the best results reported for decortication before World War II were by Eggers (45) in 1923, 146 operations with only 5 deaths (3.4 percent).

Decortication in World War II

As these various facts show, decortication was an operation whose real potentialities were not fulfilled when it was first introduced, in World War I, or in the interim between the wars. Not until the North African campaign in World War II was it finally appreciated that infection of the pleura in an otherwise healthy chest, most often from a neglected hemothorax with clotting and organization, was entirely different from empyema resulting from disease within the lung; that is, pneumonia. In July 1943, at the chest center established by Colonel Churchill at the 53d Station Hospital, Bizerte, Maj. Thomas H. Burford, MC, performed the first decortication, with strikingly successful results.

The idea of decortication in organizing hemothorax came to him, Major Burford related, not because of the past record of the operation but from the British operation known as "turning out the clot." This procedure was used in hemothoraces in which aspiration, for one reason or another, was not satisfactory. After the patient had been stabilized to the point at which mediastinal shift was unlikely, a limited thoracotomy was done, the clot was scooped out, and drainage instituted.

The firmness of the exudate or peel, which the British repeatedly emphasized, led Major Burford to speculate that it might be worthwhile to cut through it and see what lay underneath. He had the opportunity at the chest center in Bizerte when two patients with organizing hemothoraces of almost precisely the same degree came under his observation. He used one of them, an American soldier, as a control, treating him by the standard routine. The other patient, a German prisoner of war, was treated by thoracotomy and decortication. A small incision in the pleura revealed that it was entirely normal. When the incision was extended, normal lung, to the surgeon's surprise and delight, herniated through the opening. The peel was then pulled off the lung, just as one would pull off a glove. The patient made an excellent recovery.

After this demonstration, decortication was brilliantly developed in the North African theater by Major Burford, Maj. (later Lt. Col.) Paul C.


28

Samson, MC, and their associates. It proved not only safe but strikingly successful in the management of organized hemothorax and hemothoracic empyema. The optimum time for its performance was within 3 to 6 weeks after wounding. At this time, there were few organizing adhesions between the overlying exudate or peel and the underlying healthy lung. It was therefore possible to strip off the peel, with complete reexpansion of the lung, just as Delorme had observed this phenomenon when he introduced the operation 50 years earlier.

THE PERIOD BETWEEN THE WORLD WARS

There were three reasons for the founding of the American Association for Thoracic Surgery in 1918, (1) the awakening realization of the importance of chest physiology, (2) the work of the Empyema Commission, and (3) the development of surgery for pulmonary tuberculosis. The major portions of the first programs of the association were occupied with problems of empyema and tuberculosis.

At this time, acute empyema and chronic empyema were both so common and so much a part of general surgical practice that it was seriously debated whether this condition should even be included in thoracic surgery. During the years between the wars, unfortunately, the lessons of World War I that were so ably recorded in the official medical history of the war were forgotten. Until the advent of the sulfonamides in the late 1930's, chest surgeons continued to concern themselves with the management of empyema by aspiration, closed drainage, various techniques of irrigation, and open thoracotomy, as well as with collapse operations for chronic empyema.

Hemothorax was not a major problem in civilian injuries of the lungs and pleura, which were chiefly crushing or were caused by bullets or small weapons such as ice picks. Carnes Weeks (46), a surgeon for the New York Police Department, from his experience with a small group of patients with bullet wounds of the chest, recommended prompt evacuation of hemothoraces, to permit reexpansion of the lung and to avoid protracted invalidism.

By the end of the period between the World Wars, whole blood transfusions were being freely used in civil practice. The significance of Robertson's (47) work in World War I, however, had not been read aright, and the profession had been lulled into a false sense of security by erroneous concepts of blood substitutes. Therefore, as the United States entered the war, the entire emphasis was upon plasma and the so-called blood substitutes, and no preparations were made for the use of whole blood in quantity, upon which, during the war, the chief emphasis was to be placed for resuscitation and for preparation for surgery.

During the period between the wars, there was a dramatic development in thoracic surgery. This was partly from the impetus received in this field during World War I and the return to civil life of young surgeons who


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had seen the possibilities in it. Also during this period there were enormous advances in anesthesia for chest surgery. In addition, and perhaps most important of all, interne and residency systems in the United States were developed, and many young thoracic surgeons were well trained and ready to take over where their pioneering predecessors had left off.

The United States was catapulted into World War II, in which it fought in three major theaters, each of which, in turn, produced its own peculiar diseases and problems. By this time, preventive medicine was a highly developed specialty. In World War II, therefore, there were no serious epidemics in military camps in the United States, as in World War I, nor was there a worldwide epidemic of influenza. Pneumonia had been on the decline for many years, and the sulfonamides, and later penicillin, were available as powerful therapeutic agents. As a result, infection was never a serious problem, and attention could be focused upon (1) the proper surgical treatment of wounds by methods that rested upon a sound anatomic and physiologic basis, and (2) early wound closure, with restoration of as nearly normal function as possible.

It was realized from the beginning by the theater consultants in surgery (Colonel Churchill in the Mediterranean theater, and Col. (later Brig. Gen.) Elliott C. Cutler, MC, in the European theater) that adequate initial surgery furnished the surest means of preventing infection. It was also promptly recognized by them that plasma was not an adequate substitute for blood, which was provided and utilized in steadily increasing quantities.

In the Mediterranean theater, under the guidance of Colonel Churchill, the attention in chest wounds was centered on the status of the lung rather than, as in World War I, upon the pleural space. The physiologic disturbances incidental to wounding, which required prompt treatment, were managed in the most forward hospital unit, sometimes by very simple measures, sometimes by extensive surgery. Emphasis was placed upon adequate resuscitation, measures to secure prompt reexpansion of the lung, and rehabilitation. Chest centers for expert reparative surgery and convalescent care were established in the communications zone.

As a result of the principles and policies developed for their management, empyema and other complications of chest wounds were relatively infrequent, and the mortality rate was surprisingly low. The treatment of these wounds probably reached its zenith in the period extending from the spring campaigns of 1944 to the end of the war. The explanation is obvious: Blood banks were established in all theaters of operations and in the United States, to supply blood for oversea use. About this time, penicillin (figs. 1 and 2) became available in quantities sufficient for general use. Perhaps most important of all, the personnel of hospitals and auxiliary surgical groups now included large numbers of well-trained thoracic surgeons who had not only profited by their training and experience in the United States but who were also veterans in the surgery of combat-incurred chest trauma.


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FIGURE 1.-Sir Alexander Fleming, who discovered penicillin in 1928.

FIGURE 2.-Sir Howard Florey, who took up Fleming's work and extracted the essential compound from the liquid in which penicillin grows.

BRITISH CHEST SURGERY IN WORLD WAR II

In 1939, when Britain entered World War II, there were a number of favorable circumstances in the management of war wounds (13, 48). Gordon-Taylor (13) listed them as follows:

1. Important information concerning combat-incurred chest wounds had been gained by the observation and secondary treatment of the pensioners


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of World War I. A great deal had thus been learned about the late results of retained foreign bodies, imperfectly treated hemothorax, and the management of chronic empyema.

2. The technique of anesthesia for chest surgery was well developed.

3. The importance of blood replacement was realized, and blood banks had been established.

4. One-stage lobectomy had been introduced, and radical chest surgery of an extent that had previously been impossible was now feasible.

5. The importance of physical therapy and active chest exercises, to prevent deformity and respiratory impairment, had come to be realized.

6. Thoracic surgeons had been trained in increasing numbers in recent years. This group, together with the residue of chest surgeons who had gained their experience in World War I, provided a nucleus of competent thoracic surgical personnel for both the Armed Forces and the special Emergency Medical Service centers in the United Kingdom.

The British also had excellent equipment for thoracic surgery, which was looked upon with envy by U.S. chest surgeons in the early days of the war, before their own equipment reached the optimum quantitative and qualitative levels later attained. Before this desirable situation developed, the generosity of the British War Office made it possible for U.S. surgeons to obtain a good deal of much needed equipment.

Administrative Considerations

The British Medical Service had a civilian consultant in chest surgery, Mr. A. Tudor Edwards, but had no Army consultant in this specialty. The greatest number of chest injuries incurred in combat were not handled in Army installations but in the Emergency Medical Service centers in the United Kingdom. Mr. Tudor Edwards controlled their organization, which was based on a regional system. Some regions, because of shortages or specialized personnel, were undesirably large. Surgeons attached to various hospitals often acted as consultants for much larger areas.

These centers continued the primary treatment initiated by Army surgeons and cared for practically all casualties with chest wounds returned to the United Kingdom. The period between the outbreak of the war and the heavy fighting in May 1940 provided the opportunity for them to become well organized and highly developed. They were therefore in an excellent state of readiness when the first battle casualties began to arrive in May 1940 and when the enormous numbers were received shortly afterward from Dunkirk. In the emergency, the chest centers could not limit their admissions to thoracic casualties, but the attempt to direct all chest casualties to them was generally successful.

Soon after the British entered the war, plans were made for the formation of special chest units, but they had not been implemented by the time of the


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Battle of France. Two small surgical chest units, which were later organized for service in the Middle East, worked in Italy, and two similar units were established after the Normandy landings. No special provisions were made for chest surgery in Burma, but a unit was preparing to go to India when the war ended.

Clinical Considerations

Air-raid casualties.-The British learned a great many lessons from the casualties of air raids, both before Dunkirk and during the entire war. There were exceptional opportunities for early treatment-much earlier than was possible under battlefield conditions-because the injuries so often occurred in close proximity to hospitals. Many casualties survived who might not have lived had they sustained similar injuries in the field.

During the air raids, even very severely wounded casualties were often treated by primary thoracotomy, with complete wound excision, evacuation of hemothorax, and resection of damaged lung, and were discharged from the hospital within 3 weeks.

Crushed and so-called stove-in chests were frequent, from falling masonry and from traffic accidents in the blackout, as well as from bomb injuries. Paradoxical respiration, a serious feature of these injuries, was easily controlled by effective strapping over a pad laid over the damaged portion of the chest.

Two complications were characteristic of air-raid injuries. One was severe, acute dilatation of the heart, which occurred so rapidly that in some of the earlier cases, before its importance was realized and a routine of treatment adopted, the casualty did not survive. The second was the accumulation of tracheobronchial secretions (the wet lung of U.S. surgeons), which had to be evacuated promptly to prevent purulent bronchitis, atelectasis, and fatal pneumonia. Bronchoscopy was employed if simpler methods, including catheterization, did not achieve prompt results.

Combat casualties-In the period before Dunkirk, the British, according to their official history (48), made many errors in the management of chest injuries because they ignored the principles of primary wound management that they should have known well. Almost all casualties who received initial wound surgery underwent wound repair without wound excision or provision for drainage. When they were received in the British Isles, almost every wound thus treated was heavily infected, and many patients were seriously ill with intrathoracic infections. Ironically, many casualties who had received only first aid, with the simple application of a field dressing, were in much better condition and presented no such sepsis as has just been described. Men who had been left untreated on stretchers for 3 or 4 days because their injuries seemed so severe that treatment was not considered practical owed their lives to the fact that their wounds had not been sutured.

