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Chapter XI

Contents

CHAPTER XI

Initial Wound Surgery

Lyman A. Brewer III, M.D.

GENERAL CONSIDERATIONS

Although it necessitates a certain amount of repetition, it seems worthwhile to begin the discussion of the forward surgery of thoracic casualties with a restatement of the principles which governed their management in the division and army area. As pointed out in detail earlier (p. 199), the indications for thoracotomy in forward hospitals remained in a state of flux from the landings in North Africa in November 1942 until they were clarified under the direction of Col. Edward D. Churchill, MC, Consultant in Surgery to the Surgeon, Mediterranean Theater of Operations, U.S. Army, at a meeting of chest surgeons in Marcianise, Italy, in March 1944. Experience satisfactorily arbitrated most of the differences of opinion that still existed, and the consulting surgeon, by discussion as well as directive, effectually settled the remaining issues. With the clarification of indications for thoracotomy, many fewer such operations were performed, and results were correspondingly better.

Establishment of Policies

One of the chief arguments of the surgeons who believed thoracotomy was frequently required in field and evacuation hospitals was that it was necessary to prevent infection. Thoracic casualties, like all other casualties, sometimes did die from infection, but infection was not the usual cause of the deaths that occurred soon after wounding. Early deaths were practically always due to disturbances of cardiorespiratory physiology.

In thoracic casualties, prevention of infection, however important it was ultimately, was thus a secondary consideration immediately after wounding. At this time, the chief attention was directed to the cardiorespiratory balance, which, in most wounds of the thorax without abdominal involvement (thoracoabdominal wounds are discussed separately (vol. II, ch. III)), could be restored to normal or close to normal by resuscitative measures alone. Respiration is dependent upon lung expansion, and lung expansion is dependent upon an intact thoracic cage. The object of the management of thoracic casualties in forward hospitals was therefore the restoration of a functioning lung that was fully expanded against a restored thoracic wall.


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Indications and contraindications for forward thoracotomy-While the general policy early in the Tunisian campaign and for some months afterward was to perform thoracotomy in forward hospitals on very liberal indications, experience rapidly accumulated to show that overzealous surgical interference soon after wounding resulted in an increased morbidity and mortality. The mortality rate was lowest, and complications were fewest, when forward surgeons performed major intrathoracic procedures only on specific indications. These results were what might have been expected. Thoracotomy, even when it was absolutely necessary, put an added burden on an already damaged cardiorespiratory system. When he performed it unnecessarily, the forward surgeon might unwittingly be administering the coup de grāce to the casualty.

At the meeting in Marcianise, in March 1944, it was decided that theater policy thereafter should be to limit primary thoracotomy, whether by extension of the wound or by a separate incision at a site of election, to the following indications:

1. Continuing intrapleural hemorrhage not controlled by hemostasis in the course of debridement of the chest wall. This situation was uncommon.

2. Anatomic or clinical evidence of penetration of the diaphragm, which was common.

3. Large intrapleural foreign bodies or other debris readily accessible by simple extension of the wound. These were common.

4. Wounds of large bronchi or of the intrathoracic portion of the trachea, which were uncommon.

5. Passage of a missile through, or its lodgment in, the mediastinum, with reason to suspect visceral damage, particularly injury to the esophagus. These injuries were not frequent.

The following conditions were not, in themselves, to be regarded as indications for thoracotomy either by extension of the wound or by a separate incision:

1. Foreign bodies, whether metallic objects or fragments of bone, whether they were in the lung or the pleural space.

2. Hemothorax. Evacuation of blood from the pleural cavity by suction at the time of debridement of the chest wall wound was not considered a thoracotomy.

3. Laceration or contusion of the lung in the absence of definite evidence of continuing hemorrhage or leakage of air.

It was eventually found practical to base the management of a wound of the chest on its size. Arbitrarily, a traumatic thoracotomy came to be defined as a wound of the chest wall that, when debrided, resulted in a pleural defect 6 cm. or greater in one diameter or one that resulted in the destruction of three or more ribs and all intervening structures. Actually, this definition covered most sucking wounds: Since these wounds had to be sutured to make the pleural cavity airtight, a wide debridement of the chest wall muscles was necessary in


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all of them. This sort of defect was most often caused by a fragment from a high explosive shell, though it was sometimes caused by a bullet that struck the thoracic cage tangentially or that emerged from the chest wall in such an erratic manner as to produce a disproportionately large defect. The size of the foreign body was not necessarily proportional to the size of the defect that it caused.

From the surgeon's standpoint, the important consideration was that a traumatic thoracotomy was not of his making. It was the result of wounding, and the wound was of such a size as to permit any indicated intrapleural manipulations. The intrathoracic damage in many instances might not, of itself, have required forward surgery. The surgeon simply took advantage of the exposure provided by the wound to perform whatever intrathoracic surgery might be necessary later.

Components of initial wound surgery-Initial wound surgery, on the basis of these indications and contraindications, was therefore to consist of:

1. Debridement of the chest wall, without inspection of, or operation on, intrathoracic structures. This restriction did not preclude aspiration of blood or air from the pleural cavity by means of thoracentesis or by the insertion of a catheter through the pleural defect, irrigation of the chest cavity, and intrathoracic instillation of penicillin solution. Closure of the pleural defect by approximation of the muscle and fascial planes was considered part of debridement. Closure of the pleura per se was often not possible; the pleura is so delicate and so friable that it tears when suture is attempted.

2. Traumatic thoracotomy (thoracotomy through the wound), with debridement of the chest wall and inspection of, or operation on, intrathoracic structures as indicated. If necessary, the traumatic wound was extended to achieve this purpose.

3. Formal thoracotomy, with the incision at a site of election separate from the wound as indicated.

Modifications of Policy

The policy of limiting surgery in field hospitals to nontransportable thoracic casualties (p. 91) was, of course, flexible. It varied with local conditions, including such considerations as speed of evacuation, the terrain over which evacuation was to be accomplished, the location of the evacuation hospital in relation to the field hospital, and the casualty load. Two other considerations were important, (1) the availability of anesthetic facilities and personnel and (2) the relative competence of the personnel of the two installations. Even though it meant an increase in the timelag, the patient's interests were usually better served if additional time were taken to transport him to a hospital staffed and equipped for thoracic surgery.

Similarly, the surgeon doing chest surgery in a field or evacuation hospital was expected to depart from the strict policies just outlined when there was valid reason to do so. He could, for instance, go far toward relieving the load on base hospitals if he removed accessible foreign bodies at debridement, though


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the presence of a foreign body was not, in itself, an indication for thoracotomy in a forward hospital. If the surgeon who performed the initial wound surgery aspirated the blood in the pleural cavity, a large hemothorax, which might later lead to infection or require decortication, would probably be avoided. The forward surgeon, by the exercise of sound judgment and by taking advantage of opportunities that presented themselves, could, while adhering to the general principles laid down for his guidance, prevent increased morbidity, including infectious complications, and make secondary surgery unnecessary.

DEBRIDEMENT

Debridement of all wounds of the external chest wall was mandatory, though in the absence of definite indications for more radical forward surgery, it could usually be postponed until an evacuation hospital was reached. No wound was too small to require debridement, and failure to perform it adequately could result in extremely serious infections. The operation included excision of all devitalized tissue, washing out of all dirt and foreign material with sterile saline solution, and packing of the wound with sterile fine-mesh gauze or roller bandage.

Chest surgeons who cared for casualties in base hospitals stated that it was practically always necessary to perform delayed debridement on wounds that had not been debrided originally because they were thought to be too small to need it or because they had been caused by high-velocity missiles and were regarded as sterile. In such wounds, a subcutaneous area of tissue destruction was invariably found, out of all proportion to the wound of entry, and direct extension of the infection to the pleural space could also be demonstrated. If the wound had been properly debrided, the fine-mesh gauze (ordinary bandage) could be removed in from 7 to 10 days at the base hospital and secondary closure of the wound performed.

Positioning

When only debridement of the chest wall was to be done, the location of the wound influenced the decision as to positioning on the operating table. Patients verging on shock were kept in the Trendelenburg position unless head wounds contraindicated it. The same position was considered desirable whenever lung tissue had been damaged or was to be cut across, on the theoretical assumption that the risk of air embolism would thus be decreased.

If a posterolateral traumatic thoracotomy or formal thoracotomy was necessary, the patient was placed on the intact side, with the chest at a right angle to the table (fig. 34). A small rolled blanket or bath towel was placed under the axilla to prevent pressure on the axillary nerves. Restricting pads were avoided, as was pressure beneath the costal margin on the underside of the chest, next to the table, so that there would be no compression of the underdiaphragm. Freedom of movement of the underdiaphragm was important during a thoracotomy that collapsed the uppermost lung. The thigh and leg nearer the table


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were flexed, to help stabilize the patient. The other thigh and leg were extended, and the foot was fixed to the end of the table. Rolled blankets or sandbags were used to support the anterior chest. Satisfactory positioning on the table was completed by passing a broad adhesive strapping from the lower edge of the table across the hips, between the crest of the ilium and the greater trochanter of the femur, and thence down to be fixed to the opposite side of the table.

FIGURE 34.-Position on operating table for posterolateral thoracotomy. A. Adhesive strap over hips to hold patient to table. B. Fixation of position by sandbags, used in field and evacuation hospitals when regular operating tables were not available. C. Rolled towel or small pillow in underlying axilla, to prevent injury to brachial plexus. D. Pillow under head. E. Pillow between legs. F. Site of posterolateral incision.

Steps of the Operation

The cardinal principle of debridement was that it be thorough. Failure to perform adequate debridement introduced the risk of pleural infection and could lead to empyema. The wound was often grossly contaminated by dirt and bits of clothing. Large masses of muscle were often so badly contused as to be nonviable. Bone fragments were numerous, and accessible foreign bodies were frequent.

A nice balance between radical and conservative surgery was always attempted. The wound track was excised down to the pleural opening, but only devitalized tissue was excised. Only loose fragments of bone were removed; as much as possible of the ribs, periosteum, and intercostal structures was preserved. Too radical removal of the bony structures might be followed after operation by instability of the chest wall and paradoxical motion. Rib fractures that had not penetrated the pleura were not disturbed except to smooth


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FIGURE 35.-Debridement of chest wound in field hospital.

the sharp, rough edges of the stumps with a rib-cutter. If only the inner or the outer table of a fractured rib was displaced, the intact half was left in situ, on the ground that half a rib furnished more support to the chest wall than no rib at all. Periosteum was saved at all costs; it was used to bridge defects, for the bone regenerating from it prevented paradoxical movement of the chest wall. Only accessible foreign bodies were removed. All damaged intercostal bundles were ligated anteriorly and posteriorly, whether or not free bleeding was occurring. Care was taken not to include intact intercostal nerves in the ligated bundles. Intercostal structures were not resected unless they were actually damaged, since their excision would have enlarged the defect.

A simple debridement of the chest wall (fig. 35) included removal of damaged muscle tissue; removal of accessible foreign bodies and debris; and removal of fragments of the scapula, clavicle, superficial portions of the sternum, and superficial rib fragments. The pleura was not disturbed by any of these procedures. Once the debridement had become extensive enough to include the undersurface of the ribs and the pleura, then a traumatic thoracotomy had been performed, and the resulting open pneumothorax required positive pressure anesthesia and introduced other problems and risks. It was unwise to undertake a debridement of any considerable extent without facilities for intratracheal anesthesia.

When debridement was performed according to the technique and limitations just described, it was found that no other forward surgery was necessary


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in three-quarters or more of all chest injuries. Whatever other surgery was indicated could be safely performed later at a fixed hospital in the base.

Aspiration of the pleural cavity-All but the most insignificant wounds of the chest caused a pleural defect large enough to admit a No. 15 or No. 18 French catheter. In most cases, however, diligent aspiration of the chest with a needle was just as effective in the removal of retained blood as was the use of a catheter, and, being simpler, was preferable. When a catheter was used, a suction machine was attached to it. If aspiration was adequate at operation, postoperative aspiration was seldom necessary for any length of time and was frequently not necessary at all.

In some cases in which the blood had clotted and could not be satisfactorily removed by thoracentesis, a catheter was inserted through the pleural defect and worked back and forth to break up the clots. When as much material as possible had been removed by this method, the pleural space was irrigated with from 1,000 to 2,000 cc. of physiologic salt solution, which was then aspirated through the catheter with the aid of the suction machine. A hole cut in the catheter near the proximal end permitted digital control of the degree of suction applied.

