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Preface

Contents

Preface

The history of thoracic surgery in World War II comprises two volumes of the total series dealing with the history of the U.S. Army Medical Department in that War. The fact that it did not prove possible to tell the complete story in any briefer compass is, in itself, an indication of the importance attached to this specialty in the Second World War.

The first volume contains a summary of the development of thoracic surgery in previous wars, the general and statistical background of the World War II experience, administrative considerations in the Mediterranean and European theaters and in the Zone of Interior, the evolution of policies of management of chest wounds, and the routine of management of thoracic casualties from their emergency care on the battlefield through their rehabilitation in chest centers.

The second volume is concerned with special types of chest injuries and with the management of general and special complications, with particular emphasis on the wet lung syndrome, hemothorax and hemothoracic empyema, and retained foreign bodies. It also contains a followup study, made in 1960 and 1961, of 167 casualties who sustained chest wounds in the 1943-45 period.

The history of thoracic surgery contained in these two volumes represents the full flowering of this specialty in World War II. Its development, however, was by a process of evolution. In spite of the advances in it between the World Wars, the management of thoracic injuries in the early months of the U.S. participation in the Second World War must be described as tentative. It was based on the previous experience and the personal practices of individual chest surgeons, whose number was small, and of general surgeons, whose experience in this field was limited and sporadic.

By the spring of 1944, a number of developments, including increasing experience with combat-incurred thoracic wounds, permitted the standardization of policies and practices and led to more excellent results than had ever before been achieved in chest trauma. These developments were as follows:

1. It became evident that plasma was not the answer to the problem of resuscitation of combat casualties, including thoracic casualties, and that whole blood was essential to prepare them for, and carry them through, the necessary surgery. In February 1944, a blood bank was established in Naples. Thereafter, blood was available in such amounts as were needed before, during, and after operation, and all the surgeons who handled chest wounds could now administer it according to the necessities of their patients.

2. With the advent of penicillin, the possibilities of thoracic surgery were greatly expanded, and operations previously considered impossible became feasible and safe.


3. Efficient anesthetic apparatus was provided for the use of the anesthesiologists who, by training and experience, were especially qualified to give anesthetics for chest surgery.

4. A routine for the management of chest injuries, with procedures properly spaced as to time and place of performance, was set up in the Mediterranean theater by Col. Edward D. Churchill, MC, Consultant in Surgery to the theater surgeon. It was derived from the wartime experience of the chest surgeons who, in the preceding months, had applied their peacetime training and experience to the management of these injuries, and it was based on the concept that the goal of resuscitation, surgery, and postoperative care was the restoration of normal pulmonary function.

The availability of blood was extremely important. The availability of penicillin was extremely important. Expert anesthesia is always essential for chest surgery. But it was the correct, properly timed and properly spaced surgical management of chest injuries and their sequelae that was primarily responsible for the outstanding results achieved in them in World War II.

The routine of management of chest injuries set up early in 1944 included prompt and adequate debridement; the performance of thoracotomy in forward hospitals only on strict indications; prompt and adequate measures to control such potentially dangerous complications as wet lung; the management of hemothorax by aspiration; the management of organizing hemothorax and hemothoracic empyema by decortication; and the judicious removal of retained foreign bodies, whose presence seldom furnished the sole indication for thoracotomy in a field or evacuation hospital.

As a result of these policies and practices, lives were saved; morbidity was reduced; and most thoracic casualties who survived their wounds were returned to duty or separated from service without the crippling sequelae characteristic of so many thoracic injuries in World War I.

The fact that several circumstances favored thoracic surgeons in World War II does not detract at all from their brilliant achievement. The epidemics of measles and influenza, with their sequelae of pneumonia and empyema, which had plagued the surgeons of World War I did not occur in World War II. In the interim between the wars, the United States had ceased to be a rural nation and had become an urban nation, and most of the World War II troops had long since been exposed to these diseases. Streptococcic infections no longer held the terror they once held because the sulfonamides, which are particularly useful in this type of infection, were already available and had been well tested before the United States entered the war.

The evolution of the management of chest injuries in World War II occurred in the Mediterranean theater, in which fighting began in late 1942. The thoracic surgeons in the European theater built their policies of management largely upon the experience in this theater, but they had ample time to develop their own philosophy before the Normandy invasion.

In May 1943, Maj. Gen. Paul R. Hawley, Chief Surgeon, European theater, visited the Mediterranean theater and observed the management of all varieties 


of surgery. Later in the same year, Col. (later Brig. Gen.) Elliott C. Cutler, MC, Senior Consultant in Surgery in the European theater, also visited the Mediterranean theater. By this time, the experience of the first chest center in the theater, at Bizerte, was available for analysis. The thoracic surgeons in the European theater also leaned heavily on the extensive British experience, particularly that of Mr. A. Tudor Edwards, Consultant in Thoracic Surgery to the British Emergency Medical Service. As a result of these various contacts, the policies outlined in the booklet entitled "Manual of Therapy" published in the European theater in May 1944 represented a compendium of previous experiences with thoracic injuries and their management, and they served admirably when they were tested in combat.

