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HISTORY OF THE OFFICE OF MEDICAL HISTORY
Administrative and Basic Clinical Considerations in the European Theater of Operations
Dwight E. Harken, M.D.
Section I. Administrative Considerations
THE CONSULTANT SYSTEM
General Functions of Consultants
In the summer of 1942, a Professional Services Division was set up in the Office of the Chief Surgeon, Headquarters, ETOUSA (European Theater of Operations, U.S. Army), composed of senior consultants in most of the major medical and surgical specialties.1 It is probably indicative of the still uncertain status of thoracic surgery at this time that a theater consultant in this specialty was not included in the list, although a consultant was appointed for such a specialty as plastic surgery, for instance, which was concerned with injuries that were far less potentially lethal.
After their appointment, these consultants originated all policies pertaining to specialized care and settled all problems referred to them concerning their specialties. Administratively, the activities of the senior consultants were limited to hospitals in the communications zone and the advanced section zone. Practically, their services were also fully utilized by surgeons of the armies. As a result, during the active campaign, there were seldom any difficulties in coordinating the professional services of hospitals in the rear and in the forward echelons.
In May 1943, 36 regional consultants were appointed in general surgery and the various specialties, and a number of additional medical officers were appointed to this position before a regional consultant in thoracic surgery was appointed in May 1944. In February 1944, base section consultants were appointed in general surgery and in medicine. Still later, regional consultants
in the various specialties were appointed on the Continent, though thoracic surgery was not included in the list.
Regional consultants who were appointed to centers for specialized care in appropriate hospital centers retained their own services in the hospitals to which they were attached. Tables of organization did not provide for these regional consultants, but by D-day, and in a number of instances long before, general hospitals had thoracic surgery sections. Difficulties arose in connection with rank. In the table of organization, the chief of the thoracic surgery section was a major. The problem was, when he served as regional consultant in his specialty, to make him a lieutenant colonel without taking the rank away from the head of some other section. Eventually, this was worked out, and when it was, it was routine for regional consultants to have the rank of lieutenant colonel.
The smoothness of operation and the brilliant success of the entire senior consultant and regional consultant system made it even more unfortunate that a consultant in thoracic surgery was not appointed when the system was set up in the Office of the Chief Surgeon, Headquarters, ETOUSA, and that none was appointed during the war.
Consultant Activities in Thoracic Surgery
During World War II, the responsibility for thoracic surgery, at least nominally, rested with Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in Surgery to the Chief Surgeon, ETOUSA, Brig. Gen. (later Maj. Gen.) Paul R. Hawley. Colonel Cutler had always had a great interest in chest surgery though he was not a thoracic surgeon at heart in the modern sense of the term. In fact, when the Professional Services Division was first set up in General Hawley's Office, Colonel Cutler was convinced that thoracic surgery was not a true surgical specialty.
As time passed, his idea of supervising thoracic surgery himself seemed less practical. His associations with British surgeons who had had a wide experience in it, and his own observations on these injuries, gradually modified his point of view, and, by the end of the war, both he and General Hawley were prepared to accept thoracic surgery as an important surgical specialty.
In December 1943, in a comment in his official diary on his recent visit to Italy, Colonel Cutler listed the admirable management of thoracic and thoracoabdominal wounds that he had observed in the hospitals of the North African (later Mediterranean) theater as the chief surgical advance in the theater. He noted several points of importance: the fact that the chest wall rather than the lung was the most frequent source of hemorrhage in thoracic wounds; the consequent emphasis on adequate debridement of the parietal wound, with effective hemostasis; the minimal need for pulmonary surgery; the prevention of empyema by early, repeated thoracentesis; the importance of roentgenologic control in all thoracic injuries; and the frequency and seriousness of thoracoabdominal injuries.
On 24 January 1944, Colonel Cutler wrote to Col. James C. Kimbrough, MC, Chief, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, that for some time he had been having considerable difficulty in his assumption of personal responsibility for the proper care of thoracic surgery in the theater. He had done a great deal of the supervisory work himself, particularly in the training of medical officers in this specialty; the training was necessary because very few surgeons had come to the theater qualified to do chest surgery. The caseload had now become so large that it demanded the attention of a properly qualified consultant who could assist him in controlling the work and in standardizing procedures and routines. The work, of course, could be expected to become very much heavier after the invasion of the Continent.
Colonel Cutler did not ask that the consultant whom he was requesting be on the table of organization at the theater chief surgeon's headquarters. In fact, he believed that it would be more efficient for him to carry on his work from a general hospital.
Colonel Cutler's recommendation for consultant in thoracic surgery was Maj. H. Brodie Stephens, MC, who was then attached to the 30th General Hospital, near Mansfield, Nottinghamshire. He regarded Major Stephens as fully qualified for the position, and he believed that his seniority and other qualifications would make him generally acceptable to other surgeons who would work under him.
On 4 February, Colonel Cutler wrote to Major Stephens to tell him that he had made the official request that he be appointed senior consultant in thoracic surgery in the European theater but that General Hawley did not wish to make any more official appointments in the consultant group. He was quite willing, however, that Colonel Cutler should use Major Stephens unofficially.
In the meantime, Capt. (later Lt. Col.) Dwight E. Harken, MC, had arrived in the theater, in the fall of 1943, with the 1st Auxiliary Surgical Group. His interest in thoracic surgery, plus the fact that he had done work with the British group of thoracic surgeons and had served as resident under Mr. A. Tudor Edwards, F.R.C.S. (fig. 11), at the Brompton Hospital in London, admirably fitted him to act as liaison officer with the British and as Colonel Cutler's representative in thoracic surgery. In particular, he did the active work in the courses on thoracic surgery given in British hospitals under Mr. Tudor Edwards' supervision. In May 1944, when the 160th General Hospital was established as a thoracic surgery center in the 15th Hospital Center, Cirencester, Gloucestershire, Major Harken was appointed chief of the thoracic surgery section and regional consultant in thoracic surgery. Also, although he was never officially appointed to the position, he served as theater consultant in thoracic surgery under Colonel Cutler.
In fulfillment of his consultant functions, Captain Harken:
1. Did the active teaching in the courses in thoracic surgery for selected U.S. medical officers at British hospitals (p. 120).
FIGURE 11.-Mr. A. Tudor Edwards, 1941-45, civilian consultant in thoracic surgery for the British Emergency Medical Service, British Army, and Royal Air Corps; Surgeon-in-Charge, Department of Thoracic Surgery, London Hospital; Surgeon, Brompton Hospital for Diseases of the Chest; Consultant Advisor to Minister of Health for Chest Casualties; and Consulting Surgeon, King Edward VII Sanatorium, Midhurst.
2. Reviewed the experience of the principal British thoracic centers in their care of chest injuries from a vast number of air-raid casualties. The surgical policies and practices set up for U.S. Army thoracic surgeons were derived from the aggregate of the British experience.
3. Wrote a large part of the original draft of the thoracic surgery section in the "Manual of Therapy, European Theater of Operations" (p. 141).
4. Wrote the original draft of the standing operating procedure that governed policies in thoracic surgery in the European theater after D-day (p. 138).
5. Briefed all U.S. hospitals in the United Kingdom before D-day on the management of chest injuries.
When Colonel Cutler wrote to Major Stephens to tell him that he had been unable to secure General Hawley's permission for his appointment as consultant in thoracic surgery but had his permission to use him unofficially, he explained Captain Harken's activities and said that, under these new circum-
stances, they would be improper without Major Stephens' sanction. He therefore directed Major Stephens to get in touch with Captain Harken, so that together they could set up general principles and policies in the field of thoracic surgery. On 9 March, Major Stephens wrote Colonel Cutler that Captain Harken had visited the 30th General Hospital the preceding week, where he had made an excellent talk on thoracic injuries. Captain Harken had also provided him with slides for use in the talk he himself was scheduled to make on the same subject at the Eastern Base Section meeting on 24 March.
Major Stephens expressed himself as anxious to have a conference with Colonel Cutler, to obtain his general views on thoracic surgery, so that he could incorporate them in this talk and in other instructions. So far as is known, nothing further came of Major Stephens' proposed activities as consultant.
Recommendations for the U.S. Army of Occupation
From time to time after the war ended, Colonel Cutler, in response to requests from the theater chief surgeon's office, made recommendations for the organization of professional services in the U.S. Army of Occupation. A system of hospital centers was planned for the administration of the farflung network of hospitals that would be required for the occupation forces. The prevailing system of regional consultants was to be continued; that is, qualified medical officers were to be appointed to serve in this role for their own hospitals and the surrounding hospitals. The system developed in the European theater of appointing medical officers as surgical coordinators, to coordinate all surgical activities within the various hospital centers, was also to be continued.
All of these concepts were agreed to in principle. The consultant system put into effect in July 1945 did not, however, include a consultant in thoracic surgery in the Paris hospitals, for which consultants in other specialties were appointed at once. Nor was a consultant in thoracic surgery appointed in the Office of the Chief Surgeon, Communications Zone, Headquarters, ETOUSA, which was to move later to Headquarters, USFET (U.S. Forces, European Theater) in Frankfurt. In other words, in spite of the importance of this specialty, no theater consultant in thoracic surgery ever served officially in the European theater in World War II.
The number of trained thoracic surgeons in the European theater was always small. In September 1943, there were only 12 surgeons in the United Kingdom Base considered capable of handling thoracic surgery in a general hospital and only 8 considered capable of handling it in a station hospital.
These shortages had to be made up in the best fashion possible, which was to assign the small number of qualified and experienced surgeons to head chest centers and thoracic surgery sections. The shortages could not be overcome by the use of surgeons who had had 3 or 4 months' training in thoracic surgery after they had entered the Army. These officers proved extremely useful on thoracic surgery services, but they were not qualified to assume full responsibilities for them.
The situation was made more difficult than it should have been by administrative obstacles. By October 1944, it had been realized that special hospitals for thoracic surgery and other specialties would be necessary. There was still, however, no provision for a single thoracic (or plastic) surgeon in any medical installation in the communications zone. Constant difficulty was therefore encountered in fitting thoracic surgeons into the inflexible tables of organization for general and station hospitals and in providing the additional assistance necessary to run a thoracic service efficiently. It was just as important that thoracic sections operate efficiently as it was that neurosurgical services should, yet neurosurgeons were provided for in tables of organization for general and station hospitals long before either thoracic or plastic surgeons were provided.
Because of table-of-organization difficulties, it was frequently necessary to assign thoracic surgeons to such positions as chief of the surgical service, chief of aseptic surgery, or even ward officer. These were not satisfactory circumventions, and they had the added disadvantage that, once such an assignment was made, it was very difficult to change it. Colonel Cutler commented in his official diary that emergency changes of assignment could sometimes be handled quickly, but that routine changes often occupied weeks and were sometimes not accomplished at all.
In the meantime, the list of thoracic surgeons in the theater was sent to Colonel Cutler by Captain Harken, and he sent the names, in turn, to Colonel Kimbrough and General Hawley for action. Personnel difficulties continued until the end of the war, but in October 1944, after a round of visits of inspection to hospitals in the United Kingdom Base, Colonel Cutler expressed the opinion that this section had four "superlatively good" thoracic surgeons: Lt. Col. (later Col.) Laurence Miscall, MC, at the 137th General Hospital, located near Ellesmere, Shropshire; Lt. Col. George N. J. Sommers, Jr., MC, at the 140th General Hospital, near Blandford Forum, Dorsetshire; Lt. Col. (later Col.) Arthur S. W. Touroff, MC, at the 155th General Hospital, Malvern Wells; and Major Harken at the 160th General Hospital. In Colonel Cutler's opinion, this base section was now adequately covered from the point of view of thoracic surgery, in which he said that more advances had been made during the war than in any other surgical specialty.
It was the general opinion that, in the future, the personnel of a thoracic section should be made up of a team composed of a lieutenant colonel as chief of section; a captain as anesthesiologist; two captains to serve as surgical assistants and also as ward officers; three surgical nurses, one of whom would be a
first lieutenant; and three surgical technicians, grade 4. These groups should either be sent overseas from the Zone of Interior as table-of-organization cellular units or should be assigned by the Professional Services Division, Office of The Surgeon General. Obviously, personnel for such groups must be selected with great care.
Anesthesia for chest surgery was never a problem in the European theater. Expert anesthesiologists were available all the way from field hospitals near the frontlines to general hospitals in the base area. They had at their disposal a wide variety of anesthetic agents and could use intravenous, inhalation, or regional techniques according to the requirements of the individual patient. When differential pressure was needed for intrathoracic surgery, endotracheal anesthesia was always used, with safety for the patient and satisfaction for the surgeon.
At a meeting of the theater consultants in December 1944, Lt. Col. (later Col.) Ralph M. Tovell, MC, presented an analysis which he had prepared for the theater chief surgeon on the use, according to medical echelon, of inhalation, regional, and local anesthesia. At the conclusion of the presentation, General Hawley paid tribute to the quality of the work done by anesthesiologists in the theater, under Colonel Tovell's supervision. "The fine surgical results that have been gained in this theater," he said, "are in no small way the responsibility of Colonel Tovell for the fine service that he has brought here."
In a conference with Third U.S. Army surgeons, also in December 1944, Colonel Cutler noted in his official diary that he found very gratifying the remarks made by Col. Joseph A. Crisler, Jr., MC, Consultant in Surgery, First U.S. Army, that "one of the greatest boons to surgeons in medical facilities of the field army were the anesthetists supplied by Colonel Tovell * * *. This may be taken as almost a personal triumph for Colonel Tovell, who has worked indefatigably in his special field and now is reaping a rich and well-deserved harvest."
Training in British Hospitals
Late in 1942, Mr. Tudor Edwards, who was then serving as civilian consultant in thoracic surgery for the British Emergency Medical Service (p. 115) gave a course in thoracic surgery, which consisted of lectures and demonstrations in a number of hospitals, for U.S. Army medical officers. It was a most valuable introduction to combat surgery.
When Mr. Tudor Edwards was asked to repeat the course in 1943, he felt obliged to decline. This was entirely reasonable, for his own work as consultant for the Emergency Medical Service, as well as for the British Army and the Royal Air Corps, constituted an incredible burden for a man who had already had several coronary thromboses.
Mr. Tudor Edwards' course had been so valuable, however, that Colonel Cutler could not accept his refusal as final. He therefore suggested to him that he might find it possible to lend his name and general supervision to the course if U.S. Army medical officers carried the bulk of the burden. Mr. Tudor Edwards replied that this was not practical: American medical officers, he said, would not be permitted to move freely about British hospitals, nor did they know the British hospitals and British ways well enough to make the proposed arrangement workable. In his opinion, friction would be inevitable.
As an afterthought, Mr. Tudor Edwards asked Colonel Cutler what American officer he had had in mind to supervise the courses. Colonel Cutler replied that he was considering Captain Harken. Mr. Tudor Edwards said that this appointment would be entirely acceptable to him, and he then withdrew all of his objections to the courses in British hospitals, but, he said, "Harken is not your man, he's mine. He was my resident at the Brompton Hospital before the war, and he knows us well enough to do the job."
Circular Letter No. 174, issued on 28 November 1943 (1), called attention in paragraph 4g to the 2-week courses in thoracic surgery to be conducted at several British thoracic surgery centers in the London area under Mr. Tudor Edwards. It was intended for thoracic surgeons or for medical officers with some previous training in thoracic surgery.
There were seven of these 2-week sessions. Each consisted of lectures and demonstrations by the most eminent thoracic surgeons in England. Between 8 and 10 U.S. medical officers participated actively in each course, and visitors who attended the sessions but did not actively participate brought the number in each course to about 15. Major Harken served as director and coordinator of all of the courses. The slides used in the lectures and demonstrations represented probably the most complete collection of roentgenograms of chest trauma ever collected.
The formal courses just described had three objects:
1. To permit the officers in attendance to learn as much as possible about the thoracic surgery of combat-incurred wounds, including both principles and practices.
2. To give medical officers interested in thoracic surgery an opportunity to become acquainted with the best British chest surgeons and internists. This was an unparalleled opportunity, for all of these British physicians and surgeons were highly skilled men, with broad visions and horizons.
3. To provide useful occupation for men bored to death with inactivity in tents and nissen huts and physically uncomfortable in the frightful British winter weather. These courses provided a brief respite for them in warm, dry, metropolitan surroundings and a little exposure to the more pleasant life in London.
In addition to the formal courses just described, selected Medical Corps officers were able to observe the work of British chest surgeons in chest centers in the areas in which their units were stationed.
In addition to the specialized training in British hospitals just described, the following training was given to medical units in the United Kingdom Base:
1. Medical Corps officers who went to North Africa in November 1942 received special instruction at Tidworth Barracks, 16-18 September. Colonel Cutler's lectures on surgical subjects included the management of sucking wounds and other thoracic injuries.
2. The Medical Field Service School was established at Shrivenham Barracks, Swindon, England, by Circular No. 22, on 23 February 1943 (2). The first courses were given on 8 March 1943, with Capt. (later Lt. Col.) Bernard J. Pisani, MC, as director. There were some initial difficulties, including the appointment of instructors without consultation with, and approval by, the Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA. In a short time, however, this school became a highly efficient functional unit. The lectures and conferences on problems in combat surgery and acute medical and neuropsychiatric conditions did not include special instruction in thoracic surgery, though chest wounds, of course, were discussed in the surgical lectures.
3. All medical units which reached the United Kingdom before D-day received a minimum of 3 hours of lectures on thoracic injuries. The content of these briefings, most of which were given by Captain Harken, was decided upon in a conference with Colonel Cutler on 27 October 1943. The policies and practices recommended were based on the experience in the North African theater to date and on an analysis of 300 British air-raid casualties in the London area. All medical and surgical problems that conceivably might arise in chest injuries were thoroughly discussed.
4. Professional training of officer personnel also included lectures by both military and civilian authorities whenever units were so situated that this was practical. These lectures were supplemented by weekly grand teaching rounds, at which problems of disposition as well as medical care were discussed.
5. Nurses received continuous training in compliance with section II, Training Memorandum No. 3, issued on 15 February 1943 (3). Thoracic surgery and penicillin therapy were covered in the training.
6. The availability of basic and current medical literature formed an important background for practical training, and Colonel Cutler therefore maintained a constant interest in hospital libraries. Originally, the medical texts and journals sent from the Zone of Interior had simply been held in supply depots and not distributed. He ended this situation promptly and also ended the foolish mutilation of U.S. medical journals by censors in the Zone of Interior before they were shipped to England.
After some initial resistance to all formal training overseas, special courses in anesthesia were given in a number of hospitals to medical officers, with spe-
cial emphasis on endotracheal anesthesia and positive pressure techniques for thoracic surgery.
Special courses for nurses were also given in some hospitals. As soon as the 160th General Hospital arrived in England in April 1944, daily lectures on anesthesia were given to 12 nurses, all volunteers for the course. Four were selected for further specialized training. This course was concluded on 3 June 1944, and on 12 June, the hospital received its first battle casualties.
In March 1944, a 3-month course of instruction in the fundamentals of general anesthesia was given at the 15th General Hospital, Ellesmere, Shropshire, to two medical officers and four nurses. It consisted of didactic lectures, demonstrations, and practical training. A small group of technicians were also trained in anesthesia and used as a reserve when casualties were heavy.
In the spring of 1944, two courses in anesthesia, each lasting a month, were given to four officers and seven nurses from the 12th Field Hospital and the 122d, 123d, 124th, and 134th Evacuation Hospitals. Mimeographed outlines, training films, and practical instruction were employed. The practical instruction included intravenous, inhalation, and endotracheal techniques.
By special arrangement with the Office of the Chief Surgeon, Headquarters, ETOUSA, a 4-day course in anesthesia for medical officers and nurses was conducted at the 10th Station Hospital in the Manchester area. This course was designed to precede a 30-day period of temporary duty in this specialty at station and general hospitals.
DISSEMINATION OF INFORMATION
Medicomilitary medicine requires a degree of uniformity in both policies and practices that is not necessary in civilian practice (p. 187). Without such uniformity, with so many medical officers of such varied training and experience working in medical installations in many different military echelons, chaos could have resulted.
In the European theater, uniformity in thoracic surgical practices was more difficult to achieve, in the absence of a theater consultant in this specialty, than it might have been otherwise. It was accomplished in the following ways:
1. Approved procedures in all types of wounds, based on the results of research, civilian experience, and experience in the Mediterranean theater, were set forth in circular letters and other directives issued by the Office of the Chief Surgeon, Headquarters, ETOUSA. These letters were later altered as necessary in the light of the post-D-day experience in the European theater.
2. A medical bulletin, containing similar material, was issued monthly.
3. Shortly before D-day, a manual of therapy was published and distributed to every medical officer in the theater (p. 141). This manual outlined official procedures in combat-incurred wounds in forward installations. The manual was authoritative, since it had been compiled by the senior consultants
in surgery and the surgical specialties in the Office of the Chief Surgeon, Headquarters, ETOUSA. Later, it was modified and supplemented as necessary in the light of combat experience in the theater. The material on thoracic injuries was a somewhat oversimplified outline of immaterial prepared by Major Harken.
4. The senior consultant group in the Office of the Chief Surgeon, Headquarters, ETOUSA, met frequently with the regional consultants in the specialties and also with their British, French, and other colleagues to discuss their joint experiences. From the overall picture, they were able to evaluate the results of treatment and suggest improvements in methods. These improvements were incorporated in circular letters, which were so widely distributed that all medical officers in the theater could keep in touch with the latest and best techniques of military practice. The letters, Colonel Cutler noted in his official diary, make up a story which might well be entitled "Surgery in the European Theater in World War II."
A great deal of information on thoracic surgery was disseminated by Colonel Cutler himself as he moved about the theater. He made it his business to keep himself informed on thoracic surgery by frequent conferences and conversations with the chest surgeons in the hospitals he visited. He was an inspiring man and was able to get the best out of all who worked with him. The information thus secured he synthesized into useful policies. He was not, as already mentioned, a chest surgeon in the modern sense of the term, but he was a vastly experienced general surgeon, with good common sense, who was willing to ask for advice and to take it. After he himself had had what seemed to him a good idea, he would often write to the thoracic surgeons in the theater and ask for their comments before issuing it as a directive. He leaned heavily for advice on Mr. Tudor Edwards, whom he always referred to as "the great man."
These policies of Colonel Cutler's proved particularly useful after D-day. He made it his business to gather professional comment from the surgical specialists who had cared for the casualties in the first days of the invasion of the Continent, and this information, based on combat experience, often under fire, was incorporated in Circular Letter No. 101 issued from the Office of the Chief Surgeon on 30 July 1944 (4).
5. In addition to the informal conferences just described, a number of formal professional meetings were held.
Circular letters issued from the Office of the Chief Surgeon contained the following information pertinent to chest wounds:
1. Circular Letter No. 71, 15 May 1944 (5), concerned the general management of battle casualties. Casualties with chest wounds who were to be considered nontransportable and cared for in field hospitals were listed as
those with thoracoabdominal wounds, thoracic wounds that were serious either because they were large and sucking or because they were associated with intrathoracic hemorrhage, and thoracic wounds of any type associated with shock that did not respond to appropriate therapy. The difficulty of diagnosing thoracoabdominal wounds was noted, and medical officers were reminded that a missile that entered via the buttocks might lodge in the thorax, while a missile that entered by way of the shoulder might produce a thoracoabdominal wound. Roentgenologic examination would clarify the situation, but if facilities for it were not available, the medical officer must be certain to examine the body cavity opposite from the point of wounding.
Many of the general directions in this circular letter were applicable to chest wounds as to all other wounds. Thus it was pointed out that infection arising from contamination caused by repeated inspections and changes of dressing might delay or prevent delayed primary wound closure after the casualty had arrived at a third echelon unit. It was also noted that one of the best safeguards a patient could have was an adequate and legible record, which would make it possible for a receiving officer farther to the rear to refer to the record rather than look at the wound.
2. Circular Letter No. 80, issued on 10 June 1944 (6), also included a general discussion of battle casualties. It mentioned hospitals for the care of special types of wounds, including thoracic surgery, and recommended that in these hospitals separate sections be maintained for each specialty and that the heads of these sections be used as regional consultants.
3. Circular Letter No. 101, issued on 30 July 1944 (4), supplemented the "Manual of Therapy, European Theater of Operations," issued on 5 May 1944 (7), and the circular letters already issued. Its contents, as already mentioned, were based on the experience acquired during the first 5 weeks of active operation after D-day.
4. Circular Letter No. 23, issued on 17 March 1945 (8), contained a section devoted to thoracic wounds, including resuscitation, sucking wounds, hemothorax, empyema, intercostal nerve block, thoracotomy, and thoracoabdominal wounds.
