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Chapter I

Contents

Part I

SPECIAL TYPES OF WOUNDS OF THE CHEST


CHAPTER I

Special Types of Thoracic Wounds

Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.

WOUNDS OF THE CHEST WALL

The simplest form of chest wound, the type which involved only the thoracic wall and produced no bony or visceral injuries (fig. 1), always had one serious possibility: The pain which followed might cause voluntary restriction of respiration and of the cough reflex, which, in turn, could cause retention of secretions and introduce the problems of wet lung. Injuries which involved only the soft parts, such as abrasions and lacerations, were usually not serious. Those associated with fractures of the ribs could be serious. Contusions of the chest wall could also be serious.

An occasional patient who seemed to have only a simple contusion of the chest wall developed pleural effusion, apparently because the pleura had shared in the trauma. In these cases, which were usually diagnosed as traumatic

FIGURE 1.-Superficial bullet wounds of chest wall not involving bony structures.


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pleuritis with effusion, the fluid was straw colored or amber and had the characteristics of a transudate. Repeated aspiration was usually the only treatment necessary, but in an occasional case, in which the pleural fluid had a high fibrin content, clotting occurred, and the total picture was suggestive of clotted hemothorax. If the condition remained static, decortication might be necessary.

Contusions of the chest wall were also responsible for some intrathoracic hematomas (p.165).

Case History

The following case history illustrates the intrathoracic complications that sometimes followed a wound of the chest wall not, in itself, of major importance:

Case 1.-This casualty was picked up by aidmen between 1 and 2 hours after he was wounded by shell fragments in the right shoulder and left knee. When he was received in an evacuation hospital 11 hours after wounding, he was found to have a perforating wound of the right upper chest, associated with a moderate hemothorax. Wet lung was demonstrated clinically by many loud rales and rhonchi and was confirmed by roentgenograms. Roentgenologic examination also showed comminuted fractures of the posterior portion of the second and third ribs, and possibly of the fourth rib, on the right side. No foreign bodies were visible on this roentgenogram nor on the roentgenogram of the left knee, which showed an epiphyseal fracture of the tibial tubercle.

Fourteen hours after the patient's admission to the hospital the wound of entrance just below the outer third of the right clavicle was widely debrided under local analgesia, and a large amount of clotted and liquid blood was evacuated. A small fragment of the fractured right clavicle was removed. The wound was sprinkled with powdered sulfanilamide, and a petrolatum-impregnated gauze dressing was applied. Paravertebral nerve block with procaine hydrochloride was carried out at the level of the seventh cervical vertebra and the first through the fourth thoracic vertebrae. The hemothorax was aspirated through the seventh intercostal space in the posterior axillary line, and the 500 cc. of blood thus obtained was used as an autotransfusion, with 500 cc. of physiologic salt solution. Bronchoscopy was employed to clear profuse secretions from the tracheobronchial tree. The wound of the left knee was debrided.

The postoperative course was satisfactory for the first 4 days. Then paravertebral block had to be repeated because of pain. No fluid was found in aspiration at this time. On the eighth day, 1,350 cc. of bloody fluid was aspirated from the right chest. Repeated aspiration on the 10th day produced 150 cc. of thick, pinkish fluid, and on the 12th day, 725 cc. of thin fluid of the same color was removed. Thereafter the chest was dry.

When the patient was evacuated on the 22d postoperative day, he had entirely recovered from his chest injury, but he still had some loss of function of the upper right arm.

Comment-Contusion of the chest wall was present to some degree in all injuries of the chest in which direct violence was a factor. It undoubtedly played a part in the case just recorded, helping to produce both wet lung and hemothorax. There was no direct communication between the pleural cavity and the wound of the chest wall.

Although this patient had an extensive wound of the chest wall, with hemothorax and wet lung, there was no indication for formal thoracotomy. The infection in the chest wall was controlled by adequate debridement. The lung was expanded by needle aspiration of the blood in the pleural cavity, thus increasing the vital capacity, and intercostal nerve block allowed the patient to breathe deeply and cough effectively with relief of the wet lung syndrome.


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SUCKING WOUNDS

General Consideration

A sucking wound (fig. 2) is defined as a wound in which there is more or less free interchange of air through the wound between the pleural cavity and the outside atmosphere. The term, as pointed out elsewhere (vol. I), is both unsuitable and misleading, and blowing wound is preferable nomenclature. Sucking wound, however, has the sanction of usage, and for that reason, its use is continued in this volume.

Potentially, if not actually, all penetrating and perforating wounds of the chest observed in World War II were sucking wounds. A sucking wound sometimes sucked (blew) constantly and sometimes only when the skin and muscle planes were in a certain alinement. The regional anatomy frequently determined whether or not a wound sucked. Generally speaking, a large wound was more likely to suck than a small wound, but size was not the most important determining factor. A relatively small wound in the anterior chest wall, 2 cm. or less in diameter, might suck constantly because in this area the muscles are scanty and the interspaces wide. A larger wound located posteriorly, in the heavy muscles of the back, might be less likely to suck.

Other considerations also determined whether or not a wound sucked. If the missile traversed the chest at such an angle that the external wound of entry was at a considerable distance from the point of its entrance into the pleural cavity, the movement of the intervening muscles of the chest wall might prevent the wound from sucking at one moment and permit it to suck at another. If the wound involved the muscles of the pectoral girdle, movement of the upper extremity on the injured side might so realine the openings in the skin and pleura that sucking occurred constantly.

Casualties with chest injuries were usually transported supine or in the sitting or semisitting position, but not many were wounded in these positions. Change of position after wounding therefore influenced the blowing characteristics of the wound.

Pathologic Physiology

Studies by Graham (1) (pp. 285-319 of reference cited) with Bell in World War I showed that a wound that exposes the lung and pleural cavity is not necessarily fatal. It can be tolerated if the amount of air entering the wound from the exterior is not greater than the difference between the tidal air and the original vital capacity. In the absence of treatment, the outcome is determined by the size of the wound and the original vital capacity.

The lung on the injured side does not collapse to the point of nonfunction when it is exposed to atmospheric pressure after wounding, even when the pleural cavity is free of adhesions (2). Furthermore, the pressures exerted on the exposed lung during the respiratory cycle are not always atmospheric.


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FIGURE 2.-Schematic showing of pathologic physiology of sucking chest wound. A. Entrance of air into chest on inspiration through wound in chest wall (a), the amount of air being directly proportional to the size of the opening as compared with the surface area of the open glottis. Collapse of lung on affected side (b), with passage of air out of affected bronchus. Entrance into bronchus of some air from collapsed lung (c), with passage to intact lung. Shift of mediastinum toward uninvolved side (d), hemothorax (e). B. Escape of air on expiration through sucking wound of chest wall (a). Expansion of collapsed lung (b). Passage of air from uninvolved side to lung on involved side, thence out trachea (c), producing the so-called pendular breathing. Shift of mediastinum to involved side (d). Hemothorax (e).


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FIGURE 2.-Continued. C. Packing of sucking wound (a), after which respiration becomes more normal. Hemothorax (e). D. Development of tension pneumothorax because air cannot escape from tear in lung (a), after wound is adequately packed. If it develops, it must be treated by closed (catheter) drainage of cavity. Hemothorax (e).


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The thorax is a flexible container, which moves during the respiratory cycle, and there may even be negative pressure in the exposed side during inspiration. The response to negative intrapleural pressure occasioned by enlargement of the chest on inspiration is a rush of air through the glottis. If the size of the traumatic opening is less than the size of the glottis, a sufficient amount of air enters through the glottis to answer the tidal air requirements and for functional necessities, and there is no danger of asphyxiation. When, however, the size of the wound approaches or exceeds the size of the glottis, the amount of air which enters the chest through the open wound during each inspiration is large enough to interfere with the tidal air requirement intake, and asphyxiation is a real danger.

Another factor must also be taken into consideration in the pathologic physiology of chest wounds, interference with the function of the contralateral side. In the healthy person, the mediastinum is not held down by adhesions or stiffened by previous inflammatory disease. It is therefore capable of transmitting pressure, and as a result, the intrathoracic pressure is likely to be almost identical in both cavities. In other words, the decrease in vital capacity caused by an open wound of the chest is bilateral in the normal person, whereas a casualty with a stiffened mediastinum can sometimes tolerate even very large wounds.

When the amount of air entering an open chest wound during each inspiration is large enough to interfere with the tidal air requirement intake, some degree of asphyxia is inevitable. A vicious circle then ensues:

1. There is an initial and increasing reduction in the vital capacity.

2. The mediastinum shifts with each inspiration and expiration, since it is no longer opposed by the lung on the injured side.

3. The mediastinal shift (flutter) increases in rapidity as the reduction in vital capacity increases.

4. The mediastinal shift has a direct and deleterious effect on the right heart, for anatomic reasons. The base of the heart is fixed, but the apex is relatively free. The apex therefore is capable of movement and is relatively unaffected by mediastinal flutter. The base is incapable of movement, and kinking of the large vessels that enter the right side of the heart is the next consequence of this phenomenon.

5. Pendulum respiration ensues and causes a further decrease in the vital capacity. On each expiration, air from the contralateral lung, with its predominant carbon dioxide content, is only partly exhaled. The residual amount enters the main and secondary bronchi on the injured side. On the next inspiration, the air taken into the uninjured lung is thus composed of both atmospheric air from the trachea and air from the injured lung, with a high carbon dioxide content.


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Immediate Management

Casualties with large sucking wounds were usually in shock and nontransportable. All casualties with actual or potential sucking wounds were always in jeopardy, whether or not the wound was blowing at the particular moment of examination.

Surgical closure was necessary to bring about permanent restoration of normal cardiorespiratory physiology and to prevent intrapleural infection. This did not mean, however, that immediate surgical closure was necessary.

Early in the war, in obedience to the dictum that all sucking wounds should be closed promptly, attempts were often made to close these wounds hastily by suture as soon as the casualty reached the most forward medical installation. U.S. Army medical officers promptly learned, just as British medical officers had learned (vol. I), that this was a disastrous policy unless ample facilities were at hand for debridement and careful surgical closure. These facilities were not available ahead of a field hospital. When closure was undertaken without careful preliminary debridement, one or all of several complications might occur, including tension pneumothorax; extensive subcutaneous emphysema; or infection of the wound, with disruption, which produced a recurrence of the original sucking wound, with the difference that it was now surrounded by tissues that were infected and no longer suitable for approximation. The incidence of empyema was high in wounds that broke down after repair. It reached 50 percent in some series.

That treatment was a matter of extreme urgency was not open to debate. It was also quite simple. As already described (vol. I), medical aidmen were originally instructed to cover sucking wounds with an occlusive dressing (fig. 2C). Later, all chest wounds were treated in this way, on the ground that a wound that did not suck at one time or in one position might suck in another. On the battlefield, any type of dressing that was available could be used, even a piece of clothing. As soon as the casualty was brought to the battalion aid station, the temporary dressing was replaced by a larger dressing, preferably at least twice as large as the wound. It was thickly impregnated with petrolatum and was covered with a still larger gauze dressing held firmly in place with strips of adhesive. If the wound was very large, coarse sutures were placed through the skin and tied over the dressings.

This sort of dressing closed the chest efficiently for 5 or 6 hours, or longer. During this period, the patient was transported to a clearing station in which it was determined, by triage, whether he should be transferred to the adjacent field hospital for emergency surgery or could safely be transported to an evacuation hospital farther to the rear, though it was frequently necessary first to change the dressing. When a petrolatum-impregnated gauze dressing had become caked with blood, it had stiffened and was no longer pliable enough to act as a one-way valve. A needle with a flutter valve attachment was usually placed in the second interspace parasternally to provide for the escape of air and prevent tension pneumothorax (fig. 2D).