These patients with severe intrathoracic infections required weeks and months of treatment. They demonstrated again the importance of correct


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initial wound surgery and the risk of suturing an unexcised or imperfectly excised chest wound.

In the North African theater, the British chest surgeons, like U.S. medical officers, learned the important lesson that war wounds of the chest must be treated in two phases:

1. Patients with gross disturbances of the cardiorespiratory system furnished the real emergencies of traumatic chest surgery. If these physiologic derangements were not promptly corrected, they could be fatal. Initial treatment must therefore consist of standard resuscitative measures, including the administration of blood and oxygen, closure of a sucking pneumothorax, and correction of mediastinal displacement by early aspiration of air and fluid.

2. The second phase of management consisted of measures to prevent infection, or its treatment if it had developed. These procedures included repeated aspirations of the chest by needle, or by major thoracotomy if aspiration failed, decortication as indicated, and the institution of physiotherapeutic measures designed to encourage normal breathing and prevent thoracic deformity. The prewar concept that wounds of the lungs would be widely excised or even treated by lobectomy was not put into practice. D'Abreu, in fact, knew of only one lobectomy performed in Italy. The U.S. experience was much the same (vol. II, ch. I).

Hemothorax and hemothoracic empyema-As the British experience progressed, certain facts concerning hemothorax and subsequent empyema became evident:

1. Clotting could be expected in from 5 to 10 percent of all hemothoraces. The U.S. experience pointed to a somewhat higher incidence.

2. The incidence of clotting was increased by inadequate or delayed aspiration.

3. Clotting was more likely to occur when thoracic damage was considerable. The theory that thromboplastic substances were liberated in severe injuries and that clotting was increased in this variety was supported by the observation that it was much more frequent in massive damage produced by a rapidly moving bullet from a rifle or a machinegun. It was thought possible that the presence of Staphylococcus aureus, which produces no fibrinolysin, might play a part in the incidence of clotting.

The British recognized three stages or forms of clotted hemothorax:

1. Multiple pockets containing air and fluid demonstrable on roentgenograms and associated with major degrees of pulmonary collapse. At operation in these cases, fluid was found entrapped among masses of organized or organizing fibrin.

2. Massive blood clots, which really represented a pleural hematoma rather than an organizing fibrinothorax and which required prompt removal. These patients had higher fever than was present in patients with the simple type of clotting, and there was rapid diminution of chest movements, associated with


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notable flattening. If the lung became atelectatic, bronchial breathing and pyrexia might lead to an erroneous diagnosis of pneumonia.

3. Hemothorax with clotting and low-grade infection. In this variety of hemothorax, the organisms were usually encased in fibrinous masses, and the bacteriologist required the clot as well as specimens of pleural fluid for satisfactory aerobic and anaerobic cultures.

Early in the war, it was the British practice to delay aspiration of hemothoraces from 36 to 48 hours, because of the fear of bleeding. Air replacement was also advocated. The latter practice was soon dropped, and it gradually became the routine to aspirate the chest promptly, particularly when surgery was not needed to repair the parietal wound or to control hemorrhage. This policy, according to Tudor Edwards (49), was based on the following objectives:

1. To relieve intrapleural pressure.

2. To eliminate blood, which is an excellent culture medium.

3. To prevent massive clotting.

4. To secure early reexpansion of the lung and thus limit the area of involvement if infection should occur.

5. To shorten the period of invalidism.

Whenever it was practical, the British preferred to perform all thoracenteses in a separate room fully equipped for the purpose and in the charge of a trained orderly. When this arrangement was possible, from 20 to 30 aspirations could be handled daily. The procedure was explained to the patient, who was told that it would cause him little pain or discomfort. The site of puncture was decided by the study of roentgenograms in two planes. It was a common error to go in too low. The fluid was examined routinely by smear and culture. Serial roentgenograms were taken during the postoperative period, and the necessity for subsequent aspiration was determined by staff conferences. Breathing exercises were part of the routine management.

The British, like U.S. Army surgeons, were somewhat slow to realize the importance of distinguishing between posttraumatic empyema, which gave rise to a far higher incidence of chronicity if not properly treated, and metapneumonic empyema. They explained the delay, as did U.S. surgeons, by the fact, already noted, that this difference was not emphasized as it should have been at the end of World War I, because the plethora of cases of influenzal empyema completely overshadowed the small number of cases of posttraumatic empyema.

By the end of 1943, the British had learned that clotted hemothorax was best handled by what they termed "turning out the clot," through a small intercostal incision. The chest wall was sutured at the conclusion of the operation, and the secondary effusion was aspirated regularly.

This technique, although it greatly reduced the risk of empyema, was not always followed by satisfactory reexpansion of the lung. Decortication,


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which had been introduced by Major Burford of the 2d Auxiliary Surgical Group (p. 27), proved the answer to this problem and came into general use. The majority of surgeons considered that results were greatly improved by temporary intercostal drainage, especially when several tubes were used, with one or more in the apex of the pleural cavity. Other surgeons closed the chest and relied on aspiration and instillation of penicillin.

When decortication came into general use, results were secured far more promptly, and were far better, than the results achieved by rib resection and drainage. Casualties treated by the latter method usually required months of hospital treatment and, despite it, often went on to develop chronic empyema, which had to be managed by elaborate thoracoplastic procedures and which often resulted in permanent disability.