Closure of the Wound

Whether initial wound surgery was limited to debridement or included some intrathoracic procedure, careful closure of the chest wall was equally important. It was essential that the muscle layer be closed, for two reasons:

1. The muscles furnish strength and support to the chest wall, which the skin and pleura do not.

2. It was imperative that any leakage of air into the pleural cavity be prevented. If the leak was small, a tension pneumothorax might result. If it was large, a sucking wound might develop.

While closure of the pleura was not always feasible, it was desirable whenever possible; an intact and well-healed pleura furnished an efficient barrier against the spread of infection from muscle layers to the pleural cavity. The risk of empyema was always reduced when the muscle layer of the chest wall was firmly closed and when the pleura, if possible, was also closed.

There were several techniques of closure:

1. Under ideal circumstances, it was a simple matter to reapproximate the muscle layers in tiers with interrupted sutures of either fine cotton or silk for all layers. Catgut was used for the pleura. The skin wound and subcutaneous tissues were closed later in a base hospital or chest center, by delayed primary wound closure.

2. Under less ideal, and more usual, circumstances, considerable skill and ingenuity might be required to effect adequate closure without tension. It was essential that tension be avoided. It was almost invariably followed by infection, and even a minor infection could rapidly result in an infected blowing wound and total empyema.


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FIGURE 36.-Techniques of closure of sucking wound. A. Mobilization of latissimus dorsi flap to cover defect of sucking wound. B. Latissimus dorsi flap tightly sutured to edges of defect of sucking wound.

3. Whenever possible, closure was effected with intercostal structures, but extracostal muscle sometimes had to be employed (fig. 36). If the desired results could be accomplished by undermining and mobilizing adjacent muscle, closure offered no great difficulties, but the available muscle structures were usually insufficient for this purpose. In these circumstances, muscle flaps had to be swung into place. Ample muscle was available posteriorly, but near the spine, muscles are not so plentiful on the thoracic cage, and it was frequently necessary to use a flap of the erector spinalis to close the defect (fig. 37). Anteriorly, only the pectoral muscles are available (figs. 38 and 39), and if for any reason they could not be employed, closure had to be effected with subcutaneous fascia and skin.

In planning a muscle flap, it was always necessary to calculate a length 50 percent greater than the distance from its base to the far side of the defect. The additional length was necessary to compensate for the retraction that inevitably occurred when the flap was cut and that would have introduced the dangerous factor of tension, which had to be avoided. The deep fascia of the flap was used for closure of the first layer of the wound. Closure of the other layers was effected by imbrication of the split edge of the flap and of the muscles adjacent to the defect.

4. Pericostal sutures as the sole method of closure were abandoned for other techniques (fig. 40) early in the war, because of the poor results (fig. 41). The ribs were approximated while the intercostal bundle was being sutured. The Lambotte bone-holding forceps or a large towel clip proved excellent rib-approximators. Catgut sutures were sometimes used to approximate separated ribs and reduce the size of the costal opening.


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FIGURE 37.-Closure of wound with swinging flap of erector spinalis. A. Location of defect in lower posterior chest wall. B. Details of technique. Sutures placed in erector spinalis flap. C. Flap sutured in place. (Note substitution of erector spinalis for paraspinalis.)

Relaxing incisions at a distance from the wound were often a great help in closure. Extensive dissection and freeing up of the subcutaneous tissue were also helpful.

5. The use of skin and fascia to effect closure was always an undesirable improvisation, since it left an unstable and unsupported chest wall. When this technique was used, pressure dressings were necessary to strengthen the wall. Usually a plastic procedure, with a fascial graft or prosthesis, had to be employed later, at the base hospital or in the Zone of Interior, to re-create a stable thoracic cage and prevent herniation of the lung.


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FIGURE 38.-Closure of anterior wound complicated by sternal defect with pectoral muscles. A. Location of sternal defect. B. Schematic showing of relation of pectoral muscle to sternal defect. C. Detail of coverage, showing developed pectoral flap.

6. The diaphragm was occasionally employed to close certain strategically located defects in the lower thoracic cage. It was also sometimes paralyzed by crushing the phrenic nerve, in the belief that it was helpful to decrease the size of the hemithorax and thus lessen the strain on a large wound during the immediate postoperative period. Neither method was generally popular.

The skin wound was usually left open, to be closed a few days later in a general hospital at the base. In many instances, primary suture at initial wound surgery would have been entirely safe. It was never possible, however, to determine the potential virulence of a latent infection which might be present in the wound at the time of initial debridement, and the infectious complications that arose in some cases in which primary closure was done more than offset any gains accomplished by this technique. It was with good reason that delayed primary wound closure became theater policy.

Dressing-The dressing was of great importance in wounds of the chest wall. Maximum support was provided by the liberal use of wide Ace ban-


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FIGURE 39.-Closure of large anterolateral sucking wound. A. Wound after debridement. B. Schematic showing of development of pectoralis major flap. C. Closure of wound with pedicled flap of pectoralis major.

dages or of adhesive applied up to, or beyond, the midline, both anteriorly and posteriorly. The skin was first painted with tincture of benzoin or some other adherent, to provide good traction and to prevent the blistering likely to occur when an adhesive dressing was applied tightly without this precaution.


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A properly applied supportive dressing, put on without tension, reduced paradoxical motion of the chest; kept the muscles of the thoracic cage in physiologic approximation; and, by reducing pain, made the patient willing to cough and thus aided in the expectoration of material from the tracheobronchial tree.

FIGURE 40.-Technique of approximating ribs and securing airtight closure of interspace without use of pericostal sutures. Care had to be taken to avoid crushing intercostal nerves.

FIGURE 41.-Section of rib 2 weeks after catgut suture had been placed around it.


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Local Chemotherapy

The practice of using local sulfonamide therapy at operation was rather general when the war began. From 5 to 10 gm. of crystalline sulfonamide was used in the pleural cavity and in the wound, depending upon the contamination found at operation. This was a matter of individual practice, not a theater recommendation, and the policy was gradually discontinued because its tendency to cause increased and often troublesome fluid production more than offset any possible bacteriostatic effect. It was also found that sulfonamide powder at times caused granulomas of the wound and delayed healing.

A few surgeons considered local sulfonamide therapy of great value. A number considered it harmful. The majority believed that whether it was used or not made no difference at all. Its general use never reached prewar expectations. Even before penicillin became available, there was a growing belief that systemic chemotherapy was all that was necessary, and it was also believed that the sulfonamides might play some part in renal shutdown (lower nephron nephrosis), which was occurring with disturbing frequency in association with profound shock.

