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MEDICAL DEPARTMENT, UNITED STATES ARMY
SURGERY IN WORLD WAR II
THORACIC SURGERY Volume I

Prepared and published under the direction of
Lieutenant General LEONARD D. HEATON
The Surgeon General, United States Army

Editor in Chief
Colonel JOHN BOYD COATES, Jr., MC, USA

Editor for Thoracic Surgery
FRANK B. BERRY, M.D.

Associate Editor
ELIZABETH M. MCFETRIDGE, M.A.

OFFICE OF THE SURGEON GENERAL
DEPARTMENT OF THE ARMY
WASHINGTON, D.C., 1963


Contents

FOREWORD

PREFACE

Part I

INTRODUCTION

Chapter:

I.Historical Note (Frank B. Berry, M.D.)

Early Observations
The Crimean War
The Civil War
World War I 
Empyema in World War I
Decortication in Empyema
The Period Between the World Wars
British Chest Surgery in World War II
German Chest Surgery in World War II
Special Types of Wounds
Retained Intrathoracic Foreign Bodies
Wounds of the Heart and Pericardium

II.  General Considerations of Thoracic Wounds(Frank B. Berry, M.D.)

Classification of Chest Wounds
Characteristics of Chest Wounds
Wounding Agents
Velocity of Missiles
Vulnerability of the Chest to Wounding
Incidence and Case Fatality Rates
Battlefield Deaths

Part II

ADMINISTRATIVE CONSIDERATIONS IN WOUNDS OF THE CHEST

III.  Administrative Considerations in the Mediterranean (Formerly North African) Theater of Operations (Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.)

The Consultant System
Thoracic Surgery Personnel
Evacuation and Transport
Training
Conferences and Meetings
Equipment
Blood Supply
Hospital Installations
Auxiliary Surgical Groups
Disposition

IV.  Administrative and Basic Clinical Considerations in the European Theater of Operations(Dwight E. Harken, M.D.)

Section I. Administrative Considerations

The Consultant System
Personnel
Training
Dissemination of Information
Supply and Equipment
Thoracic Surgical Teams
Thoracic Surgery Centers
Prisoners of War

Section II. Basic Clinical Considerations

Evolution of Clinical Policies
Manual of Therapy, European Theater
Reports of Chest Centers in the United Kingdom Base

V.  Administrative Considerations in the Zone of Interior (Brian Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.)

The Consultant in Thoracic Surgery
Subcommittee on Thoracic Surgery, Division of Medical Sciences, National Research Council
Personnel
Training
Anesthesia
Equipment
Manual on Thoracic Surgery
Thoracic Surgery Centers
Reports of Thoracic Surgery Centers
Registry of Foreign Bodies

Part III

GENERAL MANAGEMENT OF WOUNDS OF THE CHEST

VI.  Evolution of Clinical Policies in the Mediterranean (Formerly North African) Theater of Operations(Thomas H. Burford, M.D.)

General Considerations
Staging of Surgical Care
Official Policies in Chest Injuries
Early Experience in the Mediterranean Theater
Development of Concept of Chest Injuries
Formulation of Policies
Triage and Transportability
Results of Therapy
Special Types of Wounds
The Seventh U.S. Army

VII. Emergency Measures (Lyman A. Brewer III, M.D.)

Management on the Battlefield
Management in Battalion Aid and Collecting Stations
Management in the Clearing Station
Transportation

VIII.  Diagnosis (Lyman A. Brewer III, M.D.)

General Considerations
History-Taking and Physical Examination
Clinical Picture
Roentgenologic Diagnosis

IX.  Resuscitation and Preoperative Preparation (Lyman A. Brewer III, M.D.)

General Considerations
Routine of Resuscitation
Thoracentesis
Replacement Therapy
Emptying of the Stomach
Resuscitation in Thoracoabdominal Wounds
Response to Resuscitation
Psychologic Considerations

X.  Anesthesia(Ernest A. Doud, M.D.)

General Considerations
Equipment
Preoperative Preparation
Technique
Adjunct Therapy During Operation
Bronchoscopy

XI.  Initial Wound Surgery (Lyman A. Brewer III, M.D.)

General Considerations
Debridement
Traumatic Thoracotomy
Elective Thoracotomy
Special Technical Considerations
Catheter Suction and Bronchoscopy Immediately After Operation
Complications During Surgery
Postoperative Management
Chemotherapy and Penicillin Therapy