Inter-Allied Conferences on War Medicine.-On 27 October 1942, Colonel Cutler met, for the first time, at the Royal Society of Medicine, with representatives of the medical services of all the Allied countries to plan what came to be the Inter-Allied Conferences on War Medicine. The first monthly meeting was held on 7 December 1942. The presentations made at these meetings were published at the end of the war (9); there was a continuous improvement in them as the war progressed.
The subject of thoracic surgery occupied many of the meetings. In November 1943, the conference met with Captain Harken, then with the 1st Auxiliary Surgical Group. At the conference held in January 1945, Mr. Tudor
Edwards, in his role of honorary consulting thoracic surgeon to the British Army, presented an extensive discussion of thoracic surgery in the field and at the base, with particular attention to surgery at the base. His remarks were based on 1,683 thoracic casualties admitted to chest centers in the United Kingdom between D-day and 30 September 1944.
At the same meeting Mr. T. Holmes Sellors, Regional Adviser in Thoracic Surgery, British Emergency Medical Service, also discussed chest surgery at the base. Lt. Col. Charles S. Welch, MC, presented an analysis of 380 thoracic injuries observed during the first 6 months of fighting on the Continent.
Army Medical Society, European Theater of Operations-On 14 May 1943, the organizational meeting of the Army Medical Society, ETOUSA, was held with Maj. (later Col.) Robert M. Zollinger, MC, in charge. The first formal meeting was held on 23 June 1943, at the 298th General Hospital, Bristol. Monthly meetings were held thereafter at different hospitals until the pressure of combat activities brought an end to them in August 1944.
Other professional meetings-On 14 and 15 April 1943, Colonel Cutler attended the meeting of the Association of Thoracic Surgeons of Great Britain and Ireland, of which Mr. Tudor Edwards was president.
The first discussion at the Inter-Allied Consultants Conference in Brussels on 10 October 1944 concerned chest injuries. Maj. J. Leigh Collis, RAMC, stated that infection was of major importance in them. This observation came as a surprise to Colonel Cutler, since Major Harken had recently reported to him from the 160th General Hospital thoracic surgery center that empyema was not a major problem in these injuries. Col. G. A. G. Mitchell, RAMC, who opened the discussion on penicillin, stated that the British considered that a satisfactory bacteriostatic level could be maintained by the intramuscular injection of 100,000 units in physiologic salt solution each 24 hours. Major Collis thought penicillin of little value unless it was instilled in the pleural space.
At the third Anglo-American Consultants Conference held in Paris on 25-26 May 1945, the vigorous discussions conducted on thoracic surgery included anesthesia for chest operations. There was active participation by both British and U.S. medical officers.
Colonel Cutler seized the opportunity offered by the Trench Foot Conference held in Paris in January 1945 to work over the current circular letters dealing with the treatment of battle casualties. Chest surgery was extensively discussed.
The information gained at all of these meetings was transmitted by Colonel Cutler and other consultants to all medical officers in the theater by the various channels already described.
The experience of Major Harken and his associates at the 160th General Hospital thoracic surgery center was presented to the Royal Society of Medicine and the Royal College of Surgeons in January and April 1945, respectively.
SUPPLY AND EQUIPMENT
Hospitals which reached the United Kingdom in 1942 and some of those which supported the North African invasion in November of that year were poorly equipped from the standpoint of thoracic surgery (p. 84). The chest surgeons, in fact, looked with envy upon the ample equipment of excellent quality possessed by their British counterparts.
When Colonel Cutler inspected the thoracic surgery equipment in November 1942, he described it as completely outmoded and of "20-years-past" vintage. He thought most of what was on hand was close to useless. The medical chests to be used under battle conditions were totally inadequate. So were the instrument kits. There were no morphine syrettes for forward work. There was no sulfonamide powder for wounds (at this time, local chemotherapy was still advocated). There was no provision for local or intravenous anesthesia. The necessary needles and silkworm gut sutures for emergency closure of sucking chest wounds were not on hand, though this was a simple, lifesaving procedure, which almost anyone could carry out.
It was possible to supply most of these deficiencies from British sources, and Colonel Cutler took immediate steps to see that this was done. Meantime, when equipment was in short supply or totally lacking, ingenious improvisations were employed.
As in the Mediterranean theater, X-ray films were in somewhat limited supply in 1942 and early 1943, and some restrictions upon their use were necessary.
By the time of the invasion of the Continent, all of these initial shortages and deficiencies had long since been overcome. All equipment was now in full supply and of the best quality. Temporary shortages, of course, still occasionally occurred, chiefly because of transportation difficulties. This usually happened when fighting was intense and the situation critical, as in the area of the Battle of the Bulge.
Nonstandard equipment was procurable as necessary, but not all that was requested was supplied because not all of what was requested was considered necessary. As in the Mediterranean theater, chest surgeons, like all other medical officers fresh from civilian life, soon learned to do excellent surgery with no more than the generally excellent equipment provided in tables of equipment.
The following experience indicates how rapidly special equipment that was really needed could be supplied: On 22 March 1944, Major Harken wrote Colonel Cutler that the U.S. experience to date, as well as the British combat experience, had proved conclusively that the essential treatment of hemothorax
was complete and early aspiration; and that the mortality, morbidity, possible deformity, and future pulmonary function were all favorably influenced when this technique was used. At this time, the proper equipment for its employment was not available to U.S. medical officers in the United Kingdom.
Major Harken therefore requested that immediate steps be taken to provide all medical units with standard record syringes equipped with 2-way stopcocks and 15-gage aspirating needles. There was no acceptable substitute for this item. In view of the importance of the correct treatment of hemothorax, Major Harken suggested that a sufficiently large order be placed to permit automatic distribution of four of these syringes to each hospital in the theater.
The day this request was received, Colonel Cutler forwarded it, with his approval to the Supply Division, Office of the Chief Surgeon, Headquarters, ETOUSA. He not only recommended that the syringes, in the quantity requested, be distributed to all hospitals in the European theater, both Army and SOS (Services of Supply), but also recommended that they be added to the tables of equipment of all hospitals arriving in the theater. The recommendation was promptly implemented.
Some equipment was considerably improved as time passed. Thus the mounting of the field type of anesthetic machine upon a wheeled cart that also carried the large gas tanks resulted in both increased mobility of the apparatus and increased economy of operation.
Auxiliary Surgical Group Teams
Equipment for auxiliary surgical group thoracic surgical teams was always excellent. Some teams in the European theater carried accessory surgical equipment in special surgical trucks or personnel carriers, but most teams had only a single basic instrument set, which was adequate for two major thoracic procedures, and an anesthetic machine.
It was the general policy to pool the tentage and transportation for all teams, to assure economy in their use. Personal equipment for the medical officers on the teams consisted of standard Army field equipment, including a sleeping bag and an air mattress.
Thoracic Surgery Centers
Thoracic surgery centers often required specialized equipment. If it was available from Army medical depots or from British sources, usually civilian sources, it was supplied at once. The officer with ingenuity and aggressiveness was always able to get it if it existed in the European theater. When the equipment had to be brought into the theater from the Zone of Interior, supply lines were remarkably efficient.
The basic equipment of chest centers was both excellent and abundant. It was recognized that the chest surgeons working in them were performing special procedures, some of which, such as decortication, were new operations. Every attempt, therefore, was made to supply such nonstandard equipment as these chest surgeons needed for their purposes.
Supplies of Penicillin and Blood
The first shipment of penicillin to the United Kingdom, consisting of 180 boxes, was received in the theater on 5 May 1943. Each box contained 10 ampules, and each ampule contained 10,000 Florey units. This first shipment thus consisted of 18,000,000 units. The initial use of penicillin was necessarily restricted, but long before the invasion of the Continent, full supplies were available, and antibiotic therapy was possible whenever it was indicated.
The story of the supply of blood for the invasion of the Continent and the later supply of this agent is told in full in the volume in this series of histories that deals with the blood program in World War II (10). After the first shortages on the Continent after D-day, when, for a time, blood had to be rationed and used only for casualties whose need for it was critical, it was in ample supply because of the daily airlift from the Zone of Interior. When possible, however, especially for casualties who required multiple transfusions, thoracic surgeons preferred to use blood from the blood bank in the United Kingdom. This was because blood flown from the United States was preserved in Alsever's solution and the excess of fluid was undesirable in casualties with chest injuries. They were highly susceptible to pulmonary edema, and the policy was to limit replacement therapy to as small quantities of fluid (electrolytes) as were adequate (p. 253).
THORACIC SURGICAL TEAMS
The concept of the specialty surgical team was in Colonel Cutler's mind as early as the invasion of North Africa. On 6 January 1943, he recommended to the theater chief surgeon that surgical teams in various specialties, including thoracic surgery, should be appointed to serve in forward elements of the division, in order to make observations on special types of wounds from the battlefield to the evacuation hospital. The investigation of even 50 cases of each type of wound, he thought, would open a new outlook on their management and prognosis. If such teams were appointed, he wrote General Hawley, Col. Johan C. Holst, consultant in surgery to the Norwegian Forces in the United Kingdom, who was an experienced thoracic surgeon, had expressed the desire to accompany the thoracic surgical group.
A number of special studies of chest injuries were made in the European theater but none under the precise circumstances envisaged by Colonel Cutler. His concept of surgical teams in the various specialties was implemented in the teams of the auxiliary surgical groups that had just been organized.
Auxiliary Surgical Groups
There is general agreement that the reason that thoracic and thoracoabdominal injuries carried a much lower mortality in World War II than in World War I was due in large part, at least in the Mediterranean and European theaters, to the effective work of the thoracic surgical teams of auxiliary surgical groups.
In the European theater, as in the Mediterranean (p. 105), these teams worked chiefly in field and evacuation hospitals. In the European theater, however, the groups were assigned to the Army surgeon, in contrast to the Mediterranean policy, by which the teams were controlled at theater level. In the European theater, as in the Mediterranean, the effectiveness of all group teams depended to a considerable degree upon how they were received and utilized in the installations to which they were assigned. After the first-quite natural-surprise, not unmixed with resentment, at the presence of these teams in field and evacuation hospitals and at the heavy responsibilities assigned to them, their potentialities were realized, and they were fully utilized by the desire and cooperation of most commanding officers.
In addition to the care of chest casualties, the teams served usefully in the indoctrination of other members of the medical staff, as well as of the nursing staff and technicians, in the principles of management of chest injuries.
In all pre-D-day discussions, Colonel Cutler emphasized that the experience of the Mediterranean theater showed that thoracic surgical teams must be able, whenever necessary, to handle other injuries, particularly abdominal injuries. Thoracic surgical teams capable of doing only thoracic surgery would be useful in base areas, where complete segregation of injuries was possible. In the circumstances that prevailed in forward areas, team surgeons must be able to handle other wounds also, and this consideration was always borne in mind when assignments were made.
The following data on the experiences of the four auxiliary surgical groups that supported U.S. Armies in the European theater give some indication of the enormous number of thoracic and thoracoabdominal injuries that the teams handled:
1st Auxiliary Surgical Group-The 1st Auxiliary Surgical Group supplied teams to the 3d Auxiliary Surgical Group after D-day; these teams remained under the control of the latter group during most of the campaigns in Europe. Other teams from this auxiliary surgical group served with the Seventh U.S. Army, in November 1944; with the XVIII Corps (Airborne), during Operation MARKET; and with the 17th Airborne Division, during the cross-Rhine operation. The group came under the control of the Fifteenth U.S. Army on 18 April 1945.
Its work for 1944 was not tabulated. In 1945, its teams handled 701 thoracic injuries and 332 thoracoabdominal injuries.
2d Auxiliary Surgical Group-The 2d Auxiliary Surgical Group, which had the longest experience of any of these groups, served in North Africa and Sicily with the II Corps; with the Fifth U.S. Army in Italy; and with the Seventh U.S. Army in southern France and during the remainder of the fighting in Europe, after the Seventh U.S. Army passed from Mediterranean to European theater control in December 1944.
The teams of this group handled approximately 22,000 casualties. During 1944 and 1945, they cared for 1,364 thoracic wounds and 903 thoracoabdominal wounds. These data are discussed in detail elsewhere (vol. II, appendix).
3d Auxiliary Surgical Group-Teams from the 3d Auxiliary Surgical Group supported the II Corps in North Africa and Sicily and the First U.S. Army in France, Belgium, and Germany.