After penicillin was introduced, it became the rather general practice to instill it into the pleural cavity at the end of any intrathoracic operation, in 25,000- to 50,000-unit amounts, in 25 cc. of physiologic salt solution. If the infection was severe or mixed, sulfanilamide was sometimes used with penicillin. Later, this practice was also discontinued. There was never any conclusive proof of its efficacy, and most surgeons came to believe that as much was probably accomplished by systemic penicillin, in full doses. Neither local nor systemic chemotherapy nor antibiotic therapy was regarded as a substitute for extensive and thorough debridement and other sound surgical practices.

TRAUMATIC THORACOTOMY

In traumatic thoracotomy, as the term implies, the wound itself and the debridement that was a necessary part of its management provided the entrance into the pleural cavity.

In a formally planned thoracotomy, the incision was sometimes made through an extension of the original wound if the latter was so located that the necessary surgery could be carried out through it. If there was considerable damage to the ribs, the incision could be made through the bed of a resected rib. In the absence of costal damage, an intercostal incision was used. The location of the incision depended upon only one consideration, gaining the maximum exposure for the necessary manipulations. The traumatic wound was therefore not used unless, with only slight extension, it offered satisfactory exposure.


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If there was need for access to a part of the chest not readily available through an enlargement of the original incision, there was no hesitancy, after debridement had been performed, in making an elective incision that would give the desired access. If, for instance, a bullet entered the upper right chest and finally lodged in the lower lobe of the right lung, the wound of entrance was closed, and a formal intercostal thoracotomy was done at the level that would be optimum for examination of the entire right lung as well as for removal of the foreign body.

Anterior thoracotomy was discarded early in the Mediterranean experience. An incision in the thin tissues of the anterior chest wall frequently broke down, and the exposure was not so good as that secured by other incisions. By the end of the war, an anterior incision was seldom used except in traumatic thoracotomies and in an occasional cardiac wound in which it gave the necessary exposure. If it was used, an intercostal incision was preferred to rib resection, which inflicted further damage on the thoracic wall and with which closure was not as satisfactory. If an intercostal incision was used, the introduction of two rib-spreading Army-type retractors, with slow spread of the ribs, produced excellent relaxation of the chest wall and adequate exposure without rib fracture. Some surgeons carried out intercostal block with procaine hydrochloride (Novocain) before spreading the ribs. Proponents of these techniques believed that they hastened recovery and greatly reduced postoperative pain.

ELECTIVE THORACOTOMY

In the Mediterranean theater, the policy was to employ a posterolateral approach for practically all elective thoracotomies (fig. 42). It permitted satisfactory access to most of the chest structures and closure with it was seldom difficult.

A technique developed by Maj. Thomas H. Burford, MC, and suggested by Col. Frank B. Berry, MC, utilized a shortened posterolateral incision through the intercostal bundle, without costal section or resection (figs. 43 and 44). As experience accumulated, it became apparent that section of the serratus anterior was not necessary; simply reflecting it served the purpose equally well. In more than 200 thoracic injuries in which it was used, this technique provided entirely adequate exposure for the management of all types of wounds that required thoracotomy. Thoracolaparotomy, extensive decortication, lobectomy, and complete hilar dissection were accomplished through it.

A wound of the anterior superior chest presented a particularly difficult problem if it was necessary to expose the large vessels in the superior mediastinum and at the base of the neck. The mediastinal portion of the procedure


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FIGURE 42.-Exposure of thoracic cavity with rib-spreader in posterolateral thoracotomy. A. Rib-spreader. B. Rib-spreader in situ, with gentle spreading of ribs, showing: Erector spinae muscle group (a), spinous processes (b), divided latissimus dorsi, serratus anterior, and intercostal muscles (c), scapula (d), right upper pulmonary lobe (e), right middle pulmonary lobe (f), and right lower pulmonary lobe (g).


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FIGURE 43.-Burford technique of traumatic thoracotomy, using shortened posterolateral incision. A. Serratus anterior muscle. B. External intercostal muscle. C. Cut edge of latissimus dorsi muscle. (Note method of reflecting serratus anterior muscle. Thorax is entered through intercostal bundle.)

could be managed quite well intrathoracically except that the exact point of injury was frequently not determined before operation. It was therefore necessary to provide exposure of both the cervical and the mediastinal portions of the vessels. This was best accomplished by a curving anterior incision, which permitted access to the base of the neck, the clavicle, and the sternum unilaterally (fig. 45). After the clavicle had been sectioned, with Gigli's wire saw if it was available, a portion of the manubrium, with the sternoclavicular joint, could be reflected outward. All the major vascular structures could thus be exposed, and, if the pleura had not shared in the damage, the operation could be done extrapleurally.

Details of the management of wounds of the lung (vol. II, ch. I), foreign bodies (vol. II, ch. VII), cardiac wounds (vol. II, ch. II), and other special injuries are described under the appropriate headings.

Closure was effected by the same general principles described for debridement (p. 275).


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FIGURE 44.-Burford technique of traumatic thoracotomy. Closure without pericostal sutures. A. Lambotte rib clamp in place, approximating ribs. B. Closure of intercostal bundle, with removal of clamp.


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FIGURE 45.-Exposure of large vessel in superior mediastinum and at base of neck by modified Harken technique. A. Curving anterior incision exposing base of neck, clavicle, and lateral half of sternum. B. Schematic showing of section of manubrium and lateral retration of flap. C. Exposure of major vessels showing superior vena cava (a), left innominate vein (b), and arch of the aorta (c).

SPECIAL TECHNICAL CONSIDERATIONS

Lavage of the pleural cavity.-After intrathoracic procedures had been completed, all blood, blood clots, and other detritus were removed from the pleural space. As a rule, most of it could be removed by the suction tip. A certain amount, however, was likely to escape detection by this method, and the surgeons of the 2d Auxiliary Surgical Group early came to believe that thorough lavage with physiologic salt solution at body temperature was a more satisfactory plan. From 1,500 to 2,000 cc. of solution were introduced, but the amount of fluid used was not important. What mattered was that lavage be continued until the fluid returned clear and it could be assumed that all blood and blood clots that could be removed had been washed off the pleural lining.