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As the war progressed, emergency management of sucking wounds became so satisfactory that their potential seriousness was considerably minimized.

Surgical Closure

Small wounds-Small sucking wounds, 2 cm. or less in diameter, although they were likely to blow continuously if they were located in portions of the thoracic cage where muscle was scanty, could usually be closed without difficulty. Lacerated skin and muscle were trimmed away, and accessible rib fragments were removed. Blood and clots were aspirated from the pleural cavity whenever they were present. In the absence of other indications, however, the wound was not enlarged into a formal thoracotomy for exploration or for removal of small metallic foreign bodies.

The pleural defect was usually closed by a few sutures in the intercostal muscle or, occasionally, by a small muscle plug in lieu of a pedicled graft. The more superficial muscles and the subcutaneous tissues were closed in layers, with sutures of fine interrupted silk. The skin was left open, to be closed at the base.

Intercostal water-seal drainage of the pleural cavity was frequently instituted, even in small wounds, both because the lung had often been injured and because air leakage was a possibility.

Large wounds-Sucking wounds associated with large defects in the thoracic wall and with multiple rib fractures were usually grossly contaminated. Thorough excision of devitalized tissue was therefore necessary, together with excision of all loose rib fragments and of 3 to 6 cm. of the damaged costal ends. Excision was thorough, but as much periosteum and intercostal muscle and fascia was preserved as seemed safe. When a debridement had been carried out according to these principles, a traumatic thoracotomy had often been accomplished, through which intrapleural exploration could be conducted. Foreign bodies were removed if they were readily accessible. The lung was sutured if there was leakage of air or oozing of any consequence from the parenchyma. Otherwise, no lung surgery was done (p. 17). The pleural cavity was thoroughly cleansed.

The adequate exposure necessary for the debridement of large sucking wounds often made for difficulties in closure, particularly if the wound was in the anterior chest, where the muscle layer was scanty and the interspaces wider. Suture under tension had to be avoided. It was always undesirable, and it was particularly undesirable in contaminated areas. Even when the wound was located basally, the diaphragm was never used to close the pleural defect if other tissues could be utilized.

Closure of the deepest layer of the wound could often be effected by using the intercostal structures, periosteum, and deep fascia. If large segments of ribs had been removed, these tissues were relaxed and could be manipulated more readily. Relaxing incisions in the long axis of the intercostal bundles were helpful.


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When necessary, the first muscle layer could be reinforced with pedicle flaps or muscles (vol. I), or the inferior surfaces of the deep muscles could be approximated to the first layer of the closure by interrupted sutures. When muscle tissue had been lost, subcutaneous dissection of the muscle sometimes simplified closure, or relaxing incisions might be employed at some distance from the defect. The subcutaneous tissues were usually closed, but skin closure was deferred. The dressings were applied with a moderate amount of pressure.

Tension pneumothorax was always a risk after a sucking wound had been closed. Some surgeons considered careful postoperative observation the only precaution necessary. Others preferred to use a safety valve in the form of a catheter with a flutter valve or a large-bore needle in the second anterior interspace.

Since the empyema rate was greater in sucking wounds associated with large defects of the thoracic wall, posterolateral closed intercostal drainage was sometimes employed. A second intercostal tube in one of the upper anterior intercostal spaces was useful in encouraging prompt reexpansion of the upper lobe. If empyema occurred, it was then limited to the base of the lung. If penicillin or a sulfonamide had been instilled into the chest and the posterior tube had been temporarily clamped off, the anterior tube could be relied upon to facilitate prompt expansion of the lung.

FRACTURES OF THE RIBS AND ADJACENT STRUCTURES

Simple Fractures

Simple fractures of the ribs were not common in combat-incurred injuries. When they were encountered in combat zones, they were usually the result of traffic or other civilian-type accidents. Relief of pain was secured by intercostal nerve block. Strapping was not practiced.

Solid, painless healing of simple rib fractures required about 6 weeks. If several ribs were fractured, another 2 or 3 weeks had to elapse before the patient could resume his full activities.

Simple fractures represented no threat to life, but they accounted for a considerable loss of manpower because of the time required for total convalescence.

Costochondral separations were remarkably infrequent. They were managed, like simple fractures, by intercostal nerve block. Recovery was usually prompt, but even if pain at the costochondral joint was persistent, joint resection was never practiced.

Simple fractures of the clavicle were managed by standard measures. Wiring was unnecessarily radical; it enhanced the chances of infection and could give rise to suppuration, which often was prolonged. Such heroic surgery was occasionally encountered early in the war, but it was never performed by physicians aware of the essential function of the clavicle and of its excellent natural capacity for recovery from trauma.


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Simple fractures of the scapula were also infrequent in war wounds. They required only immobilization of the shoulder by a sling.

Acromioclavicular and sternoclavicular injuries as well as fractures of the glenoid fossa required special orthopedic care. Since they were not managed primarily by thoracic surgeons, they are discussed in the volumes on orthopedic surgery in this series.

Compound Fractures of the Ribs

About 75 percent of all combat-incurred penetrating and perforating wounds of the chest were associated with compound fractures of one or, more often, of several ribs. The scapula and clavicle were often similarly injured, and comminution of the bony structures might be extreme.

Pathologic process-Occasionally, a tangential injury to the chest resulted in the fracture of one or more ribs in such a manner that the sharp edges of the fractured ribs penetrated the pleura even though the missile itself did not. Bone fragments from fractured ribs, because of their irregular, jagged edges and the respiratory movements of the chest, sometimes caused long, ragged pulmonary lacerations and other damage more serious than that caused by the original missiles. Even if this did not happen, penetration of the intact pleura by bone fragments could cause a pneumothorax, and continued trauma to the lungs by embedded bone fragments resulted, in a few cases, in both empyema and lung abscess. Both infection and sequestration were, however, remarkably infrequent, because of the almost universal practice of adequate debridement in forward hospitals.

Flail chest-Flail chest, with paradoxical respiration, resulted from multiple fractures of several ribs. It was not often seen, but it was extremely serious because of the consequent reduction in vital capacity (fig. 3). The more the chest wall was sucked in toward the contralateral side during inspiration and the less it returned to the normal position on expiration, the greater was the decrease in vital capacity and the more the patient compensated by breathing faster.

Immediate management-The immediate treatment of fractured ribs (fig. 4) was the relief of pain by intercostal nerve block, which usually lasted for 24 hours or more. When the casualty was able to breathe deeply, cough, and raise sputum, he became transportable, if associated wounds did not require forward surgery, and definitive treatment could be deferred until he reached an evacuation hospital.

Adhesive strapping was practically never used. It was often unsuccessful in accomplishing immobilization and relieving pain, and the adhesive often caused additional discomfort. Strapping was also unphysiologic. Many patients with fractures of the ribs showed varying degrees of wet lung with increased bronchial secretions and intrapulmonary bleeding. Raising the fluid would have been difficult or impossible because of pulmonary compression and the restriction of expansion of the chest caused by strapping.


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FIGURE 3.-Schematic showing of pathologic physiology of flail chest. A. Inspiratory phase. Chest wall collapses inward (a), forcing air out of bronchus of involved lung into trachea and bronchus to uninvolved lung and causing shift of mediastinum to uninvolved side (b). B. Expiratory phase. Chest wall balloons outward (a) so that air expelled from lung on uninvolved side (b) enters lung on involved side and mediastinum shifts toward involved side (a). This is a very inefficient form of respiration, and the patient will die of hypoxia and exhaustion if it occurs in an extreme phase and is not relieved.


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FIGURE 4.-Management of flail chest. A. Intercostal nerve block, to block painful impulses on affected side and thus cut down paradoxical respirations and allow for deeper breathing and more effective cough. (For further details of technique, see fig. 68, p. 220.) B. Application of circumferential elastic binder, to prevent chest wall from ballooning out on inspiration and to allow diaphragm to function more effectively.


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FIGURE 4.-Continued. C. Overhead traction. Whether the injury is a fracture of the sternum, the cartilages, or the ribs, the paradoxically moving portion of the chest may be stabilized by the use of large towel clips fixed into the ribs or other damaged structures or by wire passed underneath them. Stabilization could usually be accomplished successfully by the use of two pulleys and weights, of not more than 5 pounds. D. Wire splint, fixed on either side of flail portion of chest, supports towel clips or wires attached to the fractured ribs by means of rubberbands.


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In civilian practice, a patient with flail chest would be ideally treated in a respirator. This was, of course, completely impractical in military surgery. Nerve block often resulted in a considerable improvement in symptoms and a considerable reduction in the paradoxical movement of the chest wall. If it was not successful, adhesive strapping, undesirable as it was, sometimes had to be employed, or an elastic binder was used. Positioning with sandbags was occasionally useful, but traction was seldom employed. If simpler measures were not successful, operation had to be resorted to. Costal fixation was secured by placing stainless steel wire or heavy silk through the ends of the shattered ribs. Tracheotomy was sometimes necessary also.

Surgical management-The surgical management of fractures of the ribs required careful individualization of patients. In most instances, debridement could be limited to the soft tissues. If the wound was tangential, there might be extensive comminution of from three to five ribs without penetration of the pleura. Often the greater portion of the damage was subscapular. In a few cases, roentgenograms showed what looked like a picket fence of bony spicules along the parietal pleura.

Whenever debridement included the removal of irregular, subpleural rib fragments, the pleural cavity was necessarily entered, and the surgeon had, in effect, performed a thoracotomy. He had to have sound reasons for extending the wound and increasing the magnitude of the operation. The mere presence of bone fragments within the pulmonary parenchyma was not an indication unless they seemed responsible for continued bleeding or for an air leak.

One exception to this generalization was the presence of fragments partly within the pulmonary parenchyma and partly within the pleural space. Fragments in this location could produce a good deal of trauma when the lung reexpanded and they came into contact with the chest wall. Both air leaks and infections were possible sequelae. A number of cases were observed in which the lung, the pleural cavity, and the chest wall were all involved in the infection that followed debridement carried down only to the muscles, the bone fragments being left in situ.

WOUNDS OF THE LUNGS

General Considerations

Lacerations of the pulmonary parenchyma were encountered in practically all perforating chest wounds. They varied from small puncture wounds to very extensive lacerations.

When surgeons, early in the war, first encountered badly contused, lacerated, boggy, hemorrhagic lungs, they found it hard to refrain from immediate lobectomy. In fact, this operation would probably have been done rather often if the casualties had not been in such poor general condition or had not had associated major wounds. For these reasons, pulmonary surgery


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was, of necessity, limited to simple suture. The sutures, also of necessity, were superficial, since the friable, hemorrhagic tissues were incapable of holding deep sutures. The practice was to perform one-layer closure, with interrupted sutures of fine, nonabsorbable material on an atraumatic needle. It proved surprisingly easy to secure an airtight closure in this manner, one reason being that the tendency to leakage was diminished by the fact that the damaged lung was somewhat slow to aerate completely. Roentgenograms examined 2 or 3 weeks after surgery showed remarkable clearing of the lung fields, and clearing was usually complete in 6 to 8 weeks.

One reason for these good results can be explained in the form of an analogy: Engineers found that the best protection for wiring in airplanes was simply to fasten the wires loosely along the side of the plane. Missiles that passed through wires thus placed seldom damaged all of them, whereas if the wiring had been placed in a conduit, a single bullet that struck the container could divide all of the wires in it. The same phenomenon was observed in the lung. The blood vessels are surrounded by an elastic medium that permits them to be easily displaced in any direction when a foreign body strikes them. As a result of this physiologic capability, damage to the lungs was frequently more limited than it might otherwise have been.

The real explanation of the tremendous recuperative power of the lung is its dual blood supply, through the pulmonary and bronchial arterial systems. The blood supply, being in the form of a tree, was irreparably damaged only when the trunk was severed. Since all the major blood vessels branch out radially from the hilus, they had to be damaged near the point of origin to cause lethal damage to the pulmonary parenchyma.1 Undoubtedly there were many such injuries in World War II, but the casualties who sustained them did not live long enough to reach field hospitals.

Management in Forward Hospitals

As the war progressed, the policy of leaving small lacerations of the lung unsutured became general. No untoward effects were noted. Untreated lungs were found to expand as well, and about as rapidly, as lungs which had been sutured. These observations bore out the theory that the surrounding airless lung, when it was infiltrated by blood, prevented postoperative parenchymal pleural fistulas.

Eventually it became the custom to suture lacerations of lung tissue only on the following indications:

1. Obvious parenchymal pleural fistulas.

2. Large lacerations, chiefly to reduce the amount of postoperative drainage.

1Wartime observations are borne out by a series of experiments on the pathologic effects of foreign bodies in the pulmonary artery reported in 1959 (3). These studies showed that the lung can recuperate when a branch of the artery or the lobar pulmonary artery is completely blocked. Only when the main artery is blocked will the pathologic changes be irreversible. Severe pathologic changes result, however, when the bronchial artery and the pulmonary artery to the involved lobe are blocked.


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3. Lacerations bleeding into the pleural cavity.

4. Lacerations bleeding into the tracheobronchial tree.

It was logical to repair pulmonary lacerations that were oozing actively or that presented serious air leaks. It was particularly important to suture lacerations that were bleeding into the tracheobronchial tree. In these circumstances, even with repeated endotracheal suction, it would have been difficult to keep the airway free of blood.

If the chest was to be drained, closure of a small air leak was not considered important. Air leaks were identified by filling the hemithorax with physiologic salt solution under pressure of 10 to 15 mm. H2O; it was necessary that the lung be completely covered with the solution.

There was no indication for pulmonary repair in the contusion type of injury, since it caused either scattered areas of hemorrhage in both lungs, as in blast injuries, or massive bleeding that involved all the lobes. This therapeutic point of view is in interesting contrast to the World War I concept that all hemorrhagic infiltrations ("splenizations") had to be resected if a fatal issue were to be prevented (4).

Occasional small peripheral wedge resections were performed for localized areas of necrosis around foreign bodies. Otherwise, there were few valid indications for resection in forward hospitals. They were limited to:

1. Irreparable damage to a major bronchus.

2. Partial traumatic amputation of a portion of a lobe in which the bronchi had been transected and little or no blood supply remained.

3. Damage to major pulmonary vessels of such a character as to require complete ligation. Very few patients in this category lived long enough to reach a forward hospital.

The records of the 2d Auxiliary Surgical Group, covering 2,267 thoracic and thoracoabdominal wounds, show only a single lobectomy in a forward hospital, on a patient who died in the course of the operation. Pneumonectomy was not attempted in any instance.

Management in Base Hospitals

Even in base hospitals, indications for pulmonary resection seldom arose. An occasional peripheral wedge resection was performed, as in forward hospitals, to remove a localized area of necrosis around a foreign body or on the indication of a small peripheral posttraumatic abscess or multiple bronchopleural fistulas. The tissue to be excised was held between clamps. After hemostasis had been secured, the raw edges of the lung were sutured together, and the edges of the pleura were inverted with two rows of interrupted sutures of fine silk. Air leakage did not occur with this type of suture.

The experience of the 2d Auxiliary Surgical Group shows how infrequent was the need in World War II for the radical excision of lung tissue. Maj. Thomas H. Burford, MC, and Maj. (later Lt. Col.) Paul C. Samson, MC, found it necessary to perform only one lobectomy and only two total pneumonectomies


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in the base hospitals in which they worked. In retrospect, they questioned the wisdom of all three operations:

The lobectomy was performed for a massive liquefied hematoma of the upper lobe, which had shown no evidence of regression over a 4-week period. The patient died on the operating table. In this case, simple external drainage would probably have been wiser.

The first pneumonectomy was performed on the indication of a chronic fistulous tract resulting from a penetrating shell-fragment wound. The tract was more than 1 cm. in diameter and extended through both upper and lower lobes at the hilus. Surgical obliteration was impractical. The patient survived the pneumonectomy but eventually died from empyema and purulent pericarditis.

The second pneumonectomy, in which death occurred from the same causes, was performed on the indication of multiple recurrent fistulas, a collapsed lung, and an infected hemothorax. The original injury was a perforating wound from a rifle bullet. Pathologic examination of the excised specimen showed multiple areas in which alveoli were ruptured, and widespread vascular damage was indicated by thrombosis of numerous small vessels. In this case, it would probably have been wiser merely to drain the empyema and accept the collapse of the injured lung as permanent.

The results in these cases show that the mortality for pulmonary resection performed for thoracic injuries or their sequelae is so high that operations of this sort are seldom if ever indicated. They should be undertaken only on clear-cut indications and only after the most careful consideration.

In the Mediterranean theater, an increasingly conservative attitude toward lobectomy and pneumonectomy was gradually crystallized as experience in the management of combat-incurred casualties increased. In the last year of the war, in treating a series of 338 chest injuries at the 21st General Hospital, Maj. Lyman A. Brewer III, MC, found no indication for lobectomy in any of the patients. In one case, it was thought that lobectomy might be necessary later, but the decision was deferred until the lung had had a chance for maximum recovery and the patient could be studied more deliberately in the Zone of Interior.

WOUNDS OF THE MEDIASTINAL STRUCTURES

General Considerations

Wounds of the mediastinal structures were uncommon in forward hospitals, chiefly because injuries to adjacent vital structures were usually lethal. Mediastinal wounds included injuries of the larger hilar blood vessels, which were usually promptly fatal; injuries of the intrathoracic trachea and major bronchi; and injuries of the esophagus. Diagnosis, which was difficult and confusing, was based upon the following considerations:


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1. The projected course of the missile was the most useful index of possible damage.

2. Signs of continuing intrapleural hemorrhage were frequently, but not necessarily, present when a large blood vessel had been injured.

3. Injuries to the trachea and major bronchi caused a rapid accumulation of air in the pleural cavity, frequently under increased pressure. Whenever leakage of air continued, it could be assumed that a bronchus or branch bronchus had been injured.

4. Mediastinal emphysema of varying degrees was frequently present, as the result of wounds of the hilar bronchi, trachea, or subglottic larynx, though in the experience of the 2d Auxiliary Surgical Group, the air was never under sufficient pressure to obstruct the venous return to the heart and give rise to symptoms. It was the opinion of these surgeons that most of the symptoms ascribed in the literature to mediastinal emphysema were more probably caused by an unrecognized associated pressure pneumothorax. The ease with which, in many cases, air in the mediastinum dissected into the pleural cavity was explained by the absence, in most World War II soldiers, of old pleural disease and subsequent pleural thickening and adhesions. The most frequent clinical evidence of mediastinal emphysema was a precordial crunch or click synchronous with the heartbeat.

Management

Correction of the pressure pneumothorax usually stabilized the patient sufficiently to permit whatever surgery was necessary. Only occasionally were suprasternal incisions into the deep fascial planes necessary as an emergency procedure to relieve emphysema.

Exploration in injuries of the mediastinum was usually carried out for one of two reasons, suspected injury to the esophagus or continued bleeding from large vessels or from the heart. The mere demonstration of shell fragments within the mediastinum was not considered a sufficient indication for surgery in the absence of one or the other of these indications.

Enlargement of the mediastinum by extravasation of blood, as demonstrated by roentgenograms, was not an indication for exploration unless there were also signs of obstruction of the superior vena cava, as shown by progressive swelling of the cervical veins or unless progressive enlargement of the mediastinal shadow suggested continued hemorrhage. Considerable enlargement of the superior mediastinum sometimes accompanied wounds of the neck as the result of dissection into it of blood from a cervical vessel. It was the rule to investigate wounds in the neck thoroughly, before proceeding with such extensive operations as removal of a part of the clavicle and the sternum, in the hope that, even if the missile was in the superior mediastinum, the source of the hemorrhage might be reached from above or might become accessible by exposure at the base of the neck. When a missile in this region could not be readily removed, the area could be drained through the cervical wound.


21

FIGURE 5.-Schematic showing of results of laceration of main bronchus. This injury will always produce a pneumothorax with leakage of large amounts of air even under closed drainage with strong suction. Thoracotomy is indicated.

As a matter of convenience, wounds of the trachea and bronchi and of the esophagus are discussed separately.

WOUNDS OF THE TRACHEA AND BRONCHI

General Considerations

Injuries of the intrathoracic trachea and main bronchi were extremely uncommon in forward hospitals, chiefly because, if they were of consequence, death promptly occurred on the battlefield. The few patients who survived to reach the hospital-there were only 4 in the 2,267 thoracic and thoracoabdominal injuries encountered by the thoracic surgical teams of the 2d Auxiliary Surgical Group-were in severe cardiorespiratory imbalance. None of them presented a sizable intrathoracic laceration of the trachea.

Unless casualties with this kind of injury had also sustained a traumatic thoracotomy, wounds of major bronchi were characterized by a rapid, complete collapse of the affected lung, associated with an extreme degree of pressure pneumothorax (fig. 5). Subcutaneous emphysema might be extreme, extend-


22

ing from the scalp down to, and into, the testicles. When the trachea was the site of a major wound, both lungs were collapsed and the patient usually died very quickly.

These findings, combined with the location of the missile, pointed to the diagnosis, particularly in injuries of the trachea. The only possible source of confusion was a sucking wound at the apex of the lung anteriorly, which might be mistaken for a perforation of the trachea.

Management

In wounds of the trachea and bronchi, immediate, adequate decompression was imperative. It was best accomplished by the introduction into the second interspace anteriorly of a large catheter, which was connected with a water trap. Large amounts of blood were frequently present in the pleura, and unless thoracentesis was also carried out promptly, the patient could drown from the sudden entrance of this blood into the tracheobronchial tree. The diagnosis was established if the lung did not reexpand completely when these procedures were instituted; the bubbles of air expelled during quiet expiration could be observed in the water-seal drainage.

If bleeding was not severe, it was best to reestablish the cardiorespiratory balance before operation was undertaken. If bleeding was continuous, operation had to be performed promptly. Even if the diagnosis was only suspected, thoracotomy was warranted, since both the bronchi and the trachea lend themselves quite well to suture.

A high posterolateral approach, preferably on the right side, provided the best exposure for wounds of the trachea. Repair was accomplished by simple closure with interrupted sutures of fine silk. If there was loss of substance in the tracheal wall, mediastinal tissue, pleural tissue, or a long-pedicled flap from the latissimus dorsi could be used to aid in the repair. Occasionally, in high tracheal wounds, repair was accomplished through an anterior approach, with division of the clavicle.

The diagnosis, or even the suspicion, of injury to a major bronchus was an indication for exploration. The mere existence of damage to a bronchus was not, however, an indication for lobectomy, though if the vein or artery to a lobe of a lung was lacerated, resection might conceivably be necessary. Not many such injuries were seen because they led to rapid exsanguination, and the casualties did not usually survive long enough to reach even forward hospitals. In contrast to the general experience, Maj. Robert H. Wylie, MC, had two recoveries after operation for injuries of major bronchi.

In one case in which serious bleeding from an upper lobe bronchus made anesthesia hazardous, Maj. (later Lt. Col.) Lawrence M. Shefts, MC, packed the main stem bronchus under endoscopic vision. It was then possible to occlude the blood supply temporarily and proceed with the repair of the damaged bronchus. The procedure in this case was lifesaving.


23

Case History

Col. Edward D. Churchill, MC, Consultant in Surgery to the Surgeon, Mediterranean Theater of Operations, U.S. Army, early predicted that no patient with an injury to a left main stem bronchus would survive to be treated in a forward hospital, as the anatomy of the left hilar region made it inevitable that a missile could not pass through it without inflicting fatal damage. No such injuries were observed. Lt. Col. W. Paul Sanger, MC, observed two casualties with damage to the right main steam bronchus. Both survived to be hospitalized because of the unusual tactical situation: Both were wounded on the Anzio beachhead, in close proximity to the hospitals to which they were admitted. One of them died early in the postoperative period because of overwhelming pleuropulmonary sepsis. The history of the other follows.

Case 2-This casualty was hospitalized within an hour after he had sustained a shell-fragment wound of the eighth posterior interspace on the right side, presumably while prone. He immediately became dyspneic and was unable to move the lower extremities. When he was admitted, he was in shock and was completely paralyzed below the eighth dorsal segment. Respiration was profoundly embarrassed, obviously because of a large wound, 5-6 cm. diameter, in the eighth right interspace posteriorly, which was sucking air and draining blood. It was filled with bits of clothing and bone fragments. The sucking was controlled at once with petrolatum-impregnated gauze packs. Paravertebral block of the sixth to the tenth intercostal nerves greatly improved the respirations and permitted the patient to cough up large amounts of blood. The blood pressure was elevated to 86/52 mm. Hg by the infusion of 25 gm. of serum albumin. Aspiration of the chest produced 800 cc. of blood, which was immediately returned to the patient by autotransfusion. Insertion of an intercostal catheter relieved the developing pressure pneumothorax.

By 9 hours after injury, the patient had become fairly well stabilized. Then there was a sudden increase in the pneumothorax. Emergency surgery was performed, under endotracheal anesthesia. The wound in the region of the eighth right rib was excised, and a posterolateral thoracotomy incision was made in the eighth right interspace. A large, ragged, bullet-shaped shell fragment, 12 cm. long, was found penetrating the posterolateral wall of the right main stem bronchus, just distal to the bifurcation of the trachea. Air and blood were pouring freely from the wound. The azygos vein was lacerated; it was sutured, without complete occlusion. Then, with considerable difficulty, the defect in the bronchus was approximated with interrupted silk sutures; the closure was reinforced with muscle. When the closure was water-tested, there was no evidence of leakage.

A transverse laceration of the upper lobe of the right lung, between 12 and 14 cm. long, was closed with interrupted silk sutures. The lung was then reexpanded except for the portion of the upper lobe in the area of laceration. The incision was closed in anatomic layers.

The patient received 1,000 cc. of blood and 250 cc. of plasma during the operation and was in fair condition at the end.

The immediate postoperative course was stormy, not because of the chest wound but because of the distention and other complications that accompany cord transection. Suprapubic cystostomy was done on the seventh postoperative day, and a hip spica was applied, to facilitate evacuation.

The right lung remained expanded, but on the 12th day, the incision became infected in the area of the original wound. Empyema followed; such an experience shows the unwisdom of including the wounded area in the thoracotomy incision. Treatment consisted of the intramuscular injection of 25,000 units of penicillin every 3 hours for 10 days; no sulfonamides were given.


24

FIGURE 6.-Thoracic laceration of esophagus. Hydropneumothorax produced by fluid and air escaping from esophagus (a), and through rupture of mediastinal pleura (b). Aspiration of esophageal fluid from pleural cavity is diagnostic (c).

Reports from the base hospital a month after wounding stated that the empyema cavity was still from 200 to 300 cc. in volume. There was some return of sensation in the extremities. The last report, 4 months later, stated that progress was continuing to be good.

WOUNDS OF THE ESOPHAGUS

Incidence

Wounds of the thoracic esophagus were uncommon. In the 1,364 thoracic wounds and 903 thoracoabdominal wounds cared for by the surgeons of the 2d Auxiliary Surgical Group, there were records of only 6 cases. In one of these, the diagnosis was doubtful; the surgeon who removed the missile from the wall of the esophagus noted that he did not think that the lumen had been penetrated. The two other cases in which surgery was done ended fatally, and the three remaining cases were diagnosed only at autopsy. This surgical group, therefore, with its wide experience of thoracic injuries, had no record of certain recovery from a confirmed penetrating wound of the intrathoracic esophagus.

Diagnosis

Diagnosis of wounds of the esophagus (figs. 6 and 7) was difficult, but it was imperative that it be made because continued spillage in an unrecognized wound was likely to be followed by mediastinal infection (fig. 8), which was


25

FIGURE 7.-Cervical laceration of esophagus. A. Air and fluid spread through deep cervical fascial planes: Trachea (a), esophagus (b), sixth cervical vertebra (c), and carotid sheath (d). B. Deep abscess formation, pointing to mediastinum (a) or, less often, externally (b).

often fatal, or massive fulminating empyema. The chief diagnostic difficulty was that neither symptoms nor signs were consistent and that suspicion was frequently not aroused until serious complications had ensued. Another difficulty was that many of the symptoms and signs present were related to wounds of associated structures, particularly large sucking wounds and massive hemothoraces, and tended to overshadow whatever clinical picture might be produced by lacerations of the esophagus.

Perhaps the most common symptom of esophageal injury was continued substernal discomfort, with acute substernal pain on swallowing. True dysphagia was not the rule. Severe pain in the back, radiating down into the lumbar region, was pathognomonic when it was present. Typically, it was not alleviated by large doses of morphine. The probable origin of the pain was the inflammatory reaction in the posterior mediastinum caused by leakage from the esophagus.

Mediastinal emphysema was often present and was sometimes associated with cervical emphysema. Equally often, it was absent, for the opening in the mediastinal pleura that usually was a part of such injuries permitted the escape of air into the pleura (fig. 6). The presence of a pneumothorax was not always helpful, for the missile which had penetrated the esophagus might very well have penetrated or perforated the lung also.


26

FIGURE 8.-Acute suppurative mediastinitis secondary to perforation of esophagus. Note widening of retrotracheal space and air in tissues.

Projection of the track of the missile was not helpful in many cases because a hemothorax or hemopneumothorax might obscure the path which the missile had taken in traversing the lung. If, however, one kept in mind the exact position of the esophagus in various parts of the thorax in relation to the location of the missile, as demonstrated by anteroposterior and lateral roentgenograms, it was often possible to make diagnostic assumptions. This help was not available when a missile of moderate size had passed completely through the mediastinum.

If an injury of the stomach could be ruled out, blood obtained on the passage of a Levin tube was an indication of possible esophageal injury. If roentgenograms showed a widening of the mediastinal shadow, a swallow or two of thin barium or Lipiodol was given and additional roentgenograms taken. Mediastinal widening was, however, a confusing finding, for it might also be caused by injuries at the base of the neck. The aspiration from the pleural cavity of gastric juice or of fluid containing food particles was pathognomonic of a gastrointestinal perforation. Food particles were identified by the naked eye. The presence of gastric juice was readily determined by the very acid


27

reaction of litmus paper to it. If the diaphragm was not injured, these findings were evidence of a perforation of the esophagus.

As a practical matter, the diagnosis of injury to the thoracic esophagus was chiefly made on suspicion, aroused by whichever of the signs, symptoms, and roentgenologic findings just listed might be present in the particular case. It almost always had to be confirmed by exploration, which was warranted even if the suspicion was based on nothing more concrete than knowledge of the course of the missile in a perforating wound or of its position in a penetrating wound. Any rent in the posterior mediastinum or any hematoma in this region found in the course of exploration of the chest on other indications was always investigated, with the possibility of injury to the esophagus in mind.

Management in Forward Hospitals

The extremely high mortality of wounds of the esophagus, as just noted, made it mandatory to perform an exploratory operation on the slightest suspicion that such an injury existed. The limited World War II experience, however, makes it impossible to make definitive statements about management.

If the patient's condition did not permit immediate operation, the best plan was to intubate the stomach, withhold all food by mouth, and keep the patient under penicillin protection.

When surgery was indicated, the esophagus, if the wound was in the upper third, was best exposed from the right side, by a posterolateral transpleural approach. If both wound and missile were on the left side, a left-sided approach was indicated.

The margins of the esophageal wound were excised back to healthy tissue. Then a two-layer closure was carried out, with the second layer of sutures in the musculature. Interrupted sutures of fine silk were used. The mediastinal pleura was left open. The pleural space was drained with two intercostal water-seal drains.

The single patient observed by the 2d Auxiliary Surgical Group on whom this total technique was used did not survive, because of other wounds, but for the 5 days he lived after operation, there was no clinical evidence of leakage from the esophagus or of pleural involvement. Post mortem examination, unfortunately, was not carried out.

Most surgeons of experience considered extrapleural posterior mediastinotomy both useless and harmful because it jeopardized the first objective of the operation, complete and permanent reestablishment of esophageal continuity. Once this was accomplished, drainage, in their opinion, would add little to the safety of the patient and might encourage breakdown of the wound. Posterior mediastinotomy was, in fact, an operation of limited usefulness in combat-incurred chest wounds.

Postoperative management-Gastrostomy for nutritional purposes was not considered necessary in a forward hospital. If decompression was required,


28

a Levin tube was used, either passed into the stomach, or, as advocated by Sweet (5) in resections of the esophagus, passed down to the site of repair.

Management in Base Hospitals

While few patients with undiagnosed wounds of the esophagus were encountered in base hospitals, it was necessary to be on the alert for such injuries. Rapid development of a fulminating empyema and aspiration of a thin pleural exudate with a musty odor characteristic of gastric juice were almost pathognomonic of an esophagopleural fistula. If methylene blue taken by mouth appeared in the pleural space, the diagnosis was confirmed. The site of the injury was localized by fluoroscopy after the patient had been given a swallow of Lipiodol or thin barium solution. If a tracheoesophageal fistula was suspected, diagnosis was made by bronchoscopy.

Once the diagnosis was made, immediate rib resection was carried out, and a large rubber tube was inserted into the empyema cavity. For the first few days, the tube was connected to a water-seal bottle. Gastrostomy was performed at the same operation even if the wound in the esophagus was very small. In this sort of case, intubation was often tried, with nothing by mouth. Full doses of penicillin were given intramuscularly.

The patient was nursed in the sitting position, to reduce the tendency to regurgitation, which was present in practically every case. Gastric contraction to a degree incompatible with nutritional needs was common, and the associated pylorospasm, which was probably the result of vagal irritation resulting, in turn, from mediastinal involvement, made continuous regurgitation almost inevitable. Unless it could be controlled, healing of the esophagus was delayed. If regurgitation was troublesome after an otherwise satisfactory gastrostomy, jejunostomy was resorted to. In addition to preventing regurgitation, the jejunostomy served admirably as a feeding route. The gastrostomy stoma then served as a decompressive vent.

The criterion of satisfactory progress was closure of the esophageal fistula, reexpansion of the lung, and obliteration of the empyema cavity. If these results were not accomplished by this regimen, a direct surgical attack was made, consisting of thoracotomy, decortication, and closure of the esophageal opening.

Case Histories

The following case histories illustrate the difficulties and complications of wounds of the esophagus:

Case 3-A paratrooper who was wounded in action on 15 September 1944 sustained a perforating bullet wound of the right chest. The wound of exit was to the left of the midline, just to the left of the xiphoid process. Debridement was carried out after resuscitation. There were no symptoms or signs to suggest a wound of the esophagus.

When the patient was received in a base hospital 5 days after wounding, he was critically ill. Investigation revealed a large total empyema on the right side, with a


29

FIGURE 9.-Large esophagopleural fistula with total right pyopneumothorax. A. Posterolateral roentgenogram. Note barium at right base. B. Same, 6 weeks after thoracotomy with pulmonary decortication and repair of fistula. A complete cure resulted.

large esophagopleural fistula (fig. 9A). Forty-eight hours later, the empyema was drained under local analgesia by rib resection, and gastrostomy was performed.

The patient improved, but leakage of regurgitated material through the fistula remained profuse, and the lung showed no tendency toward reexpansion. Four weeks after wounding, thoracotomy was performed, with decortication and closure of the 2-cm. longitudinal defect of the esophagus just above the cardia. The esophagus had been pulled well to the right by the changes consequent to injury and to subsequent infection. Operation was performed without difficulty, and pulmonary expansion was immediate and complete. Closure was effected in two layers, by interrupted sutures of fine silk, with inversion of the knots. Fibrin foam was sutured over the site of the repair. The mediastinal pleura was closed, and the usual water-seal intercostal catheter drainage was instituted.

The immediate postoperative course was uneventful, but regurgitation was troublesome, and recurrence of a small basal empyema required secondary drainage by rib resection. Methylene blue given by mouth appeared in the pleural exudate at the end of 2 hours, and fluoroscopic examination after a swallow of Lipiodol showed a very small leak at the site of repair. After jejunostomy was performed, there was prompt relief of regurgitation as well as rapid obliteration of the basal empyema cavity (fig. 9B). When the patient left the hospital, his condition was excellent in all respects.

Case 4-This patient received his initial surgery in a British mobile field hospital. A tommygun bullet had penetrated the neck at the base on the right side and traversed it obliquely, emerging at the posterior margin of the left sternocleidomastoid muscle. The right thyroid lobe was damaged, the right lateral wall of the trachea opened, and the esophagus almost completely transected.

At operation, a few hours after injury, the trachea was repaired and the esophagus was closed by end-to-end suture, presumably with catgut. The wound was closed with drainage, and gastrostomy was done.

At the end of 5 days, the neck began to swell, and on the seventh day, the anterior wound broke down and began to discharge both purulent exudate and esophageal secretions. When the patient reached the 21st General Hospital, he had a large esophageal fistula, with


30

considerable infection. Vomitus was aspirated into the lung when he vomited soon after admission, and a typical aspiration pneumonia further complicated the clinical picture. After a stormy period, the pneumonia cleared, and the cervical infection subsided. The infection had not extended to the posterior mediastinum. When the patient was last observed, he still had a large fistula of the esophagus, and his condition still did not warrant barium studies to determine what type of reparative procedure would be required.

Case 5-This patient was struck in the right shoulder and received a penetrating wound of the neck from an explosion of an antitank shell within an M-4 tank. Fluoroscopic examination revealed multiple foreign bodies in the base of the neck, one of them in the region of the right lateral wall of the esophagus. Extreme dysphagia was noted soon after the injury. The wound of entrance was debrided. No attempt was made to remove any foreign bodies.

The diet was limited to fluids, but intubation was not done. A week after injury, there was leakage from the wound of material taken by mouth, and when the patient was admitted to the 21st General Hospital, he had an esophageal fistula.

Intubation was immediately instituted, with high-caloric, high-vitamin feedings by this route. Nothing was permitted by mouth. The infection cleared rapidly, and the fistula closed with equal rapidity. Two weeks after admission, the patient's barium studies showed a normal esophagus.

Comment-This case reemphasizes the importance of recognizing dysphagia as a possible symptom of a wound of the esophagus and of resorting to intubation at once in any instance of possible perforation.

CRUSHING INJURIES

Compression or crushing injuries of the chest observed in World War II were chiefly of noncombat origin. They varied considerably in extent, but they were usually relatively mild and required only conservative management.

The pathologic lesion varied according to the degree of trauma. It included simple contusion injuries of the pleura and lung; intrathoracic hemorrhage, subpleural in slight injuries and more central and more extensive in severe injuries; hemothorax; pneumothorax; fractures of the ribs and the sternum; rupture of viscera; and massive collapse of the lung. The so-called contusion pneumonia which followed severer types of compression injury and which could be extremely serious was in reality not a specific entity but the pneumonitis resulting from factors common in thoracic trauma. These factors included the limited respiration and cough caused by chest pain, retained bronchial secretions, and hemorrhage and edema of the lung. Together they made up the clinical picture of wet lung (p. 207).

In simple crushing injuries, the only treatment necessary was rest and relief of pain. In more severe injuries, the management of shock and the correction of disturbances of cardiorespiratory physiology resulting from hemothorax, pneumothorax, and emphysema were of primary importance. Surgery was necessary when lacerations of the diaphragm were present (p. 103). Penicillin was given, to prevent infection. Late complications included pneumonia, empyema, and lung abscess.


31

Ecchymotic Mask

Ecchymotic mask is the term used for the bluish-violet discoloration of the face, neck, and upper portion of the chest that sometimes results from sudden, direct compression of the chest or abdomen. In civilian practice, it is most often seen following compression of the chest between the rear end of a truck and a loading platform. It may also occur in sudden, direct compression of the extremities as the result of a fall or some other accident in which the thigh is violently flexed on the abdomen. In wartime, the casualty may be actually crushed by falling debris from bombs.

The discoloration may also be found in the pharyngeal and retrobulbar areas, though in these regions, true hemorrhage may have occurred. It is ordinarily more marked at areas of pressure, such as in the neck from collarbands, around the head from hatbands, and across the shoulders from suspenders.

The explanation of ecchymotic mask is extreme stasis in the peripheral venous capillaries, which remain intact but become dilated. There is no evidence of diapedesis. The proof of the theory of stasis is threefold, (1) the intact state of the vessels; (2) the absence of extravasation of blood on microscopic examination; and (3) the absence of the usual shades of color observed as an ordinary ecchymotic spot gradually fades.

Clinically, the discoloration begins to fade about 48 hours after the injury and usually disappears in 2 weeks. The patients are seldom uncomfortable, and sequelae are unusual. Ocular symptoms, which are sometimes present, range from mildly blurred vision to total blindness. Fortunately, ocular involvement is uncommon, for retrobulbar or fundal hemorrhages may produce permanent atrophy of the optic nerve.

When Heuer (6), as the result of a personal experience in World War I, reported on ecchymotic mask, he was able to find 127 cases recorded in the literature up to 1923. There were 27 deaths immediately after injury and 8 deferred deaths. Autopsies were performed in 23 of the fatal cases. Symptoms and signs of intrathoracic injury were common, but they were generally slight and disappeared promptly. They included hemoptysis, pulmonary edema, hemothorax, pleural effusion with empyema, pneumonia, and subcutaneous emphysema.

Visual disturbances were reported in only 16 of the recorded cases, including Heuer's own case, but in 7 of these, there was permanent impairment or complete loss of vision, in all instances associated with progressive optic atrophy. In most of the recorded cases, there was no statement about the eyes, but in 23 reports, it vas stated specifically that the eyes were not affected, and in 10 other cases, it can be assumed that they were not affected.

Ecchymotic mask was not often observed in World War II. It did not occur in any of the forward cases treated by the 2d Auxiliary Surgical Group,


32

which suggests that the causative factor is a product of localized thoracic crushing rather than the result of a penetrating or a blast injury. Major Burford, working in base hospitals, observed it only five times in 1,200 casualties. All of these were service troops, all were injured in jeep or truck accidents, and all recovered uneventfully.

Another textbook condition, commotio thoracis, was never observed by surgeons of the 2d Auxiliary Surgical Group, whose opinion was that it should be dropped from the list of traumatic entities.

BLAST INJURIES

Incidence

The British experience with blast injury was entirely gained through German bombings of the British Isles, a fact which, for a time, misled medical officers in the U.S. Army, who believed that they would encounter the syndrome frequently in combat. They did not. Blunt injuries of the intact chest, with resulting contusion, were fairly frequent, but blast injuries were uncommon. Early in the U.S. experience, the two conditions were frequently confused. Once the differentiation was appreciated and pulmonary edema from wet lung, injudicious fluid administration, and occasional fat embolism were also excluded, very few patients were seen in field or evacuation hospitals who could be considered to be suffering from true blast injuries of the chest.

The single case of blast injury observed by surgeons of the 2d Auxiliary Surgical Group in their 2,267 thoracic and thoracoabdominal injuries was confirmed by post mortem examination. The 8 cases observed by Maj. Frank Tropea, Jr., MC, and Lt. Col. John M. Snyder, MC, in 603 chest injuries resulted in 3 deaths; in 1 case, the diagnosis was confirmed by autopsy.

Capt. William W. Tribby, MC (7), in his study of 1,000 battlefield deaths of U.S. Army troops in Italy, found 13 bodies in which there were no penetrating injuries and in which the cause of death was presumably blast injury. In four cases, the diagnosis was confirmed at autopsy, which revealed diffuse pulmonary hemorrhage in all cases and pulmonary edema in three. Because of the advanced state of decomposition of the bodies, microscopic confirmation was possible in only one case.

Captain Tribby believed that several other casualties might also have died of blast injuries, for while penetrating wounds were present, they were not sufficient, in any instance, to account for the fatality. In one body, for instance, the only injury was a penetrating wound of the right wrist.

Data prepared by the Medical Statistics Division, Office of The Surgeon General, Department of the Army, show 1,021 blast injuries of nonbattle origin in the U.S. Army for the 1942-45 period, of which 48 were fatal (table 1). For the same period, there were 13,200 battle-incurred blast injuries outside of the 


33

TABLE 1.-Blast injuries of nonbattle origin in the U.S. Army, by numbers of admissions1 and deaths,2and by area and year, 1942-45

[Preliminary data based on sample tabulations of individual medical records]3

Area

1942-45

1942

1943

1944

1945

Admis-
sions

Deaths

Admis-
sions

Deaths

Admis-
sions

Deaths

Admis-
sions

Deaths

Admis-
sions

Deaths

Number

Number

Number

Number

Number

Number

Number

Number

Number

Number

Continental United States

256

7

47

---

150

2

34

3

25

2

Overseas:4

Europe

325

18

3

---

22

---

145

5

155

13

Mediterranean5

144

10

3

---

64

1

52

1

25

8

Middle East

4

---

1

---

3

---

---

---

---

---

China-Burma-India

11

2

---

---

2

---

4

1

5

1

Southwest Pacific

128

7

5

---

16

---

27

3

80

4

Central and South Pacific

119

4

9

---

22

---

18

---

70

4

North America6

20

---

4

---

12

---

4

---

---

---

Latin America

9

---

1

---

7

---

1

---

---

---

Total overseas

765

41

26

---

149

1

255

10

335

30

Total Army

1,021

48

73

---

299

3

289

13

360

32


1Includes an unknown, but presumably a relatively small, number of cases CRO (carded for record only), mostly deaths. For the two years, 1943 and 1945, in which the number of CRO cases was known, CRO cases constituted 3.2 percent of the nonbattle blast injury "admissions."
2Underlying cause of death, year of death, and area of admission.
3
Complete files of records used for deaths, 1942 admissions, and oversea admissions in 1943. Samples of admissions were: 20 percent for 1945, U.S. 1943, and Europe 1944; 80 percent for 1944 excluding Europe.
4Includes 5 admissions aboard transports, 1 in 1943 and 4 in 1944.
5
Includes North America.
6Includes Alaska and Iceland.

continental United States, of which 140 were fatal (table 2). Of the 6,284 blast injuries which occurred in 1944 and of which 76 were fatal, 493 involved the chest, and 25 of these were fatal (table 3). Another eight injuries, one of which was fatal, involved the thoracoabdominal region (table 3). Only 68 of the survivors in both groups (65 with thoracic wounds, 3 with thoracoabdominal wounds) required evacuation (table 4). A remarkable variety of agents (table 3) were responsible for these injuries, which are generally considered to be caused only by high explosives. It must also be remembered that deaths which occurred in blast injuries were not always due to those injuries. This was true in 3 of the 25 deaths which occurred in 1944.