Tudor Edwards (49), in a presentation at the Inter-Allied Conference on War Medicine in January 1945, produced evidence of the improved results accomplished by early aspiration. In World War I, the British incidence of empyema had been 37 percent. In 249 chest injuries studied in 1943, the incidence of empyema had been 21.6 percent when aspiration was delayed beyond 48 hours and 12.5 percent when it had been done earlier. In 1,683 casualties treated in chest centers in the United Kingdom between D-day and 30 September 1944, after early aspiration had become routine, there were only 148 cases of empyema, 8.7 percent. There were only 9 deaths in these 1,683 chest injuries, 5 in the first 251 patients received in the chest centers and 4 in the remaining 1,432 patients. Penicillin, while invaluable in infected thoracic wounds, did not play a major role otherwise in the satisfactory results. What mattered most was that the pleural cavity be kept dry. If this was accomplished, infection did not gain a foothold.

GERMAN CHEST SURGERY IN WORLD WAR II

On 3 May 1945, an Allied Force Headquarters directive made captured German prisoners who were wounded or ill the responsibility of the Fifth U.S. Army medical service (50, 51). The following week after the final German surrender in Italy, the theater surgeon, Brig. Gen. (later Maj. Gen.) Joseph I. Martin, directed that a number of qualified U.S. Army medical officers, among them Lt. Col. (later Col.) Howard E. Snyder, MC, Consultant in Surgery to the Fifth U.S. Army surgeon, visit German medical installations and make a complete survey of them.

Administrative Considerations

Casualties with chest injuries, like other casualties with major wounds, were usually evacuated to the rear from the German medical installation (Hauptverbandplatz) that corresponded with the U.S. Army clearing station. In a more forward station (Truppenverbandplatz), which correspond with


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a U.S. Army battalion aid station, an occlusive dressing had been applied to an open chest wound and, if necessary, tracheotomy had been performed. Shock therapy had also been instituted (physiologic salt solution, external heat by electric heaters, Coramine (nikethamide) or Periston).

The German medical field manual listed the thoracic surgery to be performed at the Hauptverbandplatz as tracheotomy, closure of open chest wounds, and aspiration of the pericardium if cardiac tamponade was present. Blood and blood substitutes were also administered here.

Definitive primary surgery for patients with transportable chest wounds was performed at the Feldlazarett, which corresponded to a U.S. Army evacuation hospital. In very busy times, all casualties requiring major surgery might be evacuated to the general hospitals (Kriegslazaretten) assigned to an army group, to permit the units farther forward to care for men who would be able to return to their units within a reasonable time after operation. At such times, it was not unusual for patients with serious wounds to receive no surgery at all. The German system of medical care was extremely flexible, but its flexibility tended to favor the lightly wounded at the expense of the seriously wounded, the group to which U.S. Army medical officers gave first priority.

Clinical Considerations

Most of the patients with chest wounds whom Colonel Snyder observed in the German hospitals that he surveyed had been wounded weeks and months earlier. Their generally pale and anemic appearance was in contrast to the healthy appearance of most patients in U.S. Army hospitals. Clinical practices in the German medical service explained the difference: The Germans used blood in little more than homeopathic amounts, and their almost complete lack of aseptic techniques accounted for the prevalence of wound infection, the extent of which was many times more frequent than in U.S. Army hospitals and almost incomprehensible in the year 1945, regardless of military circumstances. About 60 percent of the chest patients had empyema, and Colonel Snyder was informed that this complication could be expected in about this proportion of shell-fragment wounds and in about 30 percent of all bullet wounds.

Opinions expressed by German surgeons concerning the management of chest injuries varied widely in details but were in general agreement in respect to most principles. The information secured was, in substance, as follows:

Shock of some degree was present with most chest wounds, and, unless there was a wide-open pneumothorax or a severe and menacing hemorrhage, its management took precedence. When there was serious internal bleeding or an increasing hemothorax, constant observation of the casualty was necessary, for shock might merge into collapse and the patient might bleed to death. When large numbers of wounded men were received at the same time and the surgeons were busy in the operating rooms, a junior medical officer, or whoever


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else might be available, was appointed to make so-called collapse examinations, to be certain that a failing circulation and serious hemorrhage would be detected before they became irreversible.

Surgery was not performed in perforating thoracic wounds unless rib fragments had been indriven. The policy of early, repeated aspiration in hemothorax, which was routine in U.S. Army hospitals, was not employed in German hospitals, and there seemed no routine technique of management for this complication. Some surgeons said that aspiration was never employed unless it was required to relieve dyspnea associated with a large hemothorax or hemopneumothorax. Others said that aspiration was performed within the first 5 days after wounding. One consulting surgeon said that this had been the practice earlier in the war unless respiratory difficulties demanded immediate relief but that it had recently become the policy to employ aspiration as soon as the casualty recovered from shock, usually within 48 hours after wounding.

The treatment of empyema seemed rather more uniform. Closed intercostal (von Bülow) drainage was instituted as soon as infection or purulent exudation became evident. The catheter was attached to a water-seal bottle, which was usually converted into a Wangensteen-like suction apparatus by the use of two additional bottles. Drainage was continued until the cavity was obliterated. If this had not occurred at the end of 6 months after wounding, the empyema was considered chronic, and thoracoplasty and decortication were performed by a modified Schede technique. Rib resection was seldom used.