The thoracic surgeons of the 2d Auxiliary Surgical Group had used this technique in civilian practice, and they believed that when it was employed, the postoperative effusion was reduced in amount and convalescence was smoother. The use of gauze sponges, even soaked in physiologic salt solution,


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to remove blood and blood clots from the delicate pleural surfaces was less satisfactory. The use of gauze, however gently it was employed, was certain to produce some degree of trauma, add to the amount of postoperative pleural exudation, and predispose to the formation of pleural adhesions when the lung and thoracic wall came into apposition.

A few surgeons did not accept this point of view and omitted lavage after thoracotomy, on the ground that a small amount of blood left in the pleura after aspiration would not serve as a pleural irritant. This concept was contrary to the concept prevalent as far back as World War I. Yates (1), in the history of the U.S. Army Medical Department in that war, cited Delrez' and Middleton's demonstration that blood in contact with the serosal membrane in the chest (and in the joints) is so irritating that it can provoke a serofibrinous serositis. In Yates' own opinion, any irritation of the pleural serosa provoked a very rapid serous effusion accompanied by hemothorax, the amount of fluid thus formed soon exceeding the amount of blood originally present. In view of Yates' sound approach to the problem of hemothorax, it is difficult to understand his further statement that lavage of the pleural cavity was a temptation to be resisted, as healing after it was poor. Very few of the thoracic surgeons in the Mediterranean theater shared this point of view.1

Nerve block.-While a few thoracic surgeons advocated and practiced crushing of the phrenic nerve at thoracotomy, to prevent postoperative pain, the majority believed that this was a certain way to induce paresthesis and anesthesia, which could be considerably more troublesome than pain.

As their experience increased, however, thoracic surgeons routinely performed intercostal nerve block at operation, going at least two nerves above and two below the site of injury. The decrease, or complete elimination, of pain after operation permitted the patient to breathe deeply and cough freely, and this prophylactic measure prevented many postoperative complications. A few surgeons preferred to perform intercostal nerve block by the paravertebral technique.

Manual reexpansion of the lung-Frequently, while the anesthesiologist was using positive pressure to expand the lung after intrathoracic surgery had been concluded (p. 264), it was observed that the lateral portion of the lower lobe did not expand as readily as the remainder of the lung. When the patient was lying on his side, partial collapse of the lung allowed a folding-over of this portion onto the diaphragmatic surface of the lower lobe. When the infolded portion was pulled out and unfolded manually, aeration promptly became satisfactory. The temporary manual blocking of an upper lobe bronchus, for example, sometimes allowed most satisfactory expansion of a lower lobe that was slow to expand.

1 As a matter of historical record, mention should be made of the animal experiments, on dogs and goats, carried out at the University of Chicago, to determine the effect on blood plasma proteins of filling the pleural space with plasma after loss of varying amounts of lung. The experiments were carried out by Adams and Thornton, whose final report was made to the Committee on Medical Research, Office of Scientific Research and Development, 28 Sept. 1943 (2).


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Drainage-In the early months of fighting in the Mediterranean theater, drainage was instituted routinely in lacerations of the lung, abrasions of the parietal pleura, or contamination of the pleural cavity. This was in line with the established medicomilitary policy that all thoracic wounds should be drained intercostally. An intercostal tube, however, seldom functioned more than 48 hours, and if there was fluid in the chest, aspiration then had to be employed. As the war progressed, the policy of routine drainage was replaced by the use or omission of drains according to the indications of the individual case. The decision depended not only upon the type of wound but also upon the location of the hospital, the adequacy of nursing care in it, and the surgeon's personal experience in chest surgery. If there was any question of pulmonary lacerations or pleural soiling, drainage was always instituted.

If drainage was omitted, great pains were taken to secure complete reexpansion of the lung at the time of closure; apposition of the lung with the thoracic cage was of paramount importance. The following technique was usually employed:

As pleural closure was begun, the anesthesiologist gently increased the intrabronchial pressure to between +5 and +10 cm. H2O. A No. 22 F. catheter, with at least two openings in the tip, was inserted through an opening between the sutures and was so placed as to lie in the uppermost portion of the chest. An air vent had previously been made in the catheter near the proximal end, to prevent undue suction which might damage the lung. Most thoracic surgeons did not consider it necessary to use a suction machine attached to the catheter. Attachment of the catheter to a tube with its end in a basin under water allowed all the air to bubble out. The catheter could thus be removed, and the sutures in the chest wall at the site of insertion of the catheter could be quickly tied.

By the time pleural closure was completed, the anesthesiologist had increased the intrabronchial pressure to between +15 and +20 cm. H2O. At the same time, the degree of suction was increased by digital occlusion of the hole in the catheter. The positive pressure created by the anesthesiologist and the negative pressure created by suction on the catheter usually resulted in good expansion, and when the sutures in the muscle layer were tied, the chest became airtight. After these sutures had been tied, a suture was placed around the catheter by the assistant, and it was slowly withdrawn. Then this suture was tied.

If drainage was to be employed, these precautions were not necessary, since any residual air or fluid would be expelled through the drains. It was a wise precaution, however, for the anesthesiologist to expand the lung at least once just before the wound was closed, to be certain that expansion was possible.

When drainage was considered necessary, it was preferably accomplished with two outlets (fig. 46). The first outlet was either a large rubber catheter (No. 28 or No. 30 F.), with two openings cut on each side, or standard issue red rubber tubing, ¼ inch in diameter, with a 1/16-inch wall (Catalog No. 3878000). The end was beveled, and three or four holes were cut in the distal


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2½ inches. A drainage tube of this size allowed for the escape of thick, bloody fluid, The second drainage tube, a smaller catheter, preferably of the mushroom type, was placed anteriorly in the second intercostal space to allow the escape of trapped air.

The lower catheter was not placed any farther posteriorly than the posterior axillary line or more dependently than the ninth intercostal space. Drainage through the seventh or eighth intercostal space was usually practical, since the absolute dependency essential for drainage in empyema was not necessary as a postoperative measure in an uninfected wound.

FIGURE 46.-Sites of drainage and techniques of placement of intercostal drainage tubes. External portion of tubes connected to water-seal bottles. A. Small de Pezzer catheter, with end cut out, in second interspace. B. Tube tacked to parietal pleura. C. Diaphragm. D. Fenestrated rubber tubing inserted into pleural cavity through eighth interspace in posterior axillary line.