To complete the picture, it should be added that, as might have been expected, the Navy experience with blast injury was considerably more extensive than that of the Army.


34

TABLE 2.-Battle-incurred blast injuries in the U.S. Army, by numbers of admissions1 and deaths, 2 and by area and year, 1942-45

[Preliminary data based on sample tabulations of individual medical records]

Area

1942-45

1942

1943

1944

1945

Admis-
sions

Deaths

Admis-
sions

Deaths

Admis-
sions

Deaths

Admis-
sions

Deaths

Admis-
sions

Deaths

Number

Number

Number

Number

Number

Number

Number

Number

Number

Number

Europe

9,651

106

1

---

8

---

5,405

61

4,237

45

Mediterranean3

1,345

14

15

---

462

---

620

12

248

2

Middle East

1

---

---

---

---

---

1

---

---

---

China-Burma-India

16

---

---

---

2

---

8

---

6

---

Southwest Pacific

1.455

12

10

---

33

---

176

2

1,236

10

Central and South Pacific

715

8

8

---

102

1

73

1

532

6

North America4

4

---

---

---

4

---

---

---

---

---

Latin America

---

---

---

---

---

---

---

---

---

---

Total5

13,200

140

34

---

616

1

6,284

76

6,266

63


1Excludes cases carded for record only.
2
Among cases who reached a medical treatment facility. Underlying cause of death, year of death, and area of admission.
3Includes North Africa.
4
Includes Alaska and Iceland.
5
Includes 13 admissions aboard transports: 5 in 1943, 1 in 1944, and 7 in 1945.

Experimental Studies

The British experience with German bombings early in World War II led them to carry out a number of experimental studies on blast injuries of the lung, under the direction of the Research and Experiments Department of the Ministry of Home Security. The most important of these studies was reported by Zuckerman (8) in the Lancet of 24 August 1940. In the same issue, Dean and his associates (9) reported on the clinical aspects of these injuries, and in the issue of 19 October of the same year, Hadfield, Swain, Ross, and Drury-White (10) described the pathologic process as confirmed by autopsy studies.

Zuckerman's studies on blast injury, which are now classic, were carried out on pigeons and on animals varying in size from mice to monkeys. The experimental animals were exposed, in the open, (1) to blast from the explosions of 70 pounds of high explosives and (2) to explosions of hydrodgen and oxygen in balloons. Both sets of experiments produced essentially the same results.

In the experiments with high explosives, no animals were killed at distances beyond 18 feet, and none were hurt in any observed manner at distances beyond 50 feet. When the bodies were protected by thick layers of rubber,


35

TABLE 3.-Battle-incurred blast injuries of the thorax and thoracoabdominal region, by numbers of admissions 1 and resulting deaths2in the U.S. Army, 1944, and by area of admission and causative agent


36

TABLE 4.-Battle-incurred blast injuries of the thorax and thoracoabdominal region, by numbers of admissions1 and resulting deaths2in the U.S. Army, 1944, and by area of admission and evacuee status

[Preliminary data based on sample tabulations of individual medical records]

Area

THORAX

Total

Evacuated

Not evacuated

Admissions

Deaths

Admissions

Deaths

Admissions

Deaths

Number

Number

Number

Number

Number

Number

Europe

416

20

63

---

353

20

Mediterranean3

64

5

2

---

62

5

Middle East

---

---

---

---

---

---

China-Burma-India

---

---

---

---

---

---

Southwest Pacific

9

---

---

---

9

---

Central and South Pacific

4

---

---

---

4

---

North America4

---

---

---

---

---

---

Latin America

---

---

---

---

---

---

Total

493

25

65

---

428

25

THORACOABDOMINAL REGION

Europe

5

1

3

---

2

1

Mediterranean3

3

---

---

---

3

---

Middle East

---

---

---

---

---

---

China-Burma-India

---

---

---

---

---

---

Southwest Pacific

---

---

---

---

---

---

Central and South Pacific

---

---

---

---

---

---

North America4

---

---

---

---

---

---

Latin America

---

---

---

---

---

---

Total

8

1

3

---

5

1


1Excludes cases carded for record only.
2
Deaths occurring in 1944 among admissions in theater indicated. In 3 cases, not evacuated, death was ascribed to causes other than blast injury (see footnote 2, table 3).
3Includes North Africa.
4
Includes Alaska and Iceland.

there was either no damage at all, or minimal damage, as compared to the damage suffered by control animals. This observation, it might be interpolated, furnishes additional evidence for the use of body armor.

None of the animals or birds had any external signs of injury. In every autopsy, the outstanding finding was traumatic pulmonary hemorrhage, which varied in degree according to (1) the distance of the animal from the charge and (2) the pressure exerted against the body. The lesions were bilateral unless the animals were so placed that one side acted as a shield for the other.


37

Then the lesions occurred on the side facing the explosion. This fact, as well as the anatomic sites of the hemorrhage, permitted no interpretation except that the lesions were caused by the impact of the pressure wave against the body wall. In all instances in which the lung injury was sufficiently severe to cause death, the lesions were detectable on roentgenologic examination, and blood was present in the upper respiratory passages as well as in the lungs.

Mechanism

Blast may be defined as the compression and suction waves set up by the detonation of a charge of high explosive. At every point in the neighborhood of the explosion there occur:

l. A wave of high pressure, lasting about 0.006 second, according to Zuckerman's studies with 70-pound charges, followed by

2. A negative suction pressure wave, lasting up to 0.003 second, produced by the reduction of the density of the air behind the positive compression wave to below the normal atmospheric pressure, which is about 15 pounds per square inch. The suction component of the blast wave is always much weaker than its pressure component; it can never be greater than 15 pounds per square inch, which corresponds to a perfect vacuum. It is only because of the very short duration of both components that blast waves are not more destructive than they are.

As hot gases are ejected by a detonating shell, they compress the surrounding air into a shell or belt, which is thrown against adjacent layers of air. The compressed air within the belt is characterized by high pressure and high outward velocity. It is limited by an extremely sharp front, the so-called shock front, which is less than one-thousandth of an inch and in which the pressure rises abruptly.

The initial velocity of the shock front as it travels away from the point of detonation is extremely high. Maj. Ralph W. French, MAC, and Brig. Gen. George R. Callender (11) estimated it as 3,000 feet per second at 60 feet from a 4,000-pound light-case bomb where the pressure jump is 100 pounds per square inch. The velocity then decreases rapidly down to the velocity of sound, which is about 1,100 feet per second or 750 miles per hour. The velocity of the shock front can be realized by comparing it with the velocity of gale winds from 50 to 60 miles per hour; of hurricanes, 80 to 100 miles per hour; and of tornadoes, in which estimated velocities range from 200 to 230 miles per hour.

Because the pressure wave is highest in the region of the explosion and falls off rapidly the farther it moves from it, everything in the immediate neighborhood of a bomb explosion will suddenly be exposed to violent pressure waves of many times atmospheric pressure, while everything 50 feet or more away will be exposed to only two or three times atmospheric pressure. The


38

velocity and duration of a pressure wave at any given point are such that any object as large as the human body would undoubtedly be completely immersed for an instant in a wave of almost uniformly raised pressure.

The magnitudes of the pressure and suction components of a blast wave are directly correlated with the amount of explosive. Zuckerman's studies showed, however, that if a given positive pressure is caused by a given amount of explosive at a given distance, the same degree of pressure will be experienced at twice that distance only when the amount of explosive is increased eight times.

Thus all objects in the immediate neighborhood of an explosion are first subjected to violently increased wind and hydrostatic pressure, which may tear them to pieces and blow them far from the scene of the explosion. If they are not shattered by the pressure wave and blown along in its direction, they may be pulled toward the center of the explosion by the weaker, but longer acting suction wave.

Pathologic Process and Causes of Death

The pathologic process which results from the contusive effect of a blast wave on the chest arises, according to Zuckerman's (8) experimental studies, from the pressure component of the blast, which bruises the lungs by its impact on the body wall. It varies from small ecchymotic areas on the lung surface to such extensive lesions that the lung may appear hepatized.

In the 10 autopsies performed by Hadfield and his associates (10) on civilians who died suddenly, or within a few hours, after short-range exposure to detonation of high explosives during aerial bombings, gross traumatic lesions were entirely absent or were trivial in all but one instance. In eight cases, death was due to the effects of blast, though in three cases carbon dioxide saturation of the blood was so extreme that it was considered the immediate cause of the fatality. Two casualties who were extricated from overlying debris without visible injuries were first thought to have died of blast. Further examination showed that both deaths were caused by compression asphyxia.

As in Zuckerman's experimental studies, intrapulmonary capillary hemorrhage was the single gross anatomic lesion common to all cases in which deaths were due to blast. There was free capillary bleeding over large areas, and in these areas, the bronchioles, atria, and alveoli all showed uniform and considerable overdistention. In the fatalities due to compression asphyxia, hemorrhage was relatively slight. In these cases, the air passages contained only a small amount of blood-stained fluid, which was not frothy, but capillary and venous congestion and edema were striking. In the fatalities due to carbon dioxide saturation, the pulmonary hemorrhage was of the same character as in the true blast deaths, but the blood was fresh and pink, not dark. In both groups, the air passages contained quantities of frothy, serous fluid. Tribby (7) noted that in all 13 cases in which he believed death on the battlefield to be due to blast, there was blood in the nose or mouth or in both in every instance.


39

Subpleural hemorrhage was not conspicuous in the blast deaths studied by Hadfield and his group (10). The only casualty in the series who showed hemorrhagic rib markings in the pleura died from compression asphyxia, not from blast. Bleeding into the walls of the smaller bronchioles was occasionally observed, but there was a conspicuous absence of hemorrhage into the larger structures. There was no suggestion that hemorrhages were grouped around the bronchial system. Subpleural bullae, observed microscopically, had apparently been produced by detachment of the visceral pleura and its subjacent elastic tissue from the underlying lung by air escaping from ruptured alveoli.

The most severe hemorrhages were found in two young children, one an infant, the other 13 years of age; the possible explanation was the lesser rigidity of the thoracic wall in youth. Bleeding was minimal in the only notably obese casualty in the group; it may be presumed that his excess flesh protected him from the most serious effects of the blast.