Only a small number of patients with thoracoabdominal wounds were observed in the German hospitals. None of the wounds were extensive, and in all instances, surgery had been limited to laparotomy with simple closure of the thoracic wall wound. No patients were encountered who had been treated by the transdiaphragmatic technique that was regarded so favorably by U.S. thoracic surgeons (vol. II, ch. III). When inquiries were made about this technique, the replies were vague. One surgeon stated that the thoracic approach might be used if the chest wound was large and the intra-abdominal wound small.

No facilities were provided for gas anesthesia or for positive pressure delivered by an anesthetic machine. A good machine was available for oxygen therapy, but it seemed to be seldom if ever used for expanding the lungs during intrathoracic surgery. No endotracheal tubes were seen, and no thoracic surgeon or anesthesiologist mentioned the endotracheal technique. Most anesthesia for chest surgery was supplemented by Pentothal sodium (thiopental sodium) given intravenously.

Since there were no facilities for positive pressure at operation and no well-trained anesthesiologist experienced in anesthesia for chest surgery, it was concluded that German casualties with chest wounds could not have had the advantages of modern intrathoracic and transdiaphragmatic surgical techniques.


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SPECIAL TYPES OF WOUNDS

Thoracoabdominal Wounds

The British experience in the World Wars-Thoracoabdominal wounds are discussed only briefly in the official British medical history of World War I. Gask (12), writing in 1919, noted that because of the protection afforded to the right side by the liver, the majority of these wounds were on the left side. He believed that the diaphragm could be repaired efficiently only from above. The preferred procedure was to open the chest, suture the diaphragm, deal with the chest injuries according to the indications, and then perform laparotomy if there was evidence of injury to hollow abdominal viscera. If a shell fragment had lodged in the substance of the liver, it might be necessary to remove the missile through the thoracotomy, excise any devitalized hepatic tissue, and then suture the diaphragm. Wounds which involved the diaphragm were apparently very troublesome; Lockwood and Nixon (52) considered their repair more important than the repair of any hollow or solid abdominal organ.

The discussion of thoracoabdominal wounds in the British history of World War II begins with the steadily improving prognosis of these injuries in World War I (53). In the Somme offensive in 1917, the recovery rate was 18.7 percent; all of the survivors had injuries of solid viscera only. In November 1917, General Bowlby reported to the Surgical Congress at Val-de-Grâce a recovery rate of 49 percent, and an almost similar rate was reported a few months later by Sir Cuthbert Wallace. The best results of the war, a recovery rate of 66.6 percent, were reported by Gordon-Taylor in the Hunterian Lecture in 1919, as the work of a group of Fourth British Army surgeons in the autumn of 1918. Maj. Charles Saint reported a recovery rate of more than 80 percent, but the experience included only 22 cases, in only 2 of which hollow viscera were involved. The situation was much the same in the 53 cases reported by Maj. John Anderson, in which the recovery rate was 79.2 percent.

Several series of thoracoabdominal injuries are mentioned in the official British medical history of World War II: 208 cases, with a case fatality rate of 38.0 percent; 59 cases, with a case fatality rate of 46 percent; a collected group of surgical cases, ranging in number from 10 to 78, in which the case fatality rate ranged from 8.3 percent in 12 cases (1 death) to 60 percent in 15 cases (9 deaths). The average case fatality rate was estimated at about 30 percent. As in the U.S. experience, the mortality rate depended upon the number of organs injured, whether the injured organs were solid or hollow, and the number and severity of the associated injuries. Emphasis was placed on the high incidence of thoracic complications likely after even promising surgery for thoracoabdominal wounds.

Associated hemothoraces required particularly careful attention because these patients were particularly prone to develop lower lobe atelectasis, massive pleural clotting, and empyema.


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The popularity of the transthoracic approach was somewhat less among British than among U.S. surgeons, who found it increasingly useful as the war progressed. The explanation is probably that the British had relatively few thoracic surgeons assigned to their casualty clearing stations. A few British surgeons, after visiting forward U.S. medical installations, adopted the transthoracic approach and found it satisfactory. Even from the beginning of the war, of course, a surgeon with a thoracic bias would approach the thoracoabdominal wound from above if he were certain that the injuries were confined to the upper quadrants of the abdomen.

There was general agreement among British surgeons that the transthoracic approach was indicated:

1. In injuries of the spleen.

2. In right-sided thoracoabdominal wounds in which the only abdominal injury was in the liver. In such cases, repair of the diaphragm was impossible from below but simple from above.

If the thoracic wound was too high in the chest wall to permit free access to the diaphragmatic area, even after excision of the wound and traumatic thoracotomy, it was the British practice to deal with the wound of entry first and then carry out formal thoracotomy in the region of the eighth and ninth ribs. When a separate abdominal approach was employed, the wound of the chest was dealt with first.

The U.S. experience in World War I-Thoracoabdominal wounds do not appear in the index of either the surgical volumes or the statistical volumes of the history of the U.S. Army Medical Department in World War I. Nevertheless, the seriousness of wounds involving the diaphragm was well recognized, as was the risk of bile leakage from an injured liver in right-sided thoracoabdominal wounds.

On the whole, there was fairly general agreement that when thoracoabdominal injury was suspected, it was best to attend to the chest injury first, partly because chest surgery was better tolerated than abdominal surgery and partly because more favorable conditions for laparotomy were thus established. If the chest wound was of the sucking type, it was mandatory to take care of it first. If it was small and if the major damage seemed to be in the abdomen, then the abdominal wound was handled first. In the chapter on abdominal injuries in the official U.S. history (54), Col. Burton J. Lee, MC, called attention to the straight vertical incision, beginning near the thoracic wound, used by the French Army surgeon, Pierre Duval. Repair of both the thoracic and the abdominal injury was possible through this incision.