XII.  Reparative Surgery (Thomas H. Burford, M.D.)

General Considerations
Delayed Primary Wound Closure
Replacement Therapy
Reparative Surgery and the Learning Curve

XIII.  Reconditioning and Rehabilitation (Dwight E. Harken, M.D., B. Noland Carter, M.D., and Michael B. DeBakey, M.D.)

General Considerations
General Policies
Development of Program, Mediterranean Theater
The Program in the European Theater
The Program in the Zone of Interior

APPENDIXES

A.  Material on Thoracic Exercises Given to Patients at Thoracic Surgery Center, 160th General Hospital, European Theater of Operations

B.  Greeting from Commanding Officer, Baxter General Hospital, to Thoracic Casualties

Illustrations

Figure:

1.  Sir Alexander Fleming
2.  Sir Howard Florey
3.  Chain of evacuation to oversea thoracic surgery center
4.  Unloading wounded at battalion aid station
5.  Air evacuation of wounded
5b. Air evacuation of wounded (cont.)
6.  Improvised portable suction machine
7.  Improvised portable suction machine
8.  Transportation for auxiliary surgical group team
9.  Officers' quarters at evacuation hospital on Anzio beachhead
10. Views in oversea thoracic surgery center
11. Mr. A. Tudor Edwards, British consultant in thoracic surgery, World War II
12. Air evacuation, Continent to United Kingdom Base
13. Views in oversea thoracic surgery center
14. Oversea thoracic surgery center
15. Technique of drainage of empyema
16. Technique of ligation of thoracic duct laceration
17. Combined drainage of empyema and liver abscess
18. Emergency management of sucking chest wound
19. Emergency management of sucking chest wound
20. Emergency treatment of ambulatory chest casualties
21. Chest casualty with multiple associated wounds
22. Diagrammatic showing of chest wounds and associated injuries
23. Diagrammatic showing of chest wounds and associated injuries
24. Diagrammatic showing of chest wounds and associated injuries
25. Diagrammatic showing of chest wounds and associated injuries
26. Diagrammatic showing of chest wound and associated injuries
27. Diagrammatic showing of chest wounds and associated injuries
28. Bizarre course of missile causing chest wound
29. Roentgenogram showing track of missile in lung
30. Resuscitation of chest casualty
31. Management of tension pneumothorax
32. Management of tension pneumothorax
33. Improvised anesthesia apparatus
34. Position for posterolateral thoracotomy
35. Debridement of chest wound
36. Techniques of wound closure
37. Technique of plastic wound closure
38. Technique of closure of sternal defect
39. Technique of plastic closure of anterior sucking wound
40. Technique of rib approximation without pericostal sutures
41. Effect on rib of pericostal suture
42. Exposure in posterolateral thoracotomy
43. Burford technique of traumatic thoracotomy
44. Wound closure in Burford technique
45. Modified Harken technique for exposure of vessels in superior mediastinum and base of neck
46. Sites and techniques of drainage
47. Convalescent reconditioning exercises for bed patients
47b. Convalescent reconditioning exercises for bed patients (cont.)
48. Exercises to restore shoulder function
48b. Exercises to restore shoulder function (cont.)
49. Individually prescribed exercises for early postoperative period
50. Mild chest exercises shortly after operation
51. Basic thoracic exercises
52. Basic thoracic exercises
53. Basic thoracic exercises
54. Basic thoracic exercises
54b. Basic thoracic exercises (cont.)
55. Basic thoracic exercises
56. Basic thoracic exercises
57. Basic thoracic exercises
58. Basic thoracic exercises
59. Basic thoracic exercises
60. Basic thoracic exercises
61. Basic thoracic exercises
62. Basic thoracic exercises
63. Supplementary exercises
64. Supplementary exercises
65. Supplementary exercises
66. Record of individual progress
67. Supervised group exercises

Tables

Number:

1.  Statistics of chest wounds before Crimean War
2.  Data on anatomic site and nature of injury in thoracic and thoracoabdominal wounds, 1944
3.  Data on causative agents and theaters of occurrence in chest injuries, 1944
4.  Data on causative agents and year of occurrence in chest injuries, 1942-45
5.  Data on deaths by causative agents and theaters of occurrence in chest injuries, 1944
6.  Data on case fatality ratios by causative agents in chest injuries, 1942-45
7.  Data on nature of traumatism and theater of occurrence in chest injuries, 1942-45
8.  Data on deaths by nature of traumatism and theater of occurrence in chest injuries, 1942-45
9.  Data on anatomic site and year of occurrence in thoracic and thoracoabdominal wounds, 1942-45
10.  Data on deaths in thoracic and thoracoabdominal wounds by anatomic site and year of occurrence, 1942-45
11.  Data on deaths in action by anatomic site of wound and theater of occurrence, 1942-45
12.  Data on deaths in action by anatomic site of wound and theater of occurrence, 1944
13.  Anesthesia in Seventh U.S. Army, November 1944-April 1945


SURGERY IN WORLD WAR II

Advisory Editorial Board

Michael E. DeBakey, M.D., Chairman

                        Frank B. Berry, M.D.                              John B. Flick, M.D.                  
                        Brian Blades, M.D.                                  Frank Glenn, M.D.
                        J. Barrett Brown, M.D.                            M. Elliott Randolph, M.D.
                        Sterling Bunnell, M.D. (dec.)                    Isidor S. Ravdin, M.D.
                        Norton Canfield, M.D.                             Joseph R. Shaeffer, M.D.
                        B. Noland Carter, M.D.                           Alfred R. Shands, Jr., M.D.
                        Edward D. Churchill, M.D.                       Howard E. Snyder, M.D.
                        Mather Cleveland, M.D.                           R. Glen Spurling, M.D.
                        Daniel C. Elkin, M.D. (dec.)                     Barnes Woodhall, M.D.
                                                                                       

Robert M. Zollinger, M.D.

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

Brigadier General JAMES E. GRAHAM (ex officio)

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

 

The Historical Unit, United States Army Medical Service

Colonel JOHN BOYD COATES, Jr., MC, USA, Director
Colonel REX P. CLAYTON, MSC, USA, Executive Officer
Colonel R. L. PARKER, MSC, USA, Special Assistant to Director
Lieutenant Colonel R. J. BERNUCCI, MC, USA, Special Assistant to Director
Major WARREN W. DABOLL, MSC, USA, Special Assistant to Director
Lieutenant Colonel DOUGLAS HESFORD, MSC, USA, Chief, Special Projects Branch
CHARLES M. WILTSE, Ph. D., Litt. D., Chief, Historians Branch
ERNEST ELLIOTT, Jr., Chief, Editorial Branch
Lieutenant Colonel LEONARD L. COLLIER, MSC, USA, Chief, Information Activities Branch
Major ALBERT C. RIGGS, Jr., MSC, USA, Chief, General Reference and Research Branch
HAZEL G. HINE, Chief, Administrative Branch

 

Library of Congress Catalog Card Number: 63-6000


THORACIC SURGERY

Volume I


MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department of the U.S. Army in World War II are prepared by The Historical Unit, U.S. Army Medical Service, and published under the direction of The Surgeon General, U.S. Army. These volumes are divided into two series: (1) The administrative or operational series; and (2) the professional, or clinical and technical, series. This is one of the volumes published in the latter series.

 

VOLUMES PUBLISHED

ADMINISTRATIVE SERIES

Hospitalization and Evacuation, Zone of Interior

CLINICAL SERIES

Internal Medicine in World War II:

Vol. I. Activities of Medical Consultants
Vol. II. Infectious Diseases

Preventive Medicine in World War II:

Vol. II. Environmental Hygiene
Vol. III. Personal Health Measures and Immunization
Vol. IV. Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts
Vol. V. Communicable Diseases Transmitted Through Contact or By Unknown Means

Surgery in World War II:

Activities of Surgical Consultants, vol. I
General Surgery, vol. II
Hand Surgery
Neurosurgery, vol. I
Neurosurgery, vol. II
Ophthalmology and Otolaryngology


Surgery in World War II-Continued

Orthopedic Surgery in the European Theater of Operations
Orthopedic Surgery in the Mediterranean Theater of Operations
The Physiologic Effects of Wounds
Vascular Surgery

Miscellaneous:

Cold Injury, Ground Type
Dental Service in World War II
Veterinary Service in World War II
Wound Ballistics