Even making due allowance for the rapidity of the extravasation of blood into the lungs as the result of blast, in no instance was the amount of blood found at autopsy sufficient to cause fatal circulatory embarrassment. The conclusion was that blast probably produces death by interference with some vital tissue or center, in which, because of the extreme rapidity of the process, the structural changes that occur are not detectable. Hadfield and his associates (10), however, considered the presence of hemorrhage a trustworthy indication that the patient had been struck at close range by a wave of high pressure.

In general, autopsy studies on victims of blast in the Mediterranean theater were in accord with these observations (fig. 10).

Clinical Picture and Diagnosis

Symptoms and signs-The clinical symptoms and signs of blast injury as observed in World War II were as follows:

l. Shock.-This was a universal finding and was often profound. As a rule, the degree of shock was directly proportional to the severity of the injury. It was often increased by, or was more serious because of, associated injuries in other parts of the body.

2. Restlessness.-This finding was often extreme and out of proportion to the evident severity of the injuries.

3. Chest pain, which was of two types.-Almost all casualties from blast complained of pain located laterally and related directly to respiratory movements. This type of pain was considered due to contusion and hemorrhage of the intercostal muscles, with resulting muscular spasm. The other type of pain appeared in the more severe injuries. It was deep, central, and not related to respiratory movements. It lasted only a few days and was considered to be caused by mediastinal hemorrhage.


40

FIGURE 10.-Schematic showing of pathologic physiology of blast injury (wave of positive pressure shown by solid arrow, wave of negative pressure by dotted arrow): Petechial hemorrhage, cardiac (a), petechial hemorrhage, pulmonary (b), gross pulmonary hemorrhage (c), pleural hemorrhage (d), engorged pulmonary artery (e), and engorged vena cava (f).

4. Cough and expectoration, which were present in all but the mildest injuries.-When the expectorated material first appeared, about 24 hours after injury, it was thin and mucoid. Later, it became thick and mucopurulent. Often, it was streaked with dark blood, and in an occasional case, there was free hemoptysis. Expectoration usually lasted about 10 days. Almost all dead or dying casualties were found to have frothy, blood-stained fluid in the nose and mouth.

5. Abdominal pain and rigidity.-These findings, which were present in only a few blast injuries, were explained by extrapleural hemorrhages, which had an irritative effect on the intercostal nerves and muscles. In an occasional case, the persistence and prominence of these findings provided an indication for laparotomy.

6. Partial fixation of the chest in the position of inspiration.-Movement, although limited, was equal on both sides.

In the absence of complications, the percussion note was resonant. Breath sounds were usually weaker than normal, especially at the bases, and coarse bronchial rales were frequently heard in both lungs.


41

These observations are, in general, in correspondence with those reported by Dean and his associates (9) in 27 patients whom they examined from 7 to 10 days after they had been close to bursting high explosive bombs. Three of the casualties had been immersed. External injuries included extensive, but superficial, burns in 21 cases; fractures in 5 cases; and multiple splinter wounds of the leg in 1 case.

There were no obvious chest injuries, and only six patients had symptoms referable to the chest. None complained of chest pain or hemoptysis. In no instance did the symptoms develop on the day of bombing; all appeared between the second and fifth days. Sixteen patients had abnormal physical signs, in 15 instances the characteristic fixation of the chest just described; in 1 instance the intercostal spaces shared the fullness.

Roentgenologic examination-If the classical pathologic picture was present, roentgenograms showed heavy mottling over large areas of the lung fields, corresponding with the interstitial and alveolar hemorrhages observed, and varying in size and density with the extent of the lesions. The roentgenologic findings suggested those observed in patchy pneumonia. They disappeared within a week in mild injuries but persisted for weeks in severe injuries. Roentgenologic abnormalities were present in 14 of the 27 patients studied by Dean and his associates.

Diagnosis-The first consideration in a suspected blast injury was a history of exposure, which, in spite of its importance, had to be interpreted with caution. The effects of blast were often a factor in wounds from high explosives, but the seriousness of the penetrating wounds was likely to overshadow them.

Other diagnostic criteria consisted of the presence of shock; the various respiratory symptoms described; the characteristic bulging of the lower portion of the chest, which was held almost immobile in the inspiratory position; and the finding of blood in the lungs and air passages. Ruptured eardrums were pathognomonic. Roentgenologic findings were confirmatory.

The essential features of diagnosis were:

1. The absence of any significant external evidence of violence to the chest.

2. Hemorrhagic lesions in both lungs, as shown by the character of the fluid expectorated or, less often, by hemoptysis, or by autopsy confirmation.

Management

The management of blast injury was never really satisfactory. The routine consisted of the following measures:

1. The treatment of shock.-However deep was the state of shock and however much associated injuries demanded intensive measures, resuscitation had to be carried out cautiously from the standpoint of replacement therapy. Injudicious use of any fluid, including blood, might increase pulmonary edema. An occasional patient, in fact, in whom edema and congestion were particularly marked, responded to venesection, which was employed as a lifesaving measure.


42

Some medical officers, in order to reduce the amount of fluid infused, administered serum albumin in 100-cc. doses every 4 hours for three or four doses.

2. The continuous administration of oxygen.-This measure was used especially if cyanosis was a feature of the injury, or intermittent positive pressure oxygen.

3. The cautious use of morphine.-Morphine was used on strict indications and in doses of not more than gr. 1/8 if pain could not be controlled otherwise.

4. Positioning.-Since the bases of the lungs were usually involved in the hemorrhagic process, the best position was with the shoulders raised. In the occasional instance of unilateral blast injury, the patient was placed on the damaged side, to keep the blood from trickling down the bronchi into the unaffected lung.

5. Local nerve block.-This measure was employed to control pain and permit free respiration.

6. Other medication.-The administration of adrenalin was not without risk, but it was occasionally used to overcome a temporary spasm of the bronchioles. Atropine was also occasionally used to diminish exudation. A sulfonamide, or penicillin when it became available, was used as preventive measure.

If surgery was necessary for other wounds, it was postponed as long as possible, and then was done under local analgesia or with Pentothal sodium (thiopental sodium). General anesthesia was avoided.

Case History

The following case history concerns the only valid blast injury recorded in the experience of the 2d Auxiliary Surgical Group:

Case 6-This soldier was riding in the back seat of a command car when the rear wheels ran over a landmine. When he recovered consciousness some minutes later, he was lying on the ground, beside a tree. His only complaint was a bilateral hearing impairment. Speech and cerebration were not impaired, and he had no dizziness, headache, or blurred vision. The only external wounds were a small puncture wound anterior to the left ear, near the temporal artery; a compound fracture of the right ankle; and a simple fracture of the left ankle.

Wire splints, extending above the knee, were applied in a collecting station. Later, the wound of the right leg was debrided, and plaster casts were applied to both legs.

When the patient was admitted to the 38th Evacuation Hospital, 52 hours after injury, he was in good condition, was talking rationally and normally, and had no complaints. Both pupils were equal and regular. The toes on both sides were warm.

Four hours after admission, the pulse rate began to range between 125 and 130. A little later, it rose to 140; at this time the respiration was 32 and the blood pressure 98/60 mm. Hg. After 500 cc. of plasma had been given, the pulse fell to 120, and the blood pressure was 98/50 mm. Hg. The respiration was 40 and the temperature 100.4 F. The patient was very drowsy, but he could be aroused, and he was then mentally clear.

After a brief interval, his condition rapidly worsened; the blood pressure dropped, and the pulse rate became very rapid. After the foot of the bed had been elevated and 500 cc. of blood and 750 cc. of plasma had been given, the systolic blood pressure was recorded at 100 mm. Hg, but the diastolic pressure could not be obtained. Shortly afterward, the systolic pressure fell to 70 mm. Hg.


43

About this time, moderate respiratory distress developed, and the patient began to spit up frothy blood. The breath sounds were spottedly distant, and coarse rales were heard over the entire chest. There was considerable consolidation of both bases, with a marked friction rub. The upper abdomen was distended, and no peristalsis could be heard. Voiding was involuntary.

Respiratory distress increased rapidly, and the patient became slightly cyanotic. Frothy fluid, streaked with bright red blood, was being expectorated. After the administration of two ampules of Coramine (nikethamide) and 500 cc. of blood, examination of the chest revealed diminished breath sounds and tactile fremitus on the left, with a loud to-and-fro friction rub. Oxygen therapy was instituted. The blood pressure was now 90/40 mm. Hg. The patient, although struggling for breath, remained lucid enough to answer questions. His dyspnea did not seem of the obstructive type.

Death occurred suddenly, 72 hours after injury and 24 hours after admission to the evacuation hospital. There was no response to artificial respiration.

Autopsy disclosed an entirely clear peritoneum and retroperitoneal space. The thoracic cage and diaphragm were intact, as were both pleural cavities.

The lungs were expanded, and there were numerous areas of hemorrhage and crepitation. There was no blood in the pleural cavity, but when the bronchial tubes were sectioned, they were found to contain frothy, serous fluid. The heart was grossly normal except for a questionable auricular thrombosis. The thrombi in the pulmonary artery were regarded as a post mortem development.

Histologic examination of the lungs showed extensive areas of intra-alveolar extravasations of red cells intermingled with varying numbers of pigmented macrophages. Occasional alveoli were filled with fluid containing a few red cells. Other alveoli, some emphysematous, were interspersed among them. Some of the emphysematous alveoli had ruptured walls. The bronchial lumen contained large numbers of red blood cells.

The gross pathologic diagnosis (in addition to the fractures of the lower extremities) was possible blast injury of the lung, possible thrombosis of the pulmonary artery, and possible thrombosis of the cardiac auricle. The histologic diagnosis was severe pulmonary hemorrhage, ruptured alveoli, congestion of the spleen, and epicardiac hemorrhage.

Comment-This injury was difficult to evaluate from the clinical standpoint, and the diagnosis of blast syndrome was not made early enough for therapy to be precise and effective. One can only speculate whether earlier recognition of the blast injury, with intensive treatment directed toward it, would have altered the outcome.

Unfortunately, no special fat stain was used on the tissues. In some blast injuries, fat emboli were found in the lungs, as they were in some compound fractures; they were more often seen after traumatic amputations from landmines. The diagnosis of blast injury of the lungs was made in this case on the basis of the ruptured alveoli.

ASSOCIATED WOUNDS

A large proportion of thoracic injuries, as pointed out elsewhere (vol. I), were associated with injuries in other parts of the body, and these associated injuries were frequently more serious than the chest injuries. That other injuries might exist had to be taken for granted in the approach to all chest injuries. In other words, regardless of how specialized or restricted an injury might seem, a total therapeutic approach was necessary. In caring for a casualty, the surgeon had to conceive of him as a total organism, not as an assembly of individual injuries. The management of the chest injury therefore had to be related to the management of all other injuries.


44

Compound Fractures

Compound injuries of the scapula and shoulder girdle might furnish numerous problems. A missile of high velocity that struck the scapula a glancing blow could cause extensive damage to the heavy muscles in the vicinity, in addition to shattering and fragmenting the bone. Although there was always considerable question as to how radical one should be in dealing with fractured ribs, there was rather general agreement that fractures of the scapula, especially subscapular fractures, because of the less adequate drainage possible in this area, required more radical management than fractured ribs in other locations. Infection invariably resulted if the initial debridement was not complete. Wide excision of the damaged muscles was necessary, because of the great danger of anaerobic cellulitis in this area.

Fragments of the alar portion of the scapula, if left in situ, almost invariably led to continued suppuration. Even when the scapula itself was not damaged, it was necessary to bear in mind the possible involvement of the subscapular space when reconstruction of the course of a missile that had penetrated the chest wall indicated this possibility. Abscesses in this area could remain unrecognized for long periods of time.

Debridement, to be entirely adequate, would have required an incision approaching in magnitude the incision necessary for thoracoplasty and would also have required mobilization of the scapula. Such radical measures could not be justified on the mere possibility that a clostridial infection might develop. The usual procedure was to make the incisions along the track of the missile at the vertebral and axillary borders of the scapula, then to perform as complete a debridement as the exposure permitted. Great care had to be taken during surgery in this area not to disturb the attachment of the serratus anterior; damage to it could be followed by serious functional losses. As much as possible of the scapula was preserved, particularly of the functionally important upper third. Less hesitancy was felt about removing as much as necessary of the lower two-thirds. Through-and-through Penrose drains were inserted, and a dependent drain was placed in the subscapular space through an incision in the angle of auscultation at the interior border of the scapula.

The patient was kept in the forward hospital in which operation had been done for at least 6 days after operation. The wound was examined immediately if there was a rise in the pulse rate or if he complained of local pain or if his demeanor changed, as it characteristically does in clostridial infections.

In six cases treated by the technique just described, Major Shefts and Capt. (later Maj.) Ernest A. Doud, MC, had no deaths. On the other hand, Maj. (later Lt. Col.) Reeve H. Betts, MC, and Maj. William M. Lees, MC, lost a patient from clostridial infection after what was thought to be a very radical debridement. It was their custom thereafter to use large paravertebral incisions in injuries of the subscapular area, even though intrapleural damage had not occurred.


45

When fractures ordinarily treated by traction occurred in association with wounds of the chest, some compromises in therapy were necessary. Prolonged immobilization in traction was inimical to satisfactory progress in chest injuries. The patient had to be kept maneuverable. Precise fracture alinement could not be achieved at the expense of thoracic crippling. Fortunately, the orthopedic repertoire was extensive enough and flexible enough to permit the application of a regimen that would reduce the fracture satisfactorily without jeopardizing the outcome of the chest lesion.

Vascular Injuries

Injuries to the great vessels of the axilla and at the root of the neck were not always recognized at initial wound surgery for chest injuries, and careful observation was necessary in base hospitals. Otherwise, important delayed sequelae of the vascular injuries might be overlooked. It was particularly necessary to be suspicious whenever the point of entry of the missile was over the apical region of the thorax. In one such case (p. 244), on the basis of roentgenologic examination and the repeated aspiration of clotted blood from the chest, the casualty, who had sustained a penetrating wound of the right apical region 3 months before, was thought to have only a hemothorax. His progress was satisfactory until he had a sudden attack of dyspnea and pain in the right chest. Soon after, he went into profound shock and died promptly. Necropsy revealed a rupture of a traumatic aneurysm of the first portion of the right subclavian artery.

It was always necessary, when operation was undertaken for early massive empyema or clotted hemothorax, to remember the possible presence of a traumatic aneurysm of the subclavian artery, as in the case just described, or of the innominate artery. Ignorance of the presence of the vascular lesion could easily result in catastrophe on the operating table.

In a case observed by Major Brewer at the 21st General Hospital, the patient, who had a foreign body in the chest wall, was conscious of a bruit that caused him considerable annoyance. It also made him so apprehensive that he was afraid to perform even moderate activity. A thrill was present, but there was no erosion of the rib and no cardiac embarrassment. A large hemothorax had previously been completely evacuated by repeated thoracenteses. After a diagnosis had been made of aneurysm of the intercostal artery and vein, the lesion was excised, for prophylactic reasons, and the foreign body in the chest wall was removed. The patient was able to return to full duty. It is believed that this is the only case of the kind to be observed in the Mediterranean theater during the war.

If ligation of the subclavian or axillary vessels had been necessary in a forward hospital, thoracic surgeons in general hospitals had to determine whether or not an adequate collateral circulation existed. Measures to maintain the circulation, or to increase it if it was deficient, were imperative.


46

The most useful measures to control edema were proper positioning of the hand and arm; intelligently applied massage; and procaine hydrochloride block of the inferior cervical ganglion, repeated every 24 to 48 hours as necessary.

As a rule, casualties with arteriovenous fistulas resulting from combined thoracic-vascular injuries were evacuated to the Zone of Interior for final surgery. If, however, evacuation was delayed for an inordinately long period and compression tests revealed a satisfactory collateral circulation, operation was done overseas. Quadruple ligation with excision was the procedure of choice.

Neurologic Injuries

Brachial plexus-The injuries of the brachial plexus frequently associated with chest injuries constituted a neurologic problem. Careful examination in both forward and base hospitals was necessary in every chest injury, to determine their presence or absence. It was often impossible to settle this matter positively in the first few days after injury; during this period, the neurologic findings present might be caused by contusion of the nerve as well as by laceration. If the injury was only a contusion, sensation and function would return promptly.

Head injuries-Head injuries were frequently associated with thoracic injuries, and patients with head injuries were particularly prone to chest complications. Atelectasis and pneumonitis were ever-present threats, particularly in patients who were deeply comatose. Chest surgery was kept to an absolute minimum in these circumstances. Careful nursing, drainage of the tracheobronchial tree by catheter and bronchoscope, and the administration of penicillin were all employed to avoid serious and fatal pulmonary complications.

Spinal injuries-In one series of 768 chest injuries studied by the 2d Auxiliary Surgical Group, there were 23 spinal cord injuries. Fractures of the vertebrae were also frequently associated with war wounds of the chest.

Roentgenologic examination of the spine was routine whenever there was any complaint of pain in the back or the cervical region. Some injuries were detected only when the patients became ambulatory; they had fallen or been thrown with considerable force when they were injured, and the simple vertebral fractures they had sustained were not noticed during their initial treatment because of the greater importance of other injuries.

Associated injuries of the chest and the spinal cord constituted one of the most distressing complexes seen in war surgery. The close anatomic juxtaposition of the structures of the spine and thorax made it inevitable that major injuries should affect both regions in a considerable number of cases. Casualties with these so-called thoracospinal wounds were open to the complications inherent in both lesions. There was a marked predilection for paralyzed patients with chest wounds to develop infection of either the pleura or the


47

pulmonary parenchyma. Hemothoraces were much more likely to become infected than in patients without spinal cord lesions.

The most important component of management of these combined injuries was intelligent nursing care (12). Patients were nursed in the face-down position, whenever this was practical, and were turned at frequent intervals, to prevent the development of decubitus ulcers. Air mattresses were used when they were available. Coughing and breathing exercises were carefully supervised. Repeated thoracenteses were performed, to dry up the pleural cavity as rapidly as possible. If empyema developed rib-resection drainage was usually employed; these patients were seldom in condition for the more radical procedure of decortication.

Patients with combined spinal cord-thoracoabdominal injuries were particularly difficult to care for. Many of the wounds were tangential, a type likely to be associated with far more pulmonary contusion and damage than the average penetrating or perforating wound. It was impossible for the patients to cough effectively because of paralysis of the lower intercostal and abdominal muscles. The flared costal angle, the segmental motion of the chest wall, the relaxed abdomen, and the feeble bechic blast were all characteristic of these combined wounds. In many cases, tracheobronchial aspiration was necessary as often as every 1 to 3 hours. Contrary to the usual observation, support of the abdomen and lower ribs by binders or adhesive strapping seemed to make coughing more efficient.

It was observed in certain patients with combined injuries of the chest and spinal cord that the level of anesthesia caused by the spinal injury seemed to play a considerable part in the outcome from the standpoint of the chest injury. Death sometimes occurred from intractable pulmonary edema. There was no response to positive pressure oxygen therapy or endotracheal suction, even though the chest wounds were not in themselves potentially lethal.

Analysis of a number of these fatalities led to the conclusion that the lethal factor was paralysis of the abdominis recti muscles. Normally, the tone of the recti in a gentle cough, or their actual contraction during a vigorous cough, provides the diaphragm with opposing intra-abdominal pressure. When the pressure was lost by reason of paralysis of the recti, the cough became ineffective; the expulsive action resulted in nothing more than bulging outward of the abdomen; and intractable pulmonary edema was the consequence.

This chain of events was clear in two of four cases of combined spinal cord-chest injuries treated in a field hospital in the Mediterranean theater by Major Shefts and Captain Doud. All four patients presented a typical picture of transverse myelitis, and all had pleuropulmonary damage of about the same degree. The two fatalities were directly related to the level of cutaneous anesthesia. They occurred 4 and 5 days, respectively, after debridement of the chest wounds, from pulmonary edema that did not respond to any measures, including positive pressure oxygen and endotracheal suction. One patient had anesthesia from below the xiphoid process and the other from just below


48

the nipples. The two patients who survived had skin anesthesia below the umbilicus, one just below the umbilicus and the other halfway between the umbilicus and the symphysis pubis.

While a defeatist attitude was never permitted in combined spinal cord-thoracic injuries, it would have been unrealistic not to recognize their potential lethality. In many cases, therefore, the frank objective of treatment was to salvage these unfortunate men long enough to permit them to be returned to the United States, so that they could spend their remaining days at home and with their families. This was possible in many of the most apparently hopeless cases.2

References

l. Dunham, E. K., Stevens, F. A., Graham, E. A., and Keller, W. L.: Empyema. In The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1924, vol. XI, pt. 2, pp. 33-392.

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

3. Brewer, L. A. III, Bai, A. F., King, E. L., Wareham, E. E., and Farris, J. M.: The Pathologic Effects of Metallic Foreign Bodies in the Pulmonary Circulation. A Long-Term Experimental Study. J. Thoracic Surg. 38: 670-684, 703-706, November 1959.

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

5. Sweet, R. H.: Transthoracic Resection of the Esophagus and Stomach for Carcinoma. Analysis of the Postoperative Complications, Causes of Death, and Late Results of Operation. Ann. Surg. 121: 272-284, March 1945.

6. Heuer, G. J.: Traumatic Asphyxia; With Especial Reference to Its Ocular and Visual Disturbances. Surg., Gynec. & Obst. 36: 686-696, May 1923.

7. Tribby, W. W.: Examination of One Thousand American Casualties Killed In Action in Italy. Report to Surgeon, Fifth U.S. Army, 1944, 6 vols. [Official record.]

8. Zuckerman, S.: Experimental Study of Blast Injuries to the Lungs. Lancet 2: 219-224, 24 Aug. 1940.

9. Dean, D. M., Thomas, A. R., and Allison, R. S.: Effects of High-Explosive Blast on the Lungs. Lancet 2: 224-226, 24 Aug. 1940.

10. Hadfield, G., Swain, R. H. A., Ross, J. M, and Drury-White, J. M.: Blast From High Explosive. Preliminary Report on Ten Fatal Cases, With a Note on the Identification and Estimation of Carboxyhaemoglobin in Formol-Fixed Material by Arthur Jordan. Lancet. 2: 478-481, 19 Oct. 1940.

11. French, R. W., and Callender, G. R.: Ballistic Characteristics of Wounding Agents. In Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962, pp. 91-141.

12. Medical Department, United States Army. Surgery in World War II. Neurosurgery, Volume II. Washington, U.S. Government Printing Office, 1958, pp. 31-65: 127-191.

2The reader is referred to chapter XI (p. 441) for long-term followup studies of the various types of wounds described in this chapter.

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