In a report on thoracoabdominal injuries in 1920, Charles Gordon Heyd (55) pointed out that early in the war, all injuries of the diaphragm were repaired through the abdomen. It was only when chest surgery was established on a rational basis that repair through a thoracotomy approach was found to


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be easier. It was also found possible, as the war progressed, to deal with certain intra-abdominal injuries through an enlargement of the diaphragmatic wound. Surgery through this approach was usually limited to the reduction of herniated viscera and the repair of injuries of the liver, the spleen, and portions of the cardiac end of the stomach. Injuries of the colon were also occasionally repaired through the diaphragm.

Heyd concluded that a critical review of the immense collective experience of World War I suggested that there should be a wider application of major thoracotomy to deal with wounds involving the diaphragm and the viscera immediately subjacent to it.

The Spanish Civil War experience-Since Trueta's (56) book on the Spanish Civil War experience was written from the standpoint of soft-tissue wounds and fractures, thoracoabdominal wounds do not appear in the index. In Jolly's (57) text on the same experience, there is mention of 26 such wounds observed in 238 abdominal injuries (11 percent). There were 123 recoveries in the total series, 10 of which occurred in the 26 thoracoabdominal wounds. Not included in the series are a number of cases in which only the liver was injured and operation was not considered to be indicated because hemorrhage did not threaten life.

Jolly's impressions derived from his experience with these wounds in the Spanish Civil War were in substance as follows:

The operation selected should depend upon three considerations, (1) the type and direction of the wound; (2) the type of projectile; and (3) most important, the amount of damage to thoracic and abdominal viscera.

The transdiaphragmatic operation should be reserved for wounds in which there is (1) extensive damage to the chest, manifested by intrathoracic hemorrhage or open pneumothorax; (2) a large diaphragmatic perforation, with or without herniation; and (3) a wound of exit in the upper abdomen, indicating the course of the projectile. Transdiaphragmatic laparotomy is limited to the left side unless one considers suture or tamponade of the liver by a right-sided transpleural approach as a laparotomy.

The abdominal approach should be used in longitudinal wounds or wounds of considerable obliquity, in which it appears impossible to explore the abdominal cavity adequately by the transdiaphragmatic approach. Chest injuries are cared for first, and the diaphragm is repaired from above.

Both chest and abdominal cavities should be closed without drainage with the single exception of operations in which tamponade of the posterosuperior surface of the liver has been necessary. Even in such cases, an attempt should be made to convert the open pneumothorax into a closed wound. Suture of lacerations of the liver should be carried out when feasible. If tamponade is necessary, the wound track should be separated from the pleural cavity by high suture of the diaphragm to the parietal pleura above the chest wound.


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RETAINED INTRATHORACIC FOREIGN BODIES

Early observations-Many of the older reports of retained intrathoracic foreign bodies, like those of retained intracardiac foreign bodies, are of doubtful authenticity. A truly authentic case, however, was reported by Moore (58), in 1842. The wound, incurred in action at sea in 1796, was stuffed with clothing, some of which was coughed up 18 months later. The patient, a captain in the French merchant marine, continued on active duty for many years and had an exciting life. He participated in a number of active engagements, was twice captured by the enemy, and was once shipwrecked for 7 days. For the last 15 years of his life, his health was continuously poor. At autopsy, it was found that the shot, which was in the pulmonary substance on the right side, had entered between the fourth and fifth ribs, fracturing the fourth rib on the right. The diaphragm was at the level of the fifth rib, and the affected lung was a third of normal size.

As Collis and Qvist (48) expressed it, the tendency has always been to be "hypnotized" by the presence of large foreign bodies and to think immediate operation is essential. The early idea was to remove the objects whenever possible. Fraser (4), in his monograph on chest injuries in the Crimean War, told the story of the gallant officer, who, after being "poked at" for a long time by the surgeon, finally inquired about the point of the procedure. The surgeon said that he was searching for the bullet, and the wounded man replied, "I wish you had said so earlier, because you will find it in my waistcoat pocket."

Surveys of many series of cases in subsequent wars all indicate that while retained foreign bodies frequently, sooner or later, produce grave consequences, they may also continue completely asymptomatic. The difficulty is that there is no way of distinguishing one group of cases from the other.

The World War I experience-No really reliable data on retained foreign bodies were collected during World War I. The chief controversy concerned the management of symptomless objects. There was general agreement that large objects (more than 2 cm. in any one dimension) should be removed, but there were sharp differences of opinion about smaller fragments or bullets in the absence of hemoptysis or of a clear inflammatory reaction about the object; in the latter circumstances, removal was recommended, regardless of size.

The British observed that rifle bullets and small pieces of shell lodged in the lung and pleural cavity seldom caused any disability and that, in the absence of infection, their presence did not delay the return of the soldier to full duty. Unless symptoms were present, therefore, they preferred to leave the objects in situ. In contradistinction to this general point of view, Grey Turner (14), in 1919, stated that after 4 years of military experience, he was more and more impressed by the fact that retained foreign bodies, no matter where they were situated, were likely to cause trouble.


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The psychosomatic aspects of retained foreign bodies played a part in their management from the Crimean War on (4). In the Civil War (5), it was found that "the peace of mind which the extraction of the foreign substance invariably induces in the patient is in itself a strong reason for using every judicious means for their removal." In World War I, Grey Turner (14) noted that patients received in home hospitals often complained of persistent shortness of breath and other irritative symptoms or simply suffered from the knowledge that they harbored foreign bodies. Even soldiers on pension, who did not have to fear return to military service, were apprehensive about them.