Its detailed data are not complete, but it is estimated that its personnel cared for a total of 25,000 casualties in both theaters. Complete information is available on 18,885 injuries handled in the European theater, including 2,018 thoracic wounds and 824 thoracoabdominal wounds. It was also estimated by the team surgeons that combined thoracic, thoracoabdominal, and abdominal wounds accounted for 61 percent of the work in field hospitals; 18 percent of the work in modified field hospitals; 30 percent of the work in beach clearing stations; and 10 percent of the work in evacuation hospitals.
4th Auxiliary Surgical Group-Teams of the 4th Auxiliary Surgical Group served in France and Germany with the Third U.S. Army, which became operational on 1 August 1944. Some of its teams, however, had gone ashore on Omaha and Utah Beaches on D+2. Two of its teams were flown to Bastogne on 26 December 1944, during the Battle of the Bulge, and were landed by glider not far from the German lines the same day that the 4th U.S. Armored Division broke through to relieve the city. Two teams, which were also landed by glider, were attached to the 17th Airborne Division for the cross-Rhine operation in March 1944.
The teams of the 4th Auxiliary Surgical Group cared for 27,516 casualties, of whom 1,040 are known to have had thoracic wounds. The 17,222 abdominal injuries for which it cared are not broken down into abdominal and thoracoabdominal categories.
5th Auxiliary Surgical Group-The 5th Auxiliary Surgical Group was assigned to the Ninth U.S. Army after the middle of September 1944. Previously, some of its teams had served with the Fifth U.S. Army in Italy and, for a short period, with the Third U.S. Army in France.
The records are not complete, but it is estimated that the teams of this group cared for almost 16,000 casualties, of whom 1,063 had thoracic injuries and 300 thoracoabdominal injuries. The report points out, as had other reports, that the keeping of detailed personal case records was a luxury that had to be
sacrificed in periods of duress and heavy work, during which the great majority of these casualties were treated.
The teams of the 5th Auxiliary Surgical Group spent 80 percent of their time in field hospitals, in which operations were usually long and difficult and averaged 2½ hours each. The 7,829 casualties treated in these hospitals therefore required vastly more time and effort than the 8,069 casualties treated in evacuation hospitals. As in all other auxiliary surgical groups, the high case fatality rate during the first 24-hour period after operation implied the policy of operating on all casualties who had even a remote chance of survival. No accurate statistics are available concerning the number of patients admitted to forward hospitals who died before they could be operated on, or who were not operated on because their state was considered hopeless, but it is doubtful that they accounted for 2 percent of the casualties admitted to field hospitals.
Data on the thoracic surgical experience of this group appear in detail elsewhere (vol. II, appendix).
THORACIC SURGERY CENTERS
On 6 December 1943, Colonel Cutler noted in his official diary that the theater chief surgeon did not wish specialized hospitals set up in the European theater. On further consideration, however, General Hawley reversed himself, and by D-day, a variety of hospitals for special treatment had been established. Thoracic surgery centers were included, although, as already noted, a thoracic surgery consultant had not then been appointed for the theater and none was ever appointed.
United Kingdom Base-Circular Letter No. 81, issued on 10 June 1944 (11), designated centers for specialized treatment in thoracic surgery at:
1. The 15th Hospital Center. The chest center located at the 160th General Hospital was directed by Major Harken.
2. The 12th Hospital Center, Malvern Wells, Worcestershire. The chest center was directed by Colonel Touroff, at first at the 90th General Hospital and after 1 August 1944, at the 155th General Hospital.
3. The 6810th (U.S.) Hospital Center (Provisional), Whitchurch, Shropshire. This center, later the 804th Hospital Center, had active thoracic surgical services in several of its hospitals, and Colonel Miscall, chief of the Thoracic Section, Surgical Service, 137th General Hospital, served as coordinator for thoracic surgery. This installation, however, did not function as an active thoracic center in the sense that the thoracic centers at the 160th and 155th General Hospitals functioned.
Continent-Shortly after D-day, the necessity for special centers on the Continent became evident. The first center for chest surgery was established in Paris, at the 48th General Hospital located at the 814th Hospital Center, on
6 November 1944, to serve the hospitals of the Seine Base Section. Its mission was to care for the thoracic casualties coming through the Paris area whose condition did not warrant their transfer to centers in the United Kingdom. It had an evacuation policy of 30 days, which meant that most patients had to be evacuated as soon as they reached the convalescent stage.
There were 348 admissions to the center at the 48th General Hospital during November and December 1944, upon whom the following chest surgery was performed, in addition to 9 bronchoscopies:
21 closures of wounds of the chest wall.
The plan for thoracic surgery and other specialized centers on the Continent was the outcome of discussions among the consultants at their meetings on 27 October and on 17 November 1944. The plan was to set up these centers at the largest concentrations of activities in the communications zone; that is, Paris, Liége, and Nancy. A circular letter that Colonel Cutler prepared after the November meeting (Circular Letter No. 32, Office of the Chief Surgeon, Headquarters, ETOUSA (12)) did not appear until 6 April 1945. It listed the following hospitals for specialized care:
15th General Hospital, 818th Hospital Center, Liége.
Ironically, by the time circular letter designating these centers had appeared, the field armies had moved forward so rapidly that the general hospitals in the forward sections of the communications zone had been left far behind. As a result, casualties were reaching hospitals in the Paris area, and even hospitals in the United Kingdom Base, by air (fig. 12) more rapidly than they could be evacuated by land transportation to the intervening hospitals where specialized treatment facilities had been established. The war ended about a month after the circular letter designating these centers appeared.
Thoracic surgery and other specialized centers in the United Kingdom were established in U.S. Army hospital plants obtained by lend-lease (figs. 13 and 14). Some of the buildings were of temporary type construction, of brick and tile. Nissen huts and tents were also used, winterized for year-round occupancy. Some centers had as many as 200 buildings, 40 of which served as wards. When the patient load exceeded the current capacity, expansion into tents, equipped with stoves and lighting facilities, took care of the excess.
The grouping of several general hospitals, usually about 10, into hospital centers proved an extremely sound plan. Administrative problems were simplified, and more efficient use of professional and other personnel was possible. The two most active thoracic surgery centers that functioned in the United Kingdom Base operated under this plan.
Assignment of Casualties
Chest centers in the United Kingdom were originally not used to their full capacity because there was considerable confusion over how transfers to them were to be handled. Casualties with chest injuries are not mentioned in Administrative Memorandum No. 62, issued on 3 May 1944 (13). It was not understood, at first, whether transfers to the special centers were permissive or mandatory. Difficulties were ended as soon as it became clear that the individual
commanding officer or his chief of surgery would be responsible for their unsatisfactory course if patients who required specialized care were not transferred to a center for it. The thoracic centers, like the other centers, maintained good public relations and rendered good service. Good relations with the sources of their population were therefore soon established. Once this happened, the mechanics of transfer of patients furnished no further trouble. The entire relationship worked well not because of the rules but because of the fundamental sameness of objectives in all echelons of medical care.
The October 1944 meeting of the consultants in the Office of the Chief Surgeon, Headquarters, ETOUSA, was devoted in large part to improvement of evacuation practices, particularly a better classification of transportable and nontransportable patients and better care of patients in transit hospitals. At this meeting, General Hawley stressed that the care of patients in transit was just as important as their care in hospitals. At the November meeting of the consultants, it was agreed that the airlift should continue to be used, whenever it was practical, to evacuate casualties to the United Kingdom with 4 days after wounding. The situation improved, but in January 1945, when Colonel Cutler seized the opportunity offered by the Trench Foot Conference in Paris to discuss other matters, he found that personnel at thoracic surgery centers were still complaining that casualties were unduly long in reaching these installations. They were sometimes received as late as 30 days after wounding. These delays sometimes nullified the advantages of the special treatment facil-
ities and were responsible for patients being received in poor condition and unfit for prompt definitive treatment.
By no means were all casualties with chest injuries who were returned to base sections in the European theater evacuated to the chest centers in the United Kingdom Base. The policy was to admit these patients to general hospitals and then, if they did not show improvement under standard treatment within a short period of time, to transfer them to a chest center. It was estimated that not more than 5 percent of the casualties returned to the United Kingdom Base had chest injuries and that not more than 20 percent of these required treatment at thoracic surgery centers.
As a result of selection, the population of chest centers in the United Kingdom consisted of casualties who needed treatment more radical than delayed primary wound closure, evacuation of a hemothorax, or management of simple complications. In general, the distribution of injuries and complications that required treatment in chest centers, based on the experience of the 160th General Hospital chest center, was as follows:
Hemothorax, 70 percent; unclotted, 60 percent (infected, 3 percent); clotted, 10 percent (infected, 4 percent).
Retained foreign bodies, 15 percent of which about 8 percent required surgical removal.
Thoracoabdominal wounds, 8 percent.
Hematomas, 4 percent.
Injuries of the heart and pericardium, chiefly retained foreign bodies, 3 percent.
Obviously, in the light of these facts, the definitive treatment necessary in thoracic surgery centers consisted chiefly of:
1. The management of hemothorax and its complications, including such complications as clotting and organization.
2. The management of posttraumatic (hemothoracic) empyema, by drainage or pulmonary decortication.
3. The localization of intrathoracic and other retained foreign bodies, critical evaluation of the indications for their removal, and their removal as indicated.
4. The management of other complications, chiefly those associated with thoracoabdominal wounds.
Evacuation and holding policies-A 120-day evacuation policy for the entire European theater was established in the middle of October 1944. In November, the same evacuation policy was established for the Seventh U.S. Army, which had just been brought under complete ETO control. Patients who required more than 30 days of hospitalization, but not more than 120 days, were to be evacuated to the United Kingdom Base or to SOLOC, the base section for the Seventh U.S. Army.
When the chest centers on the Continent were in the planning stage, it was Colonel Cutler's idea that strict specifications be set up for the duration of hospitalization in them. He believed that there should be a limit of 14 days.
Because of the delay in opening the planned centers, except for the center at the 48th General Hospital in Paris, and because of the success of air evacuation to the United Kingdom Base, this policy was never put into effect.
Holding limits in all the centers were loosely interpreted, and properly so, until V-E Day. As a result, many thoracic casualties were returned to duty in the theater who, by a stricter interpretation, would have been evacuated to the Zone of Interior and permanently lost to the theater manpower.
Advantages of Thoracic Surgery Centers
The thoracic surgery centers set up in the European theater were conducted, in general, by the policies that had proved so successful during the evolution and establishment of similar centers in the Mediterranean theater. As in that theater, the centers in the European theater had three chief advantages:
1. They permitted the concentration of casualties with chest injuries in hospitals especially equipped and staffed for their care.
2. They permitted the most efficient and economical use of the limited number of thoracic surgeons available in the theater.
3. As a result of the cumulative experience in these centers, it was possible to discard some policies that had proved ineffectual; alter others; and adopt new policies that had proved, by clinical trial, to be effective.
The establishment of thoracic surgery centers in the European theater had the same far-reaching effects as in the Mediterranean theater. Treatment was expedited. The definitive surgery necessary could be carried out with the most advantageous timing. Manpower losses were reduced. The crippling sequelae of chest wounds that had furnished a continuing problem after World War I were largely eliminated. The opportunity to study large numbers of patients permitted the adoption of new techniques with assurance of their advantages and disadvantages. Finally, younger officers who already had some experience in chest surgery could receive further training in these centers. This training was one of their most useful functions.
PRISONERS OF WAR
From the beginning of the fighting in the European theater, wounded and sick prisoners of war were cared for according to the provisions of the Geneva Convention.
Circular Letter No. 39, issued on 5 May 1945 (14), furnished instructions for hospitals utilizing the medical services of protected prisoner personnel in the care of prisoners of war. Commanding officers of the affected hospitals were to instruct these personnel in standard therapeutic procedures. The basis of the instruction was to be the "Manual of Therapy, European Theater of Operations" (7), and Circular Letters, all from the Office of the Chief Surgeon, No. 71, 15 May 1944 (5); No. 101, 30 July 1944 (4); No. 131, 8 November 1944
(15); and No. 23, 17 March 1945 (8). German medical officers were furnished with copies of the manual and these circular letters, which, together, contained all the basic policies for the management of the wounded.
If protected prisoner personnel were not capable of performing thoracic surgery, neurosurgery, or complicated plastic surgery, prisoners of war who needed such care were to be transferred to appropriate specialized centers. The experience in the European theater paralleled that in the Mediterranean theater, that captured German medical personnel were, for the most part, ill trained and inexperienced and that their surgical standards were remarkably low (p. 35).
According to the Geneva Convention, wounded prisoners of war had to be treated exactly as U.S. Army casualties were treated. After Major Harken made an investigation of complaints that some chest casualties being cared for by protected prisoner-of-war personnel were receiving unsatisfactory care, chest services were set up for them and were affiliated with the U.S. Army chest centers in the United Kingdom Base and on the Continent.
Section II. Basic Clinical Considerations
EVOLUTION OF CLINICAL POLICIES
In the European theater, in spite of the efforts to disseminate the knowledge gained from the experience in the Mediterranean theater, the management of chest injuries progressed through a cycle, much as in that theater. In the beginning, before surgeons had much actual experience with combat wounds, the general tendency was to be radical, and there were few casualties with chest injuries who did not undergo thoracotomy. When casualty loads became heavier, however, and there was a large backlog of patients with abdominal and thoracoabdominal wounds with high priority for surgery, thoracotomies were necessarily fewer. It was thus learned that patients with thoracic injuries could be handled with better results by delayed surgery and by less radical surgery.
Eventually, the indications for thoracotomy were stabilized about as follows:
1. Hemothorax caused by active bleeding which rapidly refilled the chest cavity after aspiration. Patients in this category were frequently in severe shock on admission and did not respond well to resuscitation. The source of bleeding was usually an intercostal or internal mammary artery, the lung itself, or, less often, the heart or some other mediastinal structure.
2. Massive clotted hemothorax that did not lend itself to aspiration. Patients in this group often presented dyspnea, cyanosis, and mediastinal shift.
Evacuation of the clotted blood and control of bleeding were readily effected through an open thoracotomy and made this operation the procedure of choice.
3. The presence of foreign bodies 2 cm. or larger in the pulmonary parenchyma or pleural cavity. The principal indication for their removal was the risk of infected hemothorax and lung abscess, but other indications were possible further damage to the lung or laceration of some blood vessel.
4. The presence of shattered rib fragments in the lung or pleural cavity or of large fragments that had not perforated the pleura. These required removal either by thoracotomy or by extrapleural rib resection. Many surgeons in the European theater came to agree with surgeons in the Mediterranean theater that bone fragments in the lung were potentially more serious than metallic foreign bodies. They were apt to be long and sharp with irregular edges, so that they could penetrate the tissues and forge ahead in them. After a time, these detached bone fragments became necrotic, and an abscess or an infected hemothorax was a likely consequence. Laceration of a blood vessel was always far more likely from contact with bone fragments than with metallic foreign bodies.
5. Sucking wounds. This type of wound always demanded definitive treatment. If simple debridement and wound closure were not adequate, and if it was known that there was intrathoracic damage of consequence, thoracotomy was indicated.
6. Tension pneumothorax due to an air leak, as in bronchopleural fistulas.
After these indications had become established, the treatment of thoracic casualties in the European theater became more conservative. There were still many departures from official policy, however, usually attributable to (1) the desire of surgeons to follow their personal preferences and (2) the difficulty of teaching them that, in wartime, policies must be standardized and that the procedure proved by group experience to be safest must be employed rather than the policy which the individual surgeon happened to consider best.
The material in the "Manual of Therapy, European Theater of Operations," issued on 5 May 1944, provided the basic principles for all surgical procedures in the theater, including wounds of the chest. Circular letters (p. 123) were issued later, to elaborate or modify various procedures in the light of experience, as well as to reemphasize certain policies that were not being followed.
The chief surgical error was the omission of adequate debridement. Next came the closure of wounds under tension, by pulling the edges together, instead of employing techniques of closure such as undermining incisions or split-thickness skin grafts. Dumping of sulfonamide powder or crystals into wounds simply made subsequent closure more difficult.
Originally, many casualties were evacuated to base hospitals with large collections of fluid in their chests. Special attention was directed to this error, but often it was not considered feasible to carry out routine roentgenologic examination or aspiration of the chest before evacuation.
Wound closure-The first procedure in most patients received in a base hospital was prompt closure of wounds that had been left open at initial wound surgery. The early experience in the Mediterranean theater had shown the disastrous consequences of primary suture, and the later experience had shown the excellent results of delayed primary wound closure, which was therefore the general policy in the European theater.
Principles and practices were the same as in wounds of other parts of the body. The routine culture of wounds was found to be unnecessary and to be wasteful of both time and material. As in the Mediterranean theater, only a brief experience was necessary to show that the clinical appearance of the wound was sufficient criterion for its closure or nonclosure. Cultures were made only when there was clinical evidence of infection and the information would be useful for subsequent clinical management.
In judging the suitability of a wound for closure, it was the practice at a number of hospitals in the theater to elevate only the outer dressing, leaving the fine-mesh gauze directly over the wound still in place. The gauze directly over the wound was not removed until the patient was in the operating room. If no sign of infection was evident through the gauze, the patient was scheduled for delayed primary wound closure. This was a practical method of determining the feasibility of closure. It reduced the risk of infection, and it saved time in the operating room.
If the wound was not clean, as indicated by induration or exudation, continuous compresses were used for from 24 to 48 hours. If devitalized tissue was present, redebridement was performed before closure, which was delayed for another 3 or 4 days.
In large soft-tissue defects, in which undermining procedures did not permit closure without tension, the prompt use of split-thickness skin grafts saved weeks of slow healing. This plan was also better than too radical undermining, in an attempt to secure satisfactory flaps for closure.
Associated wounds-Even if the casualty had associated head injuries or compound fractures of greater seriousness than the chest wound, it was the best policy to care for the chest wound first, in order to restore cardiorespiratory balance. Thoracoabdominal wounds always took precedence over other wounds. If the patient's condition at the conclusion of the thoracic or thoracoabdominal procedure was poor, operation for associated injuries was deferred for from 24 to 72 hours. The risk of development of infection in these wounds was less than the risk of subjecting a thoracic casualty who was in shock or had just been brought out of shock to additional trauma and blood loss without an interval for further resuscitation and stabilization.
Fractures of the humerus and shoulder girdle, which were often associated with wounds of the chest, introduced problems if postoperative aspiration of the chest was necessary. In some cases, a plaster Velpeau dressing was
applied and a window cut in the chest portion for this purpose or, if drainage had been instituted, to permit the exit of the catheter. In many cases, temporary dressings of elastic or adhesive bandages were applied in Velpeau fashion for the immediate postoperative period. They were replaced later by a plaster Velpeau or by a thoracobrachial cast for transportation. Hanging casts were very effective in base hospitals. Some patients with fractures of the supracondylar portion of the shaft of the humerus were put up temporarily in full arm casts, and suitable transportation casts were substituted before evacuation.
Adjunct therapy-The policies of replacement therapy set up in the Mediterranean theater on the basis of its early experience were generally followed in the European theater. The lessons of the inadequacy of plasma had been well learned in the Mediterranean theater, and the errors originally made there were not repeated in Western Europe. Shortages of supply imposed some limitations upon the use of blood in the first weeks after D-day, but when once blood began to be flown to Europe from the Zone of Interior, all restrictions were removed, and every casualty received as much as he needed.
At the beginning of the campaign in Europe, it was still the practice to sprinkle all wounds in body cavities with sulfanilamide crystals or with a mixture of dry penicillin and sulfanilamide. Later, local therapy was omitted because systemic therapy was found to be adequate. Instillations of penicillin were used in the chest cavity (p. 296). Otherwise, only systemic therapy was used, by the policies established in the Mediterranean theater. Since penicillin was administered in all cases in which it was believed to be indicated, no control series was run, and it is therefore impossible to determine the effects of antibiotic therapy on the end results. There was no doubt, however, that the basic reason for the good results secured was good surgery, with the sulfonamides and penicillin playing a very significant part, if comparison with comparable wounds in World War I had validity.
MANUAL OF THERAPY, EUROPEAN THEATER
General guidance for the management of wounds of the chest was contained in the Manual of Therapy, published in the European theater in May 1944 and distributed to all medical officers.
Wounds were divided into three types:
1. Wounds limited to the chest wall, which were managed as any other soft-tissue wound.
2. Wounds that perforated or penetrated the pleural cavity or lung without resulting cardiorespiratory embarrassment. These wounds required no specific treatment in forward areas beyond proper treatment of the external wound and priority evacuation, to permit prompt treatment of any complications that might develop.
3. Wounds associated with cardiorespiratory embarrassment. The recognition of these wounds and the associated pathologic processes was essential because management was lifesaving and often had to be instituted in forward areas.
The manual listed the important points of diagnosis in open pneumothorax, tension (pressure) pneumothorax, crushing injuries (stove-in chest), hemorrhage, subcutaneous emphysema, and blast injuries. In penetrating wounds of the chest in which the missile was not seen in the roentgenograms, additional roentgenograms should be made of the abdomen.
The following instructions were given for the emergency and definitive management of chest injuries:
1. In open pneumothorax, the primary consideration is closure of the opening in the chest wall, which is best done by the application of a large, sterile, petrolatum-impregnated gauze pad, supported by a bulky gauze dressing held firmly with adhesive tape. To avoid the danger of tension pneumothorax, the dressing should be almost, but not absolutely, airtight. If the wound is large and gaping, it may be necessary to suture the gauze pad in place, to prevent its loss into the pleural cavity. In an emergency, anything can be used to occlude the opening, even a sterile pad held over the wound by the hand, which will save life until more adequate measures can be instituted. The patient should lie on the affected side.
2. In pressure pneumothorax, a needle is introduced through the second interspace anteriorly on the involved side to allow the trapped air to escape. As a precaution against recurrence, and always if air continues to escape, the needle should be reinserted through a cork strapped in place and covered with a condom or finger cot, so that a valve is produced.2 In place of the needle, a small catheter may be introduced through an incision in the thoracic wall and attached to a closed drainage system.
3. In crush injuries, pain is relieved by intercostal nerve block. In extensive bilateral injuries, an attempt may be made to stabilize the chest wall by circular adhesive strapping. Paradoxical movements of the chest wall are controlled by strapping the injured side only.
4. Marked cyanosis indicates possible bronchial obstruction. Nerve block should be performed, and the patient encouraged to cough vigorously. These measures, with the head-down position,3 may clear the bronchial tract. The patient must not be left alone in this position, for fear of respiratory embarrassment.
5. In external bleeding, the wound should be inspected, to determine obvious bleeding points. If the site of the wound suggests possible injury to the internal mammary or intercostal vessels, an attempt is made to secure the ends of the severed vessels with hemostats and then ligate them. If the attempt fails, the wound is enlarged sufficiently to permit temporary digital control by compression of the bleeding point against the chest wall, after which deep transfixing sutures are used. If no bleeding point is found, firm packing is employed. The patient is treated for shock.
6. Subcutaneous emphysema usually needs no treatment. If it has developed after airtight closure of an open sucking wound, the associated tension pneumothorax must be treated.
7. In blast injuries, absolute rest is more important than immediate evacuation to the rear. Oxygen is of great value, but neither plasma nor blood affects the associated collapse.
Thoracoabdominal wounds are not discussed as such under emergency measures beyond the statement that any projectile that enters the chest must be regarded as a possible cause of abdominal injury.
General measures-The following general measures were employed:
1. The patient should be kept on the injured side or sitting up and should be disturbed as little as possible during examination.
2. Large doses of morphine should not be given, as they abolish the cough reflex. Intractable pain is better controlled by intercostal nerve block.
3. Open pneumothorax and rapidly progressive pressure pneumothorax are grave emergencies, but once they have been controlled, there is no need for further emergency procedures, and there can be deliberate consideration of what comes next.
4. Associated thoracic injuries should be suspected in all wounds of the upper arm, cervical region, and abdomen. Roentgenologic examination is essential for diagnosis.
5. Hemorrhage requires adequate blood replacement, as in other injuries.
6. Acute gastric dilatation is a common accompaniment of chest injuries and often accounts for disproportionately great dyspnea. The complication is potentially lethal but responds readily to decompression by the Levin tube. It should be specifically sought for in all roentgenologic examinations of the chest. It is easily recognized.
7. Untreated effusions of serum and blood are the commonest avoidable causes of complications. The pleural space must be kept empty.
8. Bronchoscopy is of inestimable value whenever the bronchi and trachea are obstructed by mucus or other excessive secretions. It is often a lifesaving measure both before and after operation.
9. Local analgesia is suitable for injuries of the chest wall. For intrathoracic surgery, positive pressure anesthesia is essential, preferably through an endotracheal tube. Intravenous Pentothal sodium (thiopental sodium) should be avoided in the presence of respiratory embarrassment.
10. Drainage tubes should be securely anchored to the chest wall. Their loss in the pleural cavity during evacuation is an avoidable cause of late complications.
11. Postoperative measures include precautions against, and prompt diagnosis of, acute gastric dilatation; oxygen therapy; repeated aspirations of the pleural space if effusion occurs; bronchial aspiration in the management of atelectasis; and early, active breathing exercises, to shorten convalescence and avoid deformities of the chest wall.
Special injuries and complications-Certain injuries and complications furnished special problems, as follows:
1. Open pneumothorax.-In open pneumothorax, the dressings are not disturbed until the patient is prepared for operation. Debridement is performed, with such intrathoracic surgery as is indicated, followed by airtight closure of the chest wall and reinflation of the collapsed lung. A large defect may be repaired by the combined use of the diaphragm and a large muscle of the chest wall, such as the latissimus dorsi or pectoralis major. Occasionally, it is necessary to suture the lung to the margin of the wound. Intercostal closed catheter drainage is instituted through a separate incision, in a dependent position, if it is required because of contamination of the pleural cavity and the risk of sepsis. If drainage is omitted, the patient must be watched carefully for subcutaneous emphysema or pressure pneumothorax.
2. Tension pneumothorax.-Tension is relieved by aspiration of air from the involved side through the second interspace anteriorly. A flutter valve is inserted, or closed drainage is instituted as a precaution against recurrence.
3. Hemorrhage.-Bleeding from the lung usually ceases spontaneously, but a pulmonary wound close to the root of a lobe may be the source of major bleeding that must be controlled by suture, or by partial resection and suture, of damaged pulmonary tissues. Bleeding from the intercostal and internal mammary vessels, the most frequent sources, can be suspected from the location of the wound. It is readily controlled under suitable operating conditions. Wounds involving the great vessels at the hilus are usually rapidly fatal, but early intervention and heroic surgery may occasionally be lifesaving. It should be remembered that a casualty can bleed to death into the pleural cavity without any mechanical embarrassment to the cardiorespiratory system.
4. Hemothorax.-A hemothorax should be evacuated within 48 hours, in order to reduce the chances of infection, prevent loss of pulmonary function by the development of fused chest, prevent deformity, and shorten convalescence. If the blood has not clotted, simple aspiration is sufficient, without introduction of air. If the blood has clotted but is uninfected, the clots are broken up and removed through a cannula. If this is impossible, it may be necessary to
make an intercostal incision to evacuate them. The chest is then closed and air aspirated from it. If infection has occurred, as shown by characteristic roentgenograms, the treatment is that employed for empyema. An attempt is made to remove the clot without risking contamination of adjacent walled-off uninfected pleural space.
5. Foreign bodies.-A conservative attitude is best. Foreign bodies should be assumed to be in the subcutaneous tissues or the parietes until they are proved unequivocally to be in the lung. Precise localization by roentgenogram is necessary before a plan of management is determined. Smooth foreign bodies, less than 2.5 cm. in diameter, seldom require urgent removal. Large, irregular objects should be removed as soon as possible because of the high incidence of serious infection arising from them. They are usually present in wounds that require debridement down to the pleural cavity. A shattered rib on the side of entry, regardless of the status of the external wound or the characteristics of an associated retained missile, requires thorough exploration of the wound of entrance and the pleural space. Explosive costal injuries are often associated with extensive damage to the lung, and rib fragments prove to be troublesome foreign bodies.
6. Crushing injures.-The treatment already described (p. 143) is continued. In most bilateral injuries, and in some unilateral injuries, the thoracic wall should be stabilized and elevated by perichondrial wire sutures or towel clips; they are attached to the mobile sections of the fractured ribs and then used to provide traction. The sutures or clips are left in place until the chest is stable, a minimum of 3 weeks.
7. Blast injuries.-The most important phases of treatment, as already described, are oxygen and absolute rest. Chemotherapy is used to prevent infection. If surgery is imperative for other injuries, inhalation anesthesia is avoided.
8. Thoracoabdominal injuries.-A thoracic approach is employed only when injuries of the thorax require urgent surgery to save life. If it is used, the diaphragmatic wound may be radically enlarged and the abdomen explored through it. Wounds of the stomach and spleen may be readily handled by this route. If exploration through the diaphragm is unsatisfactory, a secondary abdominal incision should be used after the chest surgery is completed. The diaphragm is closed by overlapping the lacerated margins with nonabsorbable sutures. Low phrenic crushing is done to keep it at rest. Repair of lung damage with closed intercostal drainage may be indicated. If the liver is lacerated, the subdiaphragmatic space is packed and drained posteriorly below the diaphragm. The patient should be observed for empyema and intra-abdominal complications, especially subphrenic abscess.4
REPORTS OF CHEST CENTERS IN THE UNITED KINGDOM BASE
A composite summary of the reports of the chest centers at the 160th General Hospital and the 155th General Hospital is appended, to show the workload and activities of these installations.
160th General Hospital
The 160th General Hospital reached the United Kingdom on 27 April 1944.5 On 10 June 1944, it was designated a thoracic surgery center (the first to be set up in the European theater) for the 15th Hospital Center. Major Harken, who had previously been working in General Hawley's office in Grosvenor Square, was sent to the center as director on General Hawley's personal orders. The assignment was entirely to his liking, for, as he had told Colonel Cutler and General Hawley many times, he personally believed that thoracic surgery should be recognized as an independent surgical specialty. In all of his contacts with U.S. chest surgeons, Mr. Tudor Edwards expressed the same opinion and pointed to the results being achieved in British chest centers by implementation of this concept.
Personnel-The personnel of the center varied considerably during the 13 months of its operation. Major Harken, the chief anesthesiologist, Capt. (later Maj.) Charles L. Burstein, MC, the senior ward nurse, and two of the surgical nurses served throughout this period. Captain Burstein was a highly competent anesthesiologist and a productive investigator. 1st Lt. (later Capt.) Margaret Evans, ANC, the senior ward nurse, was a woman of great capacity, both as a bedside nurse and as a teacher. She exercised remarkable disciplinary control over her patients, who did what she expected of them because of their affection and respect for her.
Later, two excellent additional surgeons were assigned to Major Harken at the thoracic surgery center, Capt. Joseph P. Lynch, MC, and Capt. Ashbel C. Williams, MC. Their assistance made it possible to teach and train a number of surgeons who were attached to the center on temporary duty at various times.
This nucleus of officers and nurses was augmented, at different times, by other medical officers and other personnel, and by extremely competent thoracic surgical teams from the 1st Auxiliary Surgical Group.
Enlisted men and convalescent patients were used for rehabilitation instruction and demonstration. It was possible, by standardizing all procedures, including preoperative and postoperative care, to perform a maximum amount of work with minimum help as soon as sufficient experience had been accumulated to determine the best policies and practices.
Training-When the 160th General Hospital was activated as a thoracic surgery center, the professional activities of the entire hospital were minimal.
In the few weeks before D-day, it was therefore possible to select and train ward and operating personnel, as well as nurses, with special interest in chest surgery and in anesthesia (p. 122).
Reports and records-The surgical staff found time, amid their professional activities, to prepare several articles for publication. They made frequent presentations at meetings and conferences. They prepared specimens for the Army Medical Museum and also took motion pictures not only of unusual cases but to demonstrate the techniques most frequently used in such an installation.
In his first report to Colonel Cutler, in November 1944, Major Harken reminded him that he (Colonel Cutler) had pointed out that an important aspect of the mission of a chest center was to share its experiences with others. This is difficult because of the lack of secretarial help. The staff had to maintain its own records, and such information as could be salvaged, beyond the required official records, was produced by the efforts of a badly overworked staff, who frequently felt that they were fighting a losing battle.
Population-The first patient received in the thoracic surgery center, a few days after it had been activated, was an Army Air Force sergeant who had been injured over Germany. He had been treated in a succession of hospitals for an infected hemothorax that had long since become a chronic empyema. The rib-resection drainage performed successfully at the 160th General Hospital was the first operation in a chest center in the European theater. This same technique was used in all extensive empyemas treated by rib-resection drainage in this center (fig. 15).
Casualties from the Continent began to be received on D+4, and by the time the center was deactivated, it had received 1,859 casualties by direct admission. Additional patients received by transfer from other sections of the hospital center brought the total number treated in the chest center to more than 2,000. The expansion of the center was so rapid that 500 patients were sometimes under treatment at the same time.
These figures do not include a certain number of chest casualties who were treated in other hospitals in the United Kingdom Base because they were too ill to be moved. On these occasions, Major Harken several times took a team, including one or two assistant surgeons, an anesthesiologist, and one or two surgical nurses, to the hospitals in question. They traveled at night, by ambulance, and operated during the day.
Because of the limited bed capacity and personnel at the center, every effort was made to limit admissions to the 160th General Hospital chest center to real surgical problems. Other patients were treated in the referring hospitals, by standard policies, and were moved to the thoracic surgery center only if their progress was not satisfactory. If this plan had not been followed, the census would have run well past 3,000.
A great many of the casualties received at the 160th General Hospital arrived by air. This was a satisfactory means of transport if pneumothorax was not present. A nearby airport made transport to this center easier and
FIGURE 15.-Technique of drainage of empyema employed at 160th General Hospital thoracic surgery center in United Kingdom Base. A. Rubber drainage tube. B. Adhesive used to stabilize drainage tube. C. Site of frequently used posterolateral drainage of posterior empyema pocket. Note.-Surgeons in the Mediterranean theater (q.v.) preferred another technique, which they considered simpler and more adequate.-F.B.B.
faster than to some geographically nearer installations. Casualties from the Rhine were often on the operating table at this hospital the same day they were wounded.
Case fatality rates-During the operation of this center, 1,065 major operations were performed on 951 patients. When two procedures were necessary, they were usually performed at the same sitting. Over the same period, 249 minor operations were performed on 248 patients.
The case fatality rates were a source of great satisfaction. There were only 12 deaths in the 951 surgical patients (1.4 percent), 2 in 493 foreign body removals, 1 in 203 decortications, and 9 in 170 rib resections for empyema.
While young, vigorous U.S. soldiers proved generally excellent surgical risks, many patients were received in poor condition because of the nature of their wounds; the nature and degree of associated physiologic dysfunction; and, in a certain number of cases, previous inadequate or unwise treatment. The number of patients in the latter category decreased as time passed.
Six other deaths occurred among patients with thoracic injuries who were not admitted to the center but whose thoracic component was being supervised on the wards on which they were being treated for associated conditions. Two patients had empyema and lung abscesses, which had not responded to previous drainage. One of these died of a suppurative thrombophlebitis and the other
of a high cord lesion, with a spinal fluid fistula into the pleura. Another patient had a fatal transfusion reaction, and still another died of exsanguination before surgical intervention was possible. At autopsy, the source was found to be an area of erosion from the aorta into the esophagus. The foreign body was in the stomach.
Numerous factors might be adduced to explain the good results obtained at this center. Among them were:
1. Very careful preoperative preparation.
2. Excellent anesthesia.
3. The increasing experience of the chest surgeons and their assistants, gained from the observation of such a large concentration of chest casualties.
4. An excellent system of rehabilitation, based on remedial breathing exercises. The personnel of this center preferred to handle personally as much of the rehabilitation of their patients as was practical. They regarded rehabilitation as part of therapy and believed that when it was segmentalized, it lost a major degree of its effectiveness. The special exercises employed are described in detail elsewhere in this volume (p. 314).
Anesthesia-Anesthesiologists at the center individualized their patients and used the types of anesthesia for them most suited for their special problems. Their objects were to protect the patient from untoward reflex changes, assure ample oxygenation, provide adequate ventilation for elimination of carbon dioxide, reduce annoying motion of the intrathoracic viscera to a minimum, and produce as little disturbance as possible of normal physiologic function.
The following technique was devised, or, more correctly, evolved, to achieve these objectives:
1. Rapid induction with a relatively large dose of Pentothal sodium except in patients who had suffered recent hemorrhage or were poor risks for other reasons. Then the amount of the drug was greatly reduced.
2. Intubation with a large-bore Magill endotracheal tube with an inflatable cuff.
3. Maintenance of anesthesia with nitrous oxide, oxygen, and ether, with the use of compensated respiration (continuous manual reinforcement of the automatic respiratory effort.). A constant flow of from 5 to 7 liters of oxygen per minute was maintained.
4. The use of whatever procedure was necessary to prevent untoward cardiocirculatory reflexes and peripheral circulatory depression.
This technique proved both safe for the patient and satisfactory for the surgeon. Many anesthesiologists who employed it had had relatively little general training in anesthesia, but all had had special training in this method and all worked under the continuous supervision of experienced and highly trained anesthesiologists, who themselves usually cared for bad-risk patients or those likely to present special difficulties.
From the Standpoint of anesthesia, thoracic operations fell into two groups:
1. Thoracotomy for intrathoracic exploration required endotracheal intubation, so that pulmonary ventilation could be controlled. Induction was performed with intravenous Pentothal sodium alone or combined with nitrous oxide, so that the electrical Bovie unit could be used at the beginning of the operation. The larynx was cocainized with 4 percent cocaine before intubation if the glottis and vocal cords seemed hyperactive. Ether anesthesia was begun when the chest was opened and there was no further need for the Bovie unit. Cardiovascular reflexes due to stimulation of branches of the vagus in the hilus of the lung or in the mediastinal structures were watched for, and controlled by local injection of 1 percent procaine hydrochloride. The surface of the heart was kept moistened with a solution of procaine hydrochloride when cardiac manipulations were necessary. The involved intercostal nerves were injected with from 3 to 5 cc. of procaine hydrochloride (1½ percent in oil) to prevent the shock that might follow spreading of the ribs during thoracotomy, as well as to decrease postoperative pain.
2. Rib resections for drainage of empyema were usually performed under light anesthesia secured by intravenous Pentothal sodium supplemented by nitrous oxide with oxygen in liberal amounts. This technique was considered superior to local analgesia, since it reduced the time required for operation and provided good oxygenation for a patient lying on his intact side during the procedure. Several patients who were extremely toxic from putrid empyema required unusually high concentrations of oxygen, and cyclopropane was used for them.
Retained foreign bodies-The fascinating experience of the 160th General Hospital thoracic surgery center with retained foreign bodies in the heart, pericardium, and great vessels is described in detail elsewhere (vol. II, ch. VIII). The experience with the removal of retained foreign bodies in the lung was similarly favorable. Several studies showed that it was possible to operate on a patient and transfer him to a reconditioning center for return to duty in the theater more rapidly than he could be handled by a disposition board and returned to the Zone of Interior.
Hemothorax -As the war progressed, clotting of uninfected hemothorax was observed less frequently, and fewer patients in this group required surgery, probably because of the increasing efficiency of treatment in forward hospitals. The majority of the patients received with hemothoraces could be treated by a combination of complete aspiration and breathing exercises. Decortication was employed when the hemothorax had clotted or had become infected.
For reasons that are not clear, the number of patients admitted with grossly infected hemothoraces was larger in 1945 than in 1944. These patients, like those with clotted hemothoraces, were treated by decortication.
Empyema-A small number of patients with basilar empyema, whose cavities did not exceed 500 cc. in volume, were treated by open drainage. This policy was based on four major premises:
1. Early, adequate drainage. The site, always dependent, was selected after routine roentgenologic examination, mapping of the lesion after the instillation of Lipiodol, and aspiration.
2. Maintenance of the wall of the empyema cavity in an acute inflammatory state, so that obliterative pleuritis would proceed rapidly. The frequent application of irritating packs tended to maintain the desired acute pleuritis.
3. Maintenance of the nutritional state by appropriate diet, accessory vitamin therapy, and replacement therapy as indicated.
4. General and specific remedial exercises (p. 314).
A small number of patients who were in poor or critical condition when they were received in the center were treated by open drainage, in preparation for later decortication. As a rule, they were ready for the more radical operation in from 7 to 14 days. Open drainage was also used for the small localized residual empyemas sometimes observed after decortication.
Rib-resection drainage (fig. 15) was performed in 170 cases in which the empyema was too extensive to be managed by open drainage.
Decortication-Decortication was used with increasing frequency, and with improving results, as the war progressed. The approach, however, was always conservative. The indications were as follows:
1. Clotted hemopneumothorax associated with acute cardiorespiratory embarrassment, overwhelming sepsis, or both. In such cases, the extensive loculation and clotting made both aspiration and rib-resection drainage unsatisfactory.
2. Any hemothorax in which the accumulation of clotted, infected blood was estimated to be more than 700 cc. Smaller accumulations could usually be handled satisfactorily by more conservative measures.
3. Obscuration of at least half of the involved lung field, with no evidence of clearing under attempts at aspiration and the institution of active breathing exercises, as determined by weekly fluoroscopic and roentgenologic examinations. When the obscuration was greater than half the lung field and remained stationary for more than 2 weeks, decortication was usually resorted to without further delay. With proper roentgenologic techniques, it was possible to outline the extent of the hemothorax and the encompassing membrane fairly clearly.
The technique used was, in general, that employed in the Mediterranean theater, where the operation was first introduced for organizing hemothorax and hemothoracic empyema. (p. 27). If a foreign body was retained in the lung, it was removed at the same operation.
A primary cure was obtained in possibly 75 percent or more of all cases. If infection persisted, the empyema was usually small and localized, and open drainage rapidly effected a cure. In some cases, the cause of failure was found
FIGURE 16.-Technique of ligation of lacerated thoracic duct. A. Posterolateral incision. B. Bed of fifth rib, which has been resected. C. Isolation of duct above aorta and behind left subclavian artery. D. Double ligation of duct. Decortication was also performed. Recovery was uneventful (160th General Hospital thoracic surgery center).
to be a persistent bronchopleural fistula, which prevented complete reexpansion of the lung. These patients were treated without delay by continuous high negative pressure. They were placed on suction drainage applied from a suction line set up in one of the wards, the lung thus being held in expansion until the fistula closed.
Chylothorax.-Two patients were observed at the center with chylothorax following perforating chest wounds. One, who had a moderately large cystic area in the upper left lung field, was treated by repeated aspiration of chyle from it. Convalescence was prolonged, but the response was favorable, and no further treatment was required.
The second patient had a massive effusion through which large quantities of chyle were repeatedly aspirated. When no signs of improvement were evident, the thoracic duct was ligated (fig. 16), and decortication was performed. The result was excellent.
Diaphragmatic hernia-It was the policy at the center to repair all hernias of the diaphragm that were diagnosed, no matter how small the per-
foration might be, on the ground that otherwise the opening would inevitably increase in size and permit herniation of abdominal organs. Operations for herniations that had already occurred, particularly herniations of the stomach, were often technically difficult.
Lobectomy-The 951 operations performed at the 160th General Hospital chest center included 15 lobectomies. This operation was used only when the lobe, or part of the lobe, was damaged beyond repair. Sometimes the tissue was found to have been actually blasted away. Whenever possible, the Blades-Kent technique of individual ligation, which had been described shortly before the war, was used in these cases.
Thoracoabdominal wounds-Fifty-six patients with suppurative complications of thoracoabdominal wounds were treated at the chest center at the 160th General Hospital. The data are as follows:
As was usual, the initial location of the wound greatly influenced both the number and the seriousness of the complications. There were 46 complications on the right side, against only 10 on the left. They were classified as follows:
1. Of the 15 instances of subphrenic infection without pleural involvement, 14 were on the right side, including 7 subphrenic abscesses, 6 hepatic abscesses, and 1 combined subphrenic-hepatic abscess. The single infection on the left side in this group was a subphrenic abscess. All 15 infections were successfully treated by conventional subphrenic drainage.
2. Of the 42 instances of subphrenic infection with pleural involvement, 32 were on the right side. They included 30 infected hemothoraces, 2 with subphrenic and 28 with hepatic abscesses, and 2 uninfected hemothoraces, 1 with a subphrenic and 1 with a hepatic abscess. The 10 infections on the left side included 2 uninfected hemothoraces, both with subphrenic abscesses, and 7 infected hemothoraces. In this group there were two herniations of the stomach and two gastropleural fistulas.
In the infections with pleural involvement, management depended upon whether or not the diaphragmatic perforation was sealed off. If it was, the pleural and subphrenic lesions were treated independently, by standard techniques. If the perforation was still open, the treatment depended upon the size of the thoracic component:
1. If an empyema with an associated liver abscess was shown by roentgenograms to be small, it was opened widely by rib resection, and the hepatic abscess was deroofed by removal of the overlying diaphragm and was drained into the empyema cavity (fig. 17). Sloughing tissue was removed, and the abscess was packed with gauze impregnated with zinc peroxide. Drainage was maintained by the use of multiple tubes.
Among the first patients received at this center were a number with serious liver abscesses associated with severe bleeding. One patient died. The open method of treatment gave excellent exposure and permitted hemostatic packing of the abscess under direct vision. This technique was lifesaving when bleed-
FIGURE 17.-Combined drainage of chronic empyema and liver abscess following thoracoabdominal wound. A. Site of incision. B. Transphrenic deroofing of liver abscess with drainage of liver abscess and localized chronic empyema through same wound: Empyema pocket (a), divided diaphragm (b), and deroofed liver abscess (c). (performed at 160th General Hospital thoracic surgery center.)
ing was severe, but the duration of healing was intolerably long, and the more definitive procedure was resorted to.
2. If the thoracic component was large, decortication was performed, with repair of the diaphragm and immediate reexpansion of the lung. The hepatic abscess was drained subdiaphragmatically to the point nearest to it on the chest wall.
This technique was first used as a staged procedure in two patients who were acutely ill on admission to the center, with total empyema and large liver abscesses. Both were treated by immediate drainage of the empyema, with deroofing of the liver abscess, followed by subphrenic drainage. Later, when the patients' conditions had improved, decortication was carried out, with closure of the diaphragm. In both cases, convalescence was materially shortened, and the end results were excellent. The procedure was thereafter used routinely, as a one-stage operation.
In one case in which this technique was used, the patient had a liver abscess of 600-cc. volume, a laceration of the diaphragm to which a lacerated lung was adherent, and an 80-percent mixed empyema containing bile. Bile and pus were draining through an 8-inch sucking wound in the third anterior interspace, and over a liter of fluid was being evacuated daily. Wide-open thoracotomy was performed, with decortication of the empyema, repair of the lacerated lung, and lateral drainage of the liver abscess through a liberal rib resection. Drainage of the liver abscess was effected by splitting the dome of the diaphragm wide open to the area of the lateral rib resection. This technique seemed unphysiologic to some observers, who were concerned about the future of the
collapsed lung. The patient, however, was well on the way to recovery when he was evacuated. He was typical of others who responded favorably to similar treatment.
155th General Hospital
Administrative considerations-The chest center at the 12th Hospital Center was first established at the 90th General Hospital (Hospital Plant No. 4173) on 18 May 1944. On 1 August 1944, the 90th General Hospital was replaced by the 155th General Hospital, which operated as a chest center until it was deactivated on 8 June 1945. Colonel Touroff served as director of the chest center throughout the period of operation. In addition to serving as chief of the thoracic surgery service at the 155th General Hospital, he was responsible for the care of all thoracic casualties in the various medical installations which made up the chest center.6
During the 2 weeks between the establishment of the thoracic surgery center and D-day, Colonel Touroff visited all of the hospitals in his hospital center and outlined a plan of treatment for thoracic casualties to the chiefs of the surgical services, who were encouraged to request consultation on all special problems. The policy of referring all elective thoracic surgery to the thoracic center was also inaugurated.
When the center was fully operational and carrying its heaviest load, in the first months of 1945, the personnel, in addition to the director, consisted of three ward officers, six nurses, and five corpsmen. As the ward officers gained in experience, they were able to assume most of the ward work and to relieve the director of many of the routine duties he had originally had to assume himself. Since they had had little surgical training, all major surgical procedures had to be performed by the chief of the center. As the operating load was continuously large, many patients who required extensive secondary closure of superficial wounds or operating procedures confined to the chest wall were transferred to the general surgical section.
Population-During the operation of the center, 1,388 patients were admitted, of whom 1,252 were referred from other hospitals in the hospital center. In addition, 128 patients were treated in the medical or surgical wards of the 155th General Hospital under the direction of the staff of the thoracic surgery center but were not transferred to it. The director saw 609 patients in consultation in the hospitals of the hospital center and performed 552 major operations. A few of the 836 patients treated by nonsurgical measures required minor surgical procedures, such as secondary closure of small wounds or nerve block.
The greatest patient and surgical load came in February 1945. In spite of the sharp falling off of casualties around V-E Day, admissions to the thoracic
center did not begin to slacken off until the latter part of May, and surgical activity continued into June.
Facilities-By early November 1944, casualties with chest wounds had become so numerous that they had to be housed in widely separated wards, wherever beds were available. On 11 November, the center was moved into a separate group of three buildings originally designed by the British as a venereal disease section. It continued to function here until the hospital was closed. By the utilization of the services of convalescent casualties, as will be pointed out shortly, the buildings were kept in an excellent state of repair. In the same manner, the grounds were landscaped, rehabilitation facilities were maintained, special equipment and furniture were constructed, and all nonmedical activities of the center were supported.
The thoracic surgery center functioned as a self-contained unit within the 155th General Hospital. Complete facilities were available except for the performance of major surgery, for which the general hospital operating rooms were used. Physical features included accommodations for 165 patients, an operating room for minor surgical procedures and dressings, a recovery ward for postoperative patients, a messhall, a dayroom, a central linen supply room, and adequate office space. Ample grounds surrounding the building were available for rehabilitation activities.
Plan of operation-The compactness of the unit, an efficient arrangement of facilities, and extensive use of patient labor not only resulted in better care of patients but also effected a great economy in operating personnel. Patients who required maximal medical and nursing care, including bedridden patients and those who needed special medication, were placed in rooms and wards close to the offices for the medical staff and nurses. Here they were always under close supervision. As soon as they became ambulatory or were no longer in need of special attention, they were placed in convalescent wards in which the atmosphere was more that of a military barracks than of a hospital. Noncommissioned officer patients maintained discipline and order. Patients made their own beds and were entirely responsible for the cleanliness and policing of the wards. Convalescence under these circumstances prepared them for subsequent return to duty rather than for prolonged invalidism.
Early mobilization of patients was the rule. As soon as a man became ambulatory, he walked to the operating room for dressings and other treatment. He took his meals in the messhall at the center until he was able to walk to the main messhall in the hospital. These activities not only expedited the return of the patient's strength but also resulted in considerable saving of time and effort on the part of the professional staff and maintenance personnel. Furthermore, the utilization of patient labor made it possible to use the services of medical corpsmen exclusively for medical care.
As part of their program of rehabilitation, patients operated the messhall and linen supply room. They served as clerks, messengers, firetenders, carpenters, painters, and gardeners. Convalescent patients with a special interest in medical work were trained to assist corpsmen on the wards and to help in
the operating room. Others served food to the bedridden patients and to those who took their meals in the messhall of the center.
Equipment-Equipment at the center was adequate, and every attempt was made to avoid the use of unnecessarily elaborate instruments and accessories. Improvisation was necessary only twice:
1. A new and simple type of bottle stand, for use in closed drainage, was devised, and six were constructed by one of the patients.
2. Extra-long probes, necessary for the packing technique used in certain pleural infections, were also designed at the center and constructed by a patient.
Foreign bodies-The foreign bodies removed from 318 casualties in the 155th General Hospital chest center are discussed under that heading (vol II, ch. VIII). Included in the discussion is the technique devised at this center for removing certain intrathoracic objects without entering the free pleural cavity.
Suppurative processes-In 124 cases, the major pathologic process was suppurative, as follows:
1. The infection was intrapleural in 99 cases, 84 of which were managed by open drainage, 13 by decortication, and 2 by closed drainage.
The open-drainage technique included a liberal incision, rib resection, thorough visualization of the interior of the cavity with illuminated retractors, opening of all recesses and loculations, and light packing of the cavity with plain gauze. If the pulmonary surface was rigid and it was thought that reexpansion might be slow, decortication of the lung was carried out within the limits of the visceroparietal adhesions. In none of the 48 cases in which this technique was employed was further revision of the empyema necessary.
The 13 patients selected for primary pulmonary decortication all presented collapse of the pulmonary apex, which was so bound down that a prolonged convalescence seemed inevitable if, indeed, the lung reexpanded at all. In 10 of the 13 operations, healing was by primary union, and the period of postoperative convalescence was greatly reduced. In the three other cases, subsequent open drainage was necessary before cure was accomplished.
The two cases treated by simple closed drainage needed no special comment.
Bacteriologic studies indicated that the type of organism responsible for the pleural infection did not influence the success or failure of decortication. In the two cases in which a culture of pure Clostridium welchii was obtained, the course was essentially as benign as in the ordinary pyogenic infection.
2. All four patients with abscess of the lung were treated by a single-stage drainage operation. A small, accurately positioned incision was made directly over the abscess, which was entered through the zone of visceroparietal adhesions invariably present.
In six other cases, pulmonary suppuration was treated by partial lobectomy. In five cases, the lesion was an infected, necrotic hematoma, the result of trauma by high explosive shell fragments. In the remaining case, in which the indication for surgery was continued hemoptysis, the infection, which was caused by Friedländer's bacillus was primary.
3. In each of the three mediastinal abscesses, infection was the result of injury to the esophagus by high explosive shell fragments. In each instance, the suppurative lesion was in the superior mediastinum, above the level of the aortic arch. All three operations were performed in a single stage, through an anterior cervical incision.
4. In five of the eight cases in which empyema and subphrenic abscess were present in combination, drainage was performed through two separate incisions. In the three remaining cases, a single incision was used, the subphrenic abscess being drained by enlargement of the preexistent perforation of the diaphragm.
5. In three of the four subphrenic abscesses, transdiaphragmatic-transpleural drainage was accomplished as a single procedure by the following technique: immediate marsupialization of the diaphragm, by suture, after the pleural cavity had been entered; incision of the diaphragm; evacuation of the subphrenic abscess by suction before spillage could occur; and suture of the edges of the diaphragmatic incision to the margins of the superficial wound, thus further shutting off the free pleura. This procedure, which was devised at the 155th General Hospital chest center, permitted prompt evacuation of a subphrenic abscess without the delay entailed in the usual two-stage procedure. It was of special value in those cases in which the severity of the clinical symptoms made prompt drainage desirable.
In the fourth case in this group, transdiaphragmatic drainage was performed extrapleurally. An incision was made in the costophrenic sinus below the level of the pleural reflection. An incision placed directly over the most superficial portion of the subphrenic abscess provided adequate drainage. It was thought that drainage of the abscess through the empyema cavity would delay healing because of continued contamination from the more highly placed empyema cavity.
Clotted hemothorax-Decortication was performed in 82 cases of clotted hemothorax, 14 of which were primarily infected. An intercostal incision was used, with division of one rib, or, occasionally, of two ribs, posteriorly. If the parietal membrane was unusually thick and there was considerable restriction and immobility of the chest, the thoracic parietes were decorticated with the lung and diaphragm.
In 2 of the 68 uninfected hemothoraces, a minor postoperative axillary empyema occurred; both processes were drained promptly and obliterated without incident. A small residual axillary empyema was similarly treated in one of the infected cases. Otherwise, the clinical course was the same in both clean and infected cases. In the infected cases, although cultures were positive, the fluid was not grossly purulent. Otherwise, the condition would have been classified as empyema.
Miscellaneous conditions-Other major procedures consisted of closure of an external esophageal fistula in 1 case, and closure of bronchopleural fistulas, bronchocutaneous fistulas, and large thoracic wounds in 19 cases. They require no special comment.
Fatalities-Of the four deaths which occurred at the 155th General Hospital chest center, one followed the uncomplicated removal of a superficially situated foreign body and was caused by a cerebral hemorrhage (vol. II, ch. VIII). The other three case histories were as follows:
Case 1-This patient sustained a perforating wound of the trachea and a compound comminuted fracture of the mandible, due to high explosive shell fragments. At the time of wounding, there was considerable aspiration of blood into the tracheobronchial tree.
The patient was admitted to the chest center about 2½ weeks after wounding, because of extensive pulmonary suppuration in the right lung and a mediastinal abscess. Temporary improvement followed drainage of both abscesses. About 10 days later, there was evidence of further spread of the gangrene, and death soon followed. Post mortem showed the cause of the fatality to be septic thrombophlebitis of the pulmonary vein, anaerobic septicemia, and multiple metastatic abscesses.
Case 2-This patient sustained a right-sided bullet wound which involved the liver, right diaphragm, lung, chest wall, and brachial vessels. He was received in the chest center after amputation of the right arm, drainage of an extensive hepatic and subphrenic abscess, and secondary laparotomy for acute intestinal obstruction. At this time, he had a chronic empyema, with a right-sided bronchopleural fistula. He was extremely emaciated, and a substantial excavation within the liver, with a complete external biliary fistula, was evident through a large gaping wound in the right upper quadrant. Laboratory tests revealed material reduction in liver function.
Drainage of the pleural infection was followed by prompt subsidence of toxic manifestations, but the patient presented serious nutritional problems, and death occurred 3 weeks after operation, after a progressively downhill course. Post mortem revealed extensive chronic hepatocellular damage, diffuse biliary cirrhosis, and atrophy of the liver.
Case 3-This patient sustained a thoracoabdominal wound on the left side, which was followed by pleural infection, diffuse fibrinopurulent plastic peritonitis, and multiple intra-abdominal abscesses. Neither thoracotomy nor laparotomy had influenced the septic course, and he was admitted to the center for revision of the inadequately drained empyema. Death occurred after the secondary drainage operation and was attributed at post mortem to intraperitoneal suppuration with multiple encapsulations of pus throughout the abdomen, not amenable to surgical treatment.
Results-Evaluation of the results of therapy was not possible because of the short time the patients were under observation. In most instances, those who did not require evacuation to the Zone of Interior were sent to rehabilitation and reconditioning centers to be prepared for return to duty.7
Rehabilitation-As is evident from what has already been said, the rehabilitation program at this chest center required the participation of convalescent patients in all of the activities of the center. This was an efficient and wholesome way of expediting their recovery, and the sight of these recently wounded men working about the wards and in other parts of the hospital, as well as on the grounds, was a continuing source of encouragement to newly arrived patients, who realized hopefully that they too would soon be on the road to recovery.
The rehabilitation program as such was carried out under the direct supervision of a designated officer patient, assisted by other convalescents. It con-
sisted of general physical exercises; special thoracic exercises; exercises designed to restore the function of specific muscles, especially those of the shoulder and upper arm; and graded competitive sports.
As soon as a patient arrived in the center, he was given written and personal instruction in thoracic exercises, which were engaged in by all patients, whether ambulatory or bedridden, under supervision, at least three times a day. Individual exercises were prescribed as necessary. Early mobilization was encouraged, and most patients were out of bed on the second or third day after operation. As the patients regained their strength, they were encouraged to participate in outdoor athletic activities, such as horseshoe pitching, badminton, volleyball, and basketball. The volleyball and basketball courts were constructed by the patients as part of their own advanced rehabilitation activities. Competitive activities were graded from mild to strenuous, and patients were permitted to indulge in them as their strength increased.
1. Circular Letter No. 174, Office of the Chief Surgeon, Headquarters, ETOUSA, 28 Nov. 1943.
2. Circular No. 22, Headquarters, ETOUSA, 23 Feb. 1943.
3. Training Memorandum No. 3, Headquarters, Western Base Section, ETOUSA, 15 Feb. 1943.
4. Circular Letter No. 101, Office of the Chief Surgeon, Headquarters, ETOUSA, 30 July 1944.
5. Circular Letter No. 71, Office of the Chief Surgeon, Headquarters, ETOUSA, 15 May 1944.
6. Circular Letter No. 80, Office of the Chief Surgeon, Headquarters, ETOUSA, 10 June 1944.
7. Manual of Therapy, European Theater of Operations, 5 May 1944.
8. Circular Letter No. 23, Office of the Chief Surgeon, Headquarters, ETOUSA, 17 Mar. 1945.
9. Tidy, Henry Letheby and Kutschbach, J. M. Browne (editors): Inter-Allied Conferenes on War Medicine 1942-1945; Convened by the Royal Society of Medicine. London, New York, Toronto: Staples Press, Ltd., 1947.
10. Kendrick, Douglas B., Jr.: The Blood Program. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington: U.S. Government Printing Office, 1962, pp. 121-163.
11. Circular Letter No. 81, Office of the Chief Surgeon, Headquarters, ETOUSA, 10 June 1944.
12. Circular Letter No. 32, Office of the Chief Surgeon, Headquarters, ETOUSA, 6 Apr. 1945.
13. Administrative Memorandum No. 62, Office of the Chief Surgeon, Headquarters, ETOUSA, 3 May 1944.
14. Circular Letter No. 39, Office of the Chief Surgeon, Headquarters, ETOUSA, 5 May 1945.
15. Circular Letter No. 131, Office of the Chief Surgeon, Headquarters, ETOUSA, 8 Nov. 1944.