The lower catheter was inserted through a small stab incision made at right angles through the selected intercostal space after the skin had been drawn sharply upward. The distal 2½ inches of the tube were pulled into the pleural cavity before the skin was released. With this maneuver, the intrapleural portion of the tube tended to lie slightly angulated and upward. When the tube was removed later, there was no opportunity for air to enter. In persons with a thin chest wall, the use of a loose stitch, to be tied when the tube was removed, prevented ingress of air.

After the tube had been introduced, it was pushed into contact with the parietal pleura. The tip of the beveled portion was then tacked down with a fine suture. If this was not convenient, the catheter could be held in place by looping a suture over it and tying the suture over a small gauze bolster outside of the skin. Whatever technique was used, the object was to make certain that the intrathoracic portion of the tube lay flat and unkinked along the parietal pleura.


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The smaller drainage tube, which was placed in an upper anterior intercostal space, served as an air vent. It was thought that reexpansion was more rapid and more certain when it was used.

If penicillin had been instilled into the chest, the posterior drain was clamped off for from 6 to 8 hours. Water-seal drainage was employed. Wangensteen suction was occasionally used to help remove the fluid and hasten reexpansion of the lung.

CATHETER SUCTION AND BRONCHOSCOPY IMMEDIATELY AFTER OPERATION

Though the bronchial tree was kept as dry as possible by the anesthesiologist, by suction during operation, aspiration was repeated before and during removal of the endotracheal tube. By this time, the patient was usually beginning to react and was likely to cough, from the tracheal stimulation caused by the manipulations. He thus aided in the removal of material beyond the reach of the catheter.

Whether bronchoscopy was necessary routinely at the conclusion of operation remained a matter of dispute until the end of the war:

Those who advocated routine bronchoscopy doubted that even repeated tracheal aspiration through a catheter passed through the endotracheal tube would completely clear the airway of blood and mucus. They regarded catheter aspiration as a blind procedure at best, in which it was impossible to be certain that both main stem bronchi had been adequately aspirated. They pointed out that at times it was difficult to pass a catheter into the left main bronchus, so that large amounts of material were frequently brought up through the bronchoscope after apparently satisfactory catheter aspiration (p. 291). They considered bronchoscopy as particularly necessary if there had been gross blood or clots in the tracheobronchial tree during operation.

Opponents of routine bronchoscopy took the position that when a competent anesthesiologist thought that he had cleared the air passages by catheter suction, no significant amount of blood or other material was likely to be brought up by bronchoscopy. This group of chest surgeons preferred to reserve this procedure for patients with excessive tracheobronchial bleeding and for the few cases in which resistance offered to pulmonary reexpansion raised doubts concerning the patency of the bronchi.

Both groups, of course, advocated immediate bronchoscopy if the stomach had not been properly emptied before operation and the patient vomited. As experience was gained in treating war casualties, it was seldom indeed that a patient was placed on the operating table without prior evacuation of the stomach with a Levin tube.

The persistence of audible moisture through the Magill tube or the failure of complete and prompt pulmonary reexpansion after catheter aspiration was also a positive indication for bronchoscopy.


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One objection advanced to routine bronchoscopy was that it required prolongation of the operation and deepening of the anesthetic level. The advocates of the procedure claimed that this argument was not valid because an alert anesthesiologist could so gage the depth of anesthesia that it need not be increased. It was necessary that the jaws be kept separated until the endotracheal tube was removed, and only 2 or 3 minutes were needed from that point to the completion of aspiration by bronchoscopy. Furthermore, deep anesthesia was not required or desirable for this procedure. The patient was kept sufficiently relaxed to permit easy introduction of the bronchoscope, and yet near enough consciousness to be stimulated by its passage, so that he would begin to cough.

If the position of the patient on the table permitted, bronchoscopy could be carried out while the wound was being closed or other wounds were being debrided.

There was one risk attached to bronchoscopy in this inbetween stage of anesthesia, the so-called vagovagal reflex, which was practically always associated with hypoxia. It was a general practice in civilian surgery to administer atropine (gr. 1/100 or 1/75) just before bronchoscopy was undertaken because this drug effectively blocks this reflex. This was not the routine practice in the early days of the Mediterranean theater, but after two deaths from this cause (p. 266), the policy was promptly instituted and became routine in all hospitals of the theater. These two deaths, the only ones in 436 patients in the 2d Auxiliary Surgical Group experience treated by bronchoscopy immediately after operation, represented a negligible risk, which might possibly have been eliminated by the use of atropine. Against these fatalities were the many deaths from postoperative complications probably prevented by bronchoscopy.

Failure of catheter suction was a factor of supreme importance in several cases in which recovery was complicated, and it was known to be directly responsible for at least one death:

Case 1.-A 41-year-old staff sergeant, who was somewhat overweight and barrel-chested, sustained a large posterior sucking wound of the right chest, with multiple rib fractures, 13 November 1944 at 0903 hours. Debridement was done at 2100 hours the same day. The operation was difficult and took 2½ hours. The pulse rate gradually increased during the operation, and there were several periods of cyanosis, which were relieved only by positive pressure anesthesia. Frequent aspirations through the endotracheal catheter produced only small amounts of bloody mucus. The patient died on the operating table, at the end of the operation, while bronchoscopy was being performed. The left stem bronchus was filled with blood and tenacious fluid, and the left lung was completely atelectatic. The right stem bronchus was relatively free of fluid.

Comment-This death could probably have been prevented had the essential pathologic process been recognized during operation by the surgeon and anesthesiologist and had bronchoscopy been employed without delay. It is also possible that the blocking of the left stem bronchus existed before surgery and that preoperative bronchoscopy would have insured successful anesthesia and surgery. It was consistently more difficult, as this case shows, to aspirate fluid from the left stem bronchus than from the other bronchi.


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COMPLICATIONS DURING SURGERY

Aspiration of vomitus-Aspiration of gastric contents during operation was an uncommon occurrence because vomiting was uncommon: Emptying of the stomach in the shock tent, as already pointed out, was part of the preoperative routine, and after it had been completed, the gastric tube was usually left in situ.

When vomitus was aspirated, immediate action was necessary. Fatal bronchial obstruction could develop, especially if food particles were present in the vomitus, and fatal asphyxia could supervene rapidly. Gastric contents are extremely irritating to the respiratory tract, and their presence excited an immediate, severe exudative chemical bronchitis and bronchiolitis. Without their prompt removal, a fulminating pneumonitis developed.