During World War I, a great deal of attention was paid to techniques of removing foreign bodies, including the blind fluoroscopic-triangulation technique of Petit de la Villeon and the use of the Hirtz compass.

The British experience in World War II-Early in World War II, it was the British practice to remove foreign bodies from the lung routinely, even if they caused no symptoms (13, 48). After 50 operations had been performed in one unit, removal of these objects was abandoned as unjustified unless it could be accomplished as part of thoracotomy performed on some other indication. As experience accumulated in air raids, the policy was developed of removing any fragment larger than 1 by 0.1 cm. Wedge resection of the lung, to include the foreign body, was the preferred technique, with the idea that damaged lung tissue should not be left in situ to become a source of future trouble.

Typical of the British military experience is d'Abreu's report of 339 retained missiles found in 1,000 thoracic wounds, of which 51 were in the mediastinal and cardiac tissues (13). Of the 221 objects in the lung, 100 were removed and 2 others could not be found; there were 2 deaths in the 102 operations. Of the 49 objects in the pleura, 44 were removed and 1 could not be found; there were no deaths.

Nicholson (cited by d'Abreu (13)), who reported 26 instances of empyema in 39 patients with retained intrapleural foreign bodies, had no doubt of the menace of subsequent infection and late hemoptysis in all such cases, though he granted that several years must elapse before the real risks could be proved. Most surgeons who advocated removal of foreign bodies on the ground of what might happen in the future agreed that there was no real urgency about operation.

WOUNDS OF THE HEART AND PERICARDIUM

The gravity of wounds of the heart has been recognized from ancient times. Aristotle's view that the heart alone, of all viscera, cannot withstand serious injury prevailed for many centuries.

It was not until 1895, according to Ramsdell's (59) excellent review in 1934, that the first attempt to suture a wound of the human heart was made, by Cappelan of Norway. He failed. In March of 1896, Farina of Italy


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failed in a similar attempt. In the light of these failures, Stephen Paget's (60) remark, made shortly after Farina's attempt, seemed entirely justified: "Surgery of the heart," he said, "has probably reached the limits set by Nature to all surgery; no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart."

The words had scarcely been uttered when they suffered the fate of many another medical generalization. In September 1896, Rehn of Frankfurt successfully sutured a stab wound of the right ventricle. In 1909, Peck collected from the literature 160 cardiac operations, 59 of which were successful. After successive additions to this collected series by Pool in 1912, Ballance in 1920, Smith in 1923, and Schoenfeld in 1927, Ramsdell, in 1934, tabulated 428 cardiac operations with 233 recoveries (55.5 percent). In the medical literature in the United States, 55 of these cases were recorded, in which there were 39 recoveries (70.8 percent). It is a pity that Ballance's (61) suggestion in the Bradshaw Lecture in 1920 has not been followed, that suture statistics be made up on the basis of whether or not the heart was opened at operation. In his collection of 150 surgical cases, in which the case fatality rate was 31.57 percent, 63 wounds were combat incurred; there were 16 deaths (26.03 percent).

The World War I experience-Wounds of the heart do not appear in the index of the statistical volume of the history of the U.S. Army Medical Department in World War I, and they are dismissed briefly in the text of the surgical volume (7) : Early operations on the heart and pericardium were infrequent because the wounds were either promptly fatal or were treated expectantly. Cardiac wounds disclosed by operation were "easily remedied, requiring little more than simple suture." The approach to wounds of such gravity is surprisingly casual.

A number of successful operations for cardiac wounds were done in the latter part of World War I by French surgeons, chiefly Pierre Duval. When there has been no confirmation by post mortem or exploration, however, it is often difficult to accept all recorded cases of cardiac wounds as authentic, and even exploration may not furnish absolute proof. D'Abreu (13), in his account of war wounds of the chest in World War II, questioned whether any of the four cases of early removal of a metal fragment from the heart recorded by Makins in the British official history of World War I (62) was "indubitably extracted from one of the heart chambers" except the missile removed by Fraser. At any rate, this patient recovered, as did Sampson's patient, who was operated on for a wound of the left ventricle. In the other two cases recorded by Makins, both instances of bullets in the cardiac wall, death followed surgery.

As d'Abreu observed, inspection of specimens in war museums attests the gravity of all wounds of the heart, whether they are caused by high-velocity missiles, shell fragments, or spicules of bone. Makins commented in the British medical history of World War I that the War Office Collection of specimens illustrated every lesion described from accumulated experience of


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the whole history of surgery but contributed little or nothing not already gleaned from the classical literature of cardiac surgery. The magnificent British War Office Collection of specimens in the Royal College of Surgeons was largely destroyed by enemy action in May 1941, but, fortunately, drawings exist of most of them.

According to Makins (62), wounds of the heart involve the right ventricle, the left ventricle, the right auricle, and the left auricle in the descending order of frequency. In his opinion, the anatomic incidence corresponds with the relative degree of exposure of the cardiac surfaces toward the front of the body, plus the relative size of the area presented by the external aspect of each chamber. The published records, as well as the specimens in the War Office Collection, substantiated the great frequency of ventricular wounds and suggested that, in many instances, both ventricles were implicated. A possibly misleading feature of the War Office Collection, Makins noted, was that, with four exceptions, all the specimens were secured from patients who survived their wounds long enough to reach the hospital. Limited as was the British experience in World War I, he concluded, it showed that "rare" conditions were more frequent than previously supposed, and it also afforded evidence "that the treatment of injuries to the heart has now become a definite and promising field for the surgeon."

Cardiac surgery between the World Wars-Wounds of the heart do not appear in the indexes of either Trueta's (56) or Jolly's (57) books on the Spanish Civil War. Between the World Wars, however, the writings of Tuffier, Duval, Carrel, Graham, Beck, Cutler, Bigger, Elkin, and others recorded successive advances in cardiac surgery. During this period, the basic techniques were developed that were used so successfully for the management of these wounds in World War II. Elkin's (63) cumulative study of 61 cases from Emory University Division of Grady Hospital, Atlanta, Ga., published in 1944, may be taken as typical of the status of civilian traumatic cardiac surgery at the time the United States entered World War II. In the first 38 patients, all treated before 1940, there were 16 deaths (42 percent). Seven of the fatalities were caused by infection. In the 23 patients treated after this date there were 5 deaths (22 percent), none of which was caused by infection. The lowered case fatality rate and the absence of fatal infection could not be attributed to chemotherapy; penicillin was not yet available, and the sulfonamides were used in only one case in the series. The improved results were attributed, instead, to more careful surgical technique and more precise preoperative preparation, particularly the use of intravenous replacement therapy.

The British experience in World War II-The British experience with wounds of the heart in World War II does not seem to have been extensive; these injuries do not appear in the index of the surgical volume of the official history. D'Abreu (13), in the supplement on chest surgery in the British Journal of Surgery, described several small ventricular wounds treated by suture but devoted his chief attention to retained foreign bodies. He mentioned 4 or 5 isolated cases in which they were removed and also reported 51


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cases, out of 339 cases of retained missiles, in which foreign bodies were retained in the mediastinal and cardiac tissues. Operation was undertaken in 30 cases, and the objects were successfully removed in 28. There were two deaths. One patient died on the operating table after an uneventful operation, and the other in 24 hours, "with the heart in fibrillation." In the latter case, the object, which lay in the wall of the left ventricle, had not been removed because of the friability of the heart muscle. Two of the missiles removed were in contact with the thoracic aorta, and another was removed from the lumen of the subclavian vein, which was sutured without subsequent edema.

Retained foreign bodies-The first operation for a foreign body in the heart seems to have been performed by Gerard in 1834. Between 1900 and 1938, according to Decker's (64) 1939 review of the literature, 109 cases were recorded. In nine instances the object passed out of the heart and into the arterial circulation. In the remaining 100 cases, there were 8 deaths in the 47 patients treated surgically and 16 in the 53 patients treated conservatively. The authenticity of case reports in which neither operation nor autopsy was performed is sometimes open to doubt, as just mentioned, and there were the usual arguments as to what harm was likely if retained objects were left in situ. Delorme cited the history of a veteran of the Napoleonic Wars who lived for 52 years with a round bullet fixed by adhesions in the pericardial sac and whose only complaint was that he could not lie on his left side, but the sequence of events was often much more serious.

Migrating missiles, said d'Abreu (13), were followed in "marathon pursuit" as they moved from body cavity to body cavity. He continued:

During the 1914-19 and 1939-45 conflicts, the existence of a fragment of metal in the heart wall or within one of the cardiac chambers seemed to provide an irresistible challenge to surgical courage and enterprise. The swirlings and gyrations of bullets and fragments of high explosive were watched by radiologist and surgeons with the same interest that "astronomical observers bestow on minor planets," and these fluoroscopic séances only served to whet the avidity of operators to rid the owners of their unpleasant tenants.

Blast Injuries

Blast injuries, a form of chest injuries which occur from exposure to the detonation of some high explosive, were not described as such in World War I. Their characteristic manifestations, however, were recognized. There were a number of references to the finding of dead soldiers on the battlefield, after explosions, without any external injury or any serious external injury, often with the nose and mouth full of bloodstained fluid. Thomson (65) found 24 such cases in 250 chest wounds. This incidence is close to the 10-percent incidence reported in the U.S. Medical Department history of the First World War (7). In this history, these injuries are described as involving the viscera alone and as due to indirect violence or sudden and considerable changes in atmospheric pressure resulting from nearby explosions.

Blast injuries were also reported in the Spanish Civil War. Perhaps for that reason, but more likely because of the injuries caused by indiscriminate


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bombing early in World War II, there was a considerable outpouring of interest, as manifested by numerous special reports and experimental studies in the literature (66), (vol. II, ch. I). As a matter of fact, at least in land warfare, blast injuries proved an almost inconsequential cause of injury and death among U.S. troops.

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34. Mayo, C. H., and Beckman, E.: Visceral Pleurectomy for Chronic Empyema. Ann. Surg. 59: 884-890, June 1914.

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40. Graham, E. A.: A Reconsideration of the Question of the Effects of an Open Pneumothorax. Arch. Surg. 8: 345-363, January 1924.

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42. 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.


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43. Violet (de Lyon): De in décortication pulmonaire dans l'empyème chronique. Arch. gén. de méd. 193 (vol. 1, series 10) : 657-678, 1904.

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62. 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. 431-475, passim.

63. Elkin, D. C.: Wounds of the Heart. Ann. Surg. 120: 817-821, December 1944.

64. Decker, H. R.: Foreign Bodies in the Heart and Pericardium-Should They Be Removed? J. Thoracic Surg. 9: 62-79, October 1939.

65. Thomson, F. G.: Notes on Penetrating Chest Wounds. Brit. M. J. 1: 44-46, 13 Jan. 1940.

66. DeBakey, M.: The Management of Chest Wounds; Collective Review. Internat. Abstr. Surg. (Supp. to Surg. Gynec. & Obst.) 74; 203-237, March 1942.

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