The repeated references to the data of the 2d Auxiliary Surgical Group in both these volumes are explained elsewhere, but the explanation might be repeated here. The group material on 2,267 thoracic and thoracoabdominal wounds, like the material on 3,154 abdominal injuries analyzed in another volume of this series, is available for reference because its collection was planned in advance. Thanks to the foresight and insistence of Col. (later Brig. Gen.) James H. Forsee, MC, commanding officer of the group, orders were given to keep detailed records of individual thoracic casualties, and appropriate forms were provided for this purpose. These data could not possibly have been collected after the event. As it is, while some details are understandably lacking, the magnitude of the achievement is impressive. Nowhere else in the medico-military literature of World War II or previous wars is there available for analysis and reference such a large series of thoracic and thoracoabdominal injuries.

Similar planning by the consultants in surgery of the Fifth and Seventh U.S. Armies also produced important, though somewhat less extensive, data.

The development of specialty centers was one of the important medical advances in World War II. Some of these centers existed in World War I, but thoracic surgery had not yet reached sufficient stature to be included among them. Specialty centers were established early in the Second World War, and thoracic surgery centers were among the earliest to be set up, in the Mediterranean and European theaters as well as in the Zone of Interior. The concentration of thoracic casualties in these centers permitted the most effective use of the always limited number of thoracic surgeons; greatly extended the experience of these surgeons, and thus resulted in constantly improving care of patients with these injuries.

The emphasis put upon rehabilitation in World War II was a continuation of the similar, but less intensive, efforts in the same direction in World War I. In World War II, this phase of the management of chest injuries probably developed most intensively in the European theater, where circumstances were highly favorable for the establishment of chest centers and where the influence of the British emphasis upon rehabilitation was most apparent. In one form or another, however, rehabilitation of chest casualties was uniformly practiced.


It is one of the reasons why so many thoracic casualties could be returned to duty and why Veterans' Administration hospitals are not caring for the army of chest cripples who required multiple operations and years of hospitalization after World War I.

Theater consultants in thoracic surgery were not appointed in World War II, but the consultants in surgery in both the Mediterranean and the European theaters had a special interest in this field and exercised wise and helpful guidance in it. Their efforts were supported, in turn, by the theater surgeons: Brig. Gen. Frederick A. Blessť and Maj. Gen. Morrison C. Stayer in the Mediterranean theater and General Hawley in the European theater. The theater surgeons encouraged meetings of consultants, at which it was possible to exchange ideas and after which information could be promptly disseminated.

Immediately after the war in Europe ended, the Consultant in Surgery, Seventh U.S. Army, was ordered back to Naples, to consolidate the experiences of the Seventh U.S. Army with that of the Fifth U.S. Army and thus provide a broader perspective derived from the dual experience.

A special word should be said about the excellent liaison which existed between thoracic and other surgeons also in the U.S. Army and their counterparts in the Allied armies. The consultants' meetings in the European theater always included British surgeons, both in the United Kingdom Base and on the Continent, where there were cordial relations with the surgeons of the British 21 Army Group. In the Mediterranean theater, contacts with British surgeons were chiefly local but no less cordial. At the larger medical meetings of U.S. Army surgeons, such as those held in Naples, British surgeons from nearby hospitals were always in attendance.

Early in 1943, the theater consultant in surgery had frequent contacts with the thoracic surgeons in the group of British hospitals near Algiers. Colonel Churchill visited one of these hospitals and observed the work with penicillin done by Dr. (later Sir) Howard Florey and his team. The chief of the surgical service, 9th Evacuation Hospital (later Consultant in Surgery, Seventh U.S. Army), also observed the work with penicillin and later visited several British hospitals, including a field hospital, two casualty clearing stations, and a general hospital. Throughout the war, Colonel Churchill kept in close touch with the British surgical consultants in the Mediterranean theater, Brigadier J. M. Weddell, RAMC, and Brigadier Harold Edwards, RAMC. The policies in chest surgery established in this theater were influenced by the information he received by personal contacts with Sir W. Heneage Ogilvie, from his earlier British experience in the Middle East. Colonel Churchill also had early and frequent contacts with Col. A. L. d'Abreu, RAMC.

Early in the war, Colonel Churchill had the good fortune to know Col. Etienne Curtillet, Professor of Surgery, University of Algiers and Chief Surgical Consultant, French 1st Army. During the planning for the invasion of southern France by the Seventh U.S. Army, the consultant in surgery to that Army had many and useful contacts with Colonel Curtillet, which continued throughout the entire campaign.


The story told in these two volumes is thus based upon a broad and varied experience with thoracic injuries in World War II, during which the achievements in this field laid the foundations for the brilliant advances in it which have occurred since the war. The emphasis in this history, it should be noted, is factual. The aim has been to relate the events in chronicle form, with no attempt at a critique of the motives behind, or the reasons for, the various actions taken.

The story of thoracic surgery in these two volumes covers only the Mediterranean and European theaters and the Zone of Interior. For a number of reasons, chest surgery in the Asiatic-Pacific theater will be discussed in the volume dealing with surgery in those areas.

The type of warfare in this theater was very different. This war was fought in scattered areas; on numerous, often widely separated islands; in jungles; in a tropical climate that was humid as well as hot and in which rainfall was frequent and torrential; in an environment in which parasitic and other tropical diseases furnished problems that were often more serious than the problems of battle injuries; and in areas in which transportation and evacuation were always show and difficult.

It is small wonder that in the Asiatic-Pacific theater, infected hemothorax, empyema, and other complications of chest injuries were more frequent than in other theaters. It is a tribute to the skill and devotion of the surgeons who worked in these areas that their incidence was not higher.

It would be impossible to produce books of the range of these volumes on thoracic surgery without the painstaking and devoted assistance of a great many persons and agencies. In the end, for a variety of reasons, the chief responsibility for the preparation of this material fell upon a relatively small number of authors. It is a pleasure to make acknowledgment to them:

Dr. Brian Blades (formerly Col., MC), Consultant in Thoracic Surgery to The Surgeon General and chief of the Thoracic Surgery Section at Walter Reed General Hospital, Washington, D.C., during World War II.

Dr. Lyman A. Brewer III (formerly Maj., MC), who served with Thoracic Surgical Team No. 2, 2d Auxiliary Surgical Group, in the Mediterranean theater and later in the European theater.

Dr. Thomas H. Burford (formerly Maj., MC), who served with Thoracic Surgical Team No. 3, 2d Auxiliary Surgical Group, in the Mediterranean theater.

Dr. B. Noland Carter (formerly Col., MC), Assistant Director, Surgical Consultants Division, Office of The Surgeon General. Dr. Carter, in addition to preparing the chapters which carry his name, reviewed the entire manuscript and made helpful suggestions.

Dr. Michael E. DeBakey (formerly Col., MC), Chief, Surgery Branch, Surgical Consultants Division, Office of The Surgeon General, and now chairman of the Advisory Editorial Board for Surgery.


Dr. Dwight E. Harken (formerly Lt. Col., MC), Regional Consultant in Thoracic Surgery to the Senior Consultant in Surgery, European theater. Dr. Harken also directed the chest center at the 160th General Hospital.

Mr. Milton C. Rossoff, Assistant Chief, Statistical Analysis Branch, Medical Statistics Division, Office of The Surgeon General, collected and tabulated the official statistics for the thoracic surgery volumes.

Mr. Melvin J. Hadden was responsible for the artwork in both volumes. He made usable many illustrations which originally seemed beyond salvage.

Grateful acknowledgment is also due to a number of the personnel of The Historical Unit, U.S. Army Medical Service:

Maj. Albert C. Riggs, Jr., MSC, Chief, General Reference and Research Branch, and Mrs. Esther E. Rohlader, Assistant Chief, provided much of the basic data for these volumes and patiently and efficiently answered endless queries and tracked down numerous obscurities to their final solution.

Mrs. Pauline B. Vivette, Assistant Chief, Editorial Branch, prepared both volumes for publication.

Mrs. Hazel G. Hine, Chief, Administrative Branch, handled the multiple details connected with the preparation of volumes issued under Government auspices and also supervised the final typing of the manuscript.

Finally, a special word of appreciation is due to two other persons who worked on these volumes:

Miss Elizabeth M. McFetridge, Associate Editor for the surgical series of volumes, who, after many discouragements, was able to bring together the material prepared by the group of thoracic surgeons who worked in the Mediterranean and European theaters and to prepare it for publication.

Col. John Boyd Coates, Jr., MC, who has been assigned by The Surgeon General as Director, The Historical Unit, U.S. Army Medical Service, and Editor in Chief of the history of the U.S. Army Medical Department in World War II. Colonel Coates, who served in World War II as Executive Officer, Medical Division, Third U.S. Army, saw the unfolding of the story of thoracic surgery in the European theater and, during the campaign, was in frequent contact with the Consulting Surgeon, Sixth U.S. Army Group. His firsthand knowledge has been useful, and his cooperation in all the work on these two volumes has been most helpful.

FRANK B. BERRY, M.D.

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