If vomiting occurred before the patient had completely reacted from the anesthetic, so that his cooperation could not be secured, no time was wasted in attempts to make him cough. Bronchoscopy was performed immediately because it permitted visualization of the bronchi and facilitated the removal of particulate matter. An intravenous injection of atropine was given (gr. 1/100) if no atropine had been given within the hour, to minimize the possibility of vagovagal reflex.

Cardiac standstill-Cardiac standstill was an infrequent complication of surgery in World War II. Prolonged hypoxia and shock before surgery, inadequate preoperative preparation, obstruction of the airway, poor ventilation, and blood loss during surgery were all important in its development. As experience was gained, casualties were brought to surgery in better condition and carried through operation in a better physiologic state; cardiac standstill became extremely uncommon. Probably the most important factor in reducing the risk of cardiac arrest was careful preoperative preparation (p. 237).

POSTOPERATIVE MANAGEMENT

The military experience amply corroborated the long established view that nowhere in surgery is proper postoperative care more essential to a good end result than in chest surgery. The functional level to which the patient was restored, as well as the number and extent of postoperative complications and later sequelae with which base surgeons were required to contend, was dependent, in large measure, upon the efficacy of postoperative management.

Immediate Measures

It was routine, in seriously wounded patients and in those in less than satisfactory condition, to continue transfusion during operation as well as afterward.

Patients in poor condition at the end of operation were frequently left on the table for an hour or more while additional blood was administered and oxygen was given by the intratracheal tube, Boothby-Lovelace-Bulbulian mask,


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or nasal catheter. It helped to prevent the anoxia that was the greatest hazard at this time.

There were three principal objectives of immediate postoperative care:

1. To bring the lung into apposition with the chest wall as rapidly as possible. This goal, which was essential to restore normal intrathoracic physiology and prevent empyema, was usually achieved by the use of positive pressure by the time the wound was closed.

2. To relieve pain, so that the patient would be able to maintain optimum respiratory excursions and to cough effectively.

3. To maintain a clear airway, to prevent pulmonary complications from retention of secretions.

When these requisites were fulfilled by the adoption of special measures to accomplish them, convalescence was usually as smooth as the intrinsic nature of the injury permitted.

Relief of pain-It was imperative that the patient move the chest wall after operation. His respirations had to be full and deep, and he had to cough and raise the secretions collected in the tracheobronchial tree. Both of these acts were attended with pain unless intercostal nerve block had been performed at operation (p. 246). Then this problem did not arise. If pain recurred, it could be controlled by repetition of the nerve block, which could be done without moving the patient from his bed. The effect of a single injection usually lasted for 24 hours or more, and the procedure could be repeated as often as necessary. When a patient could cough without pain, as he could when the intercostal nerves were blocked, he could usually clear his bronchi satisfactorily by his own efforts.

The effects of nerve block were longer lasting than the effects of morphine would have been. Morphine was contraindicated in these circumstances. As pointed out elsewhere (p. 246), it had undesirable effects in thoracic injuries and even more undesirable consequences after operation.

Clearance of the tracheobronchial tree-Patients were turned at regular intervals after operation until they could move themselves. Ward attendants periodically urged them to cough, in order to evacuate secretions. They helped them to sit up, and they supported the chest manually during attempts to cough. In these ways, the importance of coughing was stressed and the patients' cooperation was secured.

An increase of bronchopulmonary secretions was usual immediately after operation. If there was a preexisting bronchitis, as there frequently was during the late fall and winter, the secretions were likely to be semipurulent or purulent. If coughing was not effective and fluid was retained, the signs, in addition to a frequent, ineffectual cough, were rattling respirations, dyspnea, and sometimes cyanosis, which was a late manifestation. If the bell of a stethoscope was placed over the patient's mouth and his respirations listened to, it was easy to recognize the presence of retained tracheobronchial secretions.

When these signs appeared, an intratracheal catheter was introduced at once, and aspiration was performed at regular intervals. The expulsive effort


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which resulted from its introduction forced small plugs of material out into the larger bronchi, whence they could be removed by suction.

If catheter suction was not successful, bronchoscopic aspiration was considered to be necessary. Whenever there was doubt as to the need for bronchoscopy, the doubt was interpreted as an indication for its use. It was particularly indicated if the amounts of fluid in the tracheobronchial tree were excessive and if the patient had only partly reacted from anesthesia and the muscles of his neck and jaw had become stiff and rigid. Although bronchoscopy was a more complex technique than catheter suction, it could be performed without moving the patient from his bed.

Thoracentesis-As already mentioned, surgeons who did not drain the pleural space after forward surgery were in the minority, though a few with wide experience preferred to rely on thoracentesis. When drainage was omitted, reexpansion of the lung was maintained by the continued use of thoracentesis as long as 100 cc. or more of fluid or air was obtained by this procedure. Close postoperative observation was necessary in these cases. Some patients required no postoperative aspiration, while others required it for several days or even a week or more.

The objective of both groups of surgeons-those who used drainage and those who did not-was to obtain a dry pleura and a reexpanded lung as quickly as possible. When the techniques of drainage and thoracentesis were employed correctly, there was no discernible difference in the results accomplished.

Management of drainage tubes-Drainage tubes were milked at least once or twice daily to maintain their patency, but major adjustments and irrigations through them were avoided as increasing the risk of infection. The tubes were removed as soon as they had ceased to function, which was usually within 48 hours after operation.

It was a strict rule that no patient be evacuated with an intercostal catheter in situ. It was learned early in the war that water-seal drainage was not only unsatisfactory but dangerous during evacuation, whether the bottle was connected to a needle or to a catheter.

General Routine of Management

The remainder of the postoperative routine was, in general, much the same as after any serious chest operation:

Replacement therapy-The indications for the administration of blood, plasma, or both were the same as during resuscitation. Plasma protein and hematocrit determinations frequently revealed surprisingly low levels, even in patients who had had large amounts of blood administered before and during operation. Even in these circumstances, great care was taken not to overload the cardiovascular system, particularly in blast injuries, in which pulmonary edema was readily precipitated. It was desirable to keep the fluid intake by all routes at 2,500 cc. each 24 hours, so that the urinary output would be at least 1,000 cc. during this period. This output was regarded as the essential mini-


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mum when sulfadiazine was being given. The general policy was to give electrolytes in as small quantities as would be adequate.

Precautions against thrombosis and embolism-Thrombosis and embolism were not frequent complications in chest wounds, though they could occur, just as in any other wound. They were sometimes present as a complication of associated wounds.

The usual precautions against embolism were employed routinely. The patient's position was changed frequently. Fowler's position, which tends to cause some obstruction to the return flow of blood from the extremities, was not maintained for long periods. Simple exercises for the feet, legs, and thighs were begun the day after operation if local injuries did not contraindicate them. The lower extremities were examined daily, with a careful search for Homans' sign on each examination.

Roentgenologic examinations-Clinical observations during the postoperative period were supplemented by roentgenograms to demonstrate pulmonary reexpansion and the presence of air and fluid in the chest. Anteroposterior and lateral films were usually taken on the fourth or fifth day after operation, with the patient in a sitting position. They were taken at other times as necessary, but always within 48 hours of the time the patient was to be evacuated.

CHEMOTHERAPY AND PENICILLIN THERAPY

The Sulfonamides

Before penicillin became available in the spring of 1944, sodium sulfadiazine (1 gm. every 4 hours) was given as long as fever persisted and until the pleural space was free of fluid. To meet these requirements, it usually had to be given for from 10 to 14 days. Special precautions for the use of the sulfonamides were detailed in a medical circular issued by the Office of the Surgeon, Fifth U.S. Army, in January 1944 (3). In this circular, attention was called to the fact that most patients observed up to this time with anuria going on to lower nephron nephrosis had received sulfadiazine intravenously in 5-gm. doses. Precautions were laid down for its local use (not more than 10 gm.), and for withholding intravenous sodium sulfadiazine therapy until 24 hours after operation, after the patient had reacted from anesthesia and shock. Then the dose was not to exceed 2.5 gm. every 12 hours. Sulfonamide therapy was to be promptly discontinued if the 24-hour urinary output was less than 1,000 cc. or if gross or microscopic hematuria developed. Fluid intake was to be adequate to insure a minimum urinary output of 1,500 cc.

Since lower nephron nephrosis continued to occur in spite of these precautions, it is doubtful that sulfonamide therapy played any major role in its development. This theory was borne out by the later studies of the Board for the Study of the Severely Wounded, which produced no evidence to show that the sulfonamides played any part in the renal dysfunction (4).


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Studies on shock in the Mediterranean theater by Maj. (later Lt. Col.) John D. Stewart, MC, and his associates (5), indicated that sulfonamide levels in the blood were "erratic and uncertain." These observers warned that this "unpredictability" should be kept in mind in any appraisal of the presumed benefits of routine sulfonamide therapy in severely wounded men. Sulfonamide therapy must be controlled by blood determinations, they warned, if both overdosage and ineffective levels were to be avoided.

The early favorable results achieved in combat-incurred wounds in the Mediterranean theater led the uncritical to attribute them to chemotherapy. Accurate statistical data and control studies do not exist, but careful observation of large series of wounds convinced impartial observers that favorable results were chiefly due to early, adequate debridement, with chemotherapy of little real influence. As the war progressed, it became increasingly evident that the local or systemic use of the sulfonamides did not greatly improve the results accomplished by careful attention to surgical principles.

There was no evidence that the incidence of empyema was significantly less when either local or systemic sulfonamide therapy was employed, though established infections were thought to run a shorter course when the necessary surgery was thus supplemented.

Penicillin

By the spring of 1944, penicillin, which had originally been used only for selected cases, had become available in sufficient quantities to be used in all wounds. The routine was to begin using it as soon as the wounded man reached the battalion aid or clearing station, in the amount of 20,000 units intramuscularly every 3 hours. If it had been omitted in these installations, it was begun as soon as the field or evacuation hospital was reached. It was then continued in this amount after operation, the duration of therapy depending upon the surgeon's decision. Usually, it was given for from 7 to 10 days. If contamination was severe or infection was evident, 50,000 units was sometimes given intravenously in the shock ward and another 25,000 intramuscularly before routine administration was begun.

A few surgeons advocated instillation of penicillin (25,000 units in 25 cc. of physiologic salt solution) after all aspirations of the chest, but this was not an accepted practice.

As experience increased, it became evident that penicillin, like the sulfonamides, was not of great value, and perhaps was not even necessary if debridement had been complete. The opinion also spread that the principal benefit derived from irrigation of the pleural cavity before wound closure was not due to any chemical or antibacterial agent used in the fluid but was due, instead, to the mechanical cleansing thus achieved.

On the other hand, penicillin was of definite value in controlling infection when, for any reason, the removal of all devitalized tissue was impractical or would have resulted in excessive mutilation. Wounds around the shoulder


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are an illustration. Penicillin was also of very great value in surgery at the base.

Lack of followup studies makes it impossible to draw any conclusions as to the absolute and relative effects of these various policies. The case fatality rate among teams of the 2d Auxiliary Surgical Group for the second half of 1944, after penicillin had come into general use, was considerably lower than for the first half (25 percent against 34.9 percent) and was still lower in 1945 (20 percent). Penicillin may have played a part in this reduction. It is more likely, however, that the reduced mortality reflects the increased experience of the surgeons in the theater in the management of thoracic and thoracoabdominal wounds; their greater appreciation of the implications and possible complications of chest wounds; improvements in anesthesia; and improvements in preoperative and postoperative care, especially the liberal use of whole blood.

References

1. Yates, John L.: Wounds of the Chest. In The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 342-442.

2. Adams, W. E., and Thornton, T. F.: The Use of Plasma for Filling the Pleural Space After Loss of Varying Amounts of Lung. Thoracic Surgery Report No. 1, Committee on Medical Research, Office of Scientific Research and Development, 28 Sept. 1943.

3. Medical Circular No. 1, Office of the Surgeon, Headquarters, Fifth U.S. Army, 21 Jan. 1944.

4. Medical Department, United States Army. Surgery in World War II. The Physiologic Effects of Wounds. Washington: U.S. Government Printing Office, 1952.

5. Memorandum, Lt. Col. John D. Stewart, MC, to Surgeon, MTOUSA (Thru, C.O., 2d Medical Laboratory and Surgeon, Fifth U.S. Army, APO 464), 2 Jan. 1945, subject: Observation on the Severely Wounded in Forward Field Hospitals of the Fifth Army, With Special Reference to Wound Shock.

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