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Chapter XI

Contents

CHAPTER XI

Long-Term (1943-61) Followup Studies in Combat-Incurred Thoracic Wounds

Lyman A. Brewer III, M.D.

Followup information is as notably deficient concerning casualties with combat-incurred wounds of the chest as it is concerning most other casualties. There are almost no studies of this kind in the medicomilitary literature, which is extremely unfortunate, for it makes it impossible to determine the true end results of any given plan of management.

Up to March 1944, chest wounds sustained in the Mediterranean (formerly North African) Theater of Operations, U.S. Army, in World War II were treated according to the personal policies of the surgeon who handled the particular patient. After this date, thoracic casualties were treated by a specific regimen that differed, in many respects, from the policies employed earlier.

The investigation reported in this chapter was undertaken in an attempt to trace the postwar course of a group of casualties who had sustained chest injuries in the Mediterranean theater and who had all been treated (1) in forward hospitals, (2) under the direction of a single surgeon and his assistants, (3) by the specific regimen just mentioned. This group of patients was followed into the hospitals of the communications zone and the Zone of Interior, and some of them were followed up for varying periods of time, up to February 1961, after their separation from service.

BACKGROUND OF STUDY

In the summer of 1943, during the Sicilian campaign, studies at the thoracic surgery center at Bizerte, North Africa, on casualties returning from forward areas revealed a high mortality rate and a considerable morbidity among the group treated by thoracotomy at initial wound surgery. The impression arose that this operation was being performed on unnecessary indications in forward hospitals and that its promiscuous use was having an adverse effect on the results of chest injuries.

On the basis of these impressions, Col. Edward D. Churchill, MC, Consultant in Surgery to the theater surgeon, detached Capt. (later Maj.) Lyman A. Brewer III, MC, from his duties at the Bizerte chest center and assigned him to the forward hospitals supporting the landings at Salerno in September


442

1943. His mission was to study the problems of forward surgery in thoracic injuries and to continue the investigation as the troops advanced into Italy.

Two facts promptly became apparent to Captain Brewer:

1. Thoracotomies were indeed being performed unnecessarily in forward hospitals as part of initial wound surgery.

2. In spite of this fact, the indications for thoracotomy in forward hospitals could be very sharply defined.

At a conference of thoracic surgeons called, and presided over, by Colonel Churchill in March 1944, at Marcianese (vol. I), the results of Captain Brewer's investigations were reported. At this meeting, the indications for primary thoracotomy in forward hospitals were defined, and the so-called limited approach to this operation thereafter became the prescribed policy in the Mediterranean theater.

This followup study had its genesis during the war, when Captain Brewer took upon himself the task of keeping duplicate individual records for all casualties with thoracic injuries treated by him as head of Thoracic Surgical Team No. 4, 2d Auxiliary Surgical Group. The team consisted of Captain Brewer; Capt. Charles A. Schiff, MC; Capt. Werner F. A. Hoeflich, MC; and 1st Lt. Catherine V. Elliott, ANC.

Team No. 4 served first with the Fifth U.S. Army in Italy and then with the Seventh U.S. Army in France, Germany, and Austria. This army originated in the Mediterranean theater and remained under its operational control for the landings in southern France in August 1944 and during the first part of the campaign in France. In December 1944, it passed to the logistic control of the European theater.

The team served in forward hospitals during the landings at Salerno in September 1943 and the campaign in Italy, the landings at Saint-Raphaël and the campaign in southern France, and then during the campaigns in Germany and Austria until V-E Day in May 1945. It was variously attached to the 94th Evacuation Hospital (Salerno to Cassino), the 11th Field Hospital (Cassino), the 11th Evacuation Hospital (Anzio to Civitavecchia), the 11th Field Hospital (from the D-day landings at Saint-Raphaël into eastern France), the 66th Field Hospital (Vosges Mountains), and the 80th Field Hospital (Germany and Austria).

The casualties were thus encountered, and the surgeons worked, under a wide variety of conditions of climate and terrain, in Italy, France, Germany, and Austria, at all seasons, and from beachheads to mountains.

MATERIALS AND METHODS

Although Major Brewer and his team had personally treated more than 1,000 casualties with combat-incurred wounds, only 822 had wounds of the chest, and only 372 of these were treated in forward hospitals. Of the 210 patients


443

whose histories were reviewed when this analysis was undertaken, only 167 had sufficiently detailed records to make followup investigation of any real value.

There are numerous problems connected with such an investigation. The tracking down of a large number of former soldiers for varying periods of time (from 3 to 17 years) after the termination of hostilities and their return to civilian life was not simple. It was impossible, in fact, to follow the majority because of the general movement of the population that now seems part of the way of life in the United States. Had all of these men reported for further treatment to VA (Veterans' Administration) clinics and hospitals, there would have been no problem. Most of them did not. As will be pointed out later, their failure to seek medical advice is probably a reflection of the fact that most of them did not think that they needed it.

The Veterans' Administration, however, is the most obvious source of help in an undertaking of this kind, and with few exceptions, the men followed up in this series after separation from service are those who reported to VA hospitals and clinics, either because they were disturbed over their status or because they were actually in need of treatment.

Whatever success was achieved in this investigation is attributed to three agencies:

The project was initiated with the complete cooperation, and had the assistance throughout, of The Historical Unit, U.S. Army Medical Service, a class II activity of The Surgeon General, Department of the Army, under whose direction the volumes in this historical series are being prepared.

It also had the complete cooperation of the Veterans' Administration and of the Federal Records Center, General Services Administration, St. Louis, Mo. (formerly the Army Records Center). Through the painstaking efforts of the personnel of these two agencies, records were collected from numerous sources and were forwarded to the study center in the VA Regional Office in Los Angeles, Calif.1

In some instances, these records were well over an inch thick. A great deal of the material included in them consisted of correspondence concerning disability claims, pensions, and similar matters, but when it was winnowed, it contained sufficient medical evidence to make good followup studies possible in 167 patients.

In a number of cases, additional followup material was obtained by direct correspondence with the veterans themselves. This method made it possible to obtain firsthand, personal reports of their current status and also to secure current roentgenograms.

1It should be added that this truly unique investigation was the concept of Dr. Lyman A. Brewer III, and that it was through his vigorous personal efforts that it was brought to a successful conclusion.-F. B. B.


444

FIGURE 195.-Punchcard designed to secure data in long-term followup of veterans with combat-incurred wounds of chest. Top, front. Bottom, back.


445

BASIC DATA

The data were collected on punchcards especially made up for the project (fig. 195).

The age range of the 167 casualties was from 18 to 39 years. Of this number, 16 were in the 18- to 19-year group, 118 in the 20- to 29-year group, and the remainder (33) in the 30- to 39-year group.

In 131 instances, the wounding agents were shell fragments and in 36, gunshot.

Both in age distribution and in wounding agents, therefore, the patients in this series are representative of all types of combat casualties in World War II.

THERAPEUTIC CLASSIFICATION

The 167 patients were studied in two groups, according to their management in forward hospitals, as follows:

1. In 86 cases, wound debridement was carried out in forward hospitals, but thoracotomy was not performed.

2. In the remaining 81 cases, in 25 of which the wound was thoracoabdominal, either thoracotomy or a combined thoracic and abdominal operation was carried out.

This classification is based on the point, already emphasized, that careful definition of the indications for, and contraindications to, thoracotomy in forward hospitals was one of the major contributions made by thoracic surgeons who treated chest wounds in the Mediterranean theater in World War II. One of the most important objectives of this study was to determine whether any casualty in the group in which thoracotomy was omitted had died later from complications or had suffered delayed morbidity referable to his wound. Only a long-term followup could settle this point.

The components of both resuscitation and initial wound surgery have been described in detail in the first volume of this thoracic surgery) subseries.

INITIAL WOUND SURGERY

In the group of patients in whom thoracotomy was not considered necessary at initial wound surgery, the penetrating wound produced by the missile was of such limited dimensions that the wound did not suck (blow) originally or after adequate debridement. In this type of wound, as in all others, important considerations, in addition to the size of the missile, included its angle of penetration, its velocity, the damage to the bony cage, and the thickness of the original protecting musculature. The location of the wound was obviously a matter of great importance. A wound up to 2 cm. in diameter, if it was located in the interior thoracic cage, might result in a traumatic thoracotomy, while a wound up to 14 cm. in diameter, if it was located in the scapular region pos-


446

teriorly, might not result in traumatic thoracotomy, even after extensive debridement. It was also generally true that smaller external wounds were likely to produce less damage within the chest than would larger wounds. In 3 of the 86 cases in which primary thoracotomy was omitted, blast injuries were associated with powder and dirt burns of the chest, but neither the injury nor the possibility of internal damage was considered an indication for immediate thoracotomy.

In the remaining 81 cases, the initial wound was so extensive that it constituted, in itself, a traumatic thoracotomy; or the necessary debridement was so extensive as to produce a traumatic thoracotomy; or intrathoracic or intra-abdominal damage required entrance into these cavities to control hemorrhage or repair damaged organs.

The indication for thoracotomy in 56 of these 81 cases was serious damage to the chest wall or the intrathoracic contents. In six cases in this group, the diaphragm was lacerated, but the abdomen was not penetrated. In three other cases, the diaphragm was lacerated and the liver was penetrated by small foreign bodies, 2 mm. in diameter in each instance. In none of the three cases was the injury sufficient to cause either hemorrhage or extravasation of bile, and thoracolaparotomy did not prove necessary at the base section later. Small foreign bodies in the liver are usually well tolerated. Had the injuries been more serious, exploration of the abdomen would have been necessary.

In the remaining 25 cases, the wounds were thoracoabdominal, and intra-abdominal procedures were necessary. The number of casualties in this group would have been larger except for the fact that patients with abdominal injuries associated with chest injuries were considered within the province of general surgeons. These casualties were always classified as nontransportable at triage, and they were treated in forward installations, very often by general rather than thoracic surgeons.

Since thoracotomy was done in over half of the 167 cases in this series, the emphasis on limited thoracotomy may seem somewhat misplaced. There are at least two valid reasons for the high proportion:

1. All the patients who were treated by primary thoracotomy were first-priority, nontransportable casualties. The data (tables 20-23) show that both intrathoracic and extrathoracic damage were frequently extremely severe.

2. The concentration of so many serious injuries in such a small series is explained by the fact that frequently in forward areas in which there were few or no thoracic surgeons, thoracic casualties were referred to Thoracic Surgical Team No. 4, which served as a sort of unofficial forward thoracic surgery center. 

Another index of the severity of the injuries in this series is the length of hospitalization in forward hospitals. The 86 patients in whom primary thoracotomy was not done were held from 7 to 14 days, on the average, while the 81 who required thoracotomy were held, on the average, from 4 to 7 days longer. An occasional patient in both groups had to be evacuated before the optimum time because of the tactical situation.


447

TABLE 20.-Thoracic damage in 167 followed-up thoracic casualties according to surgical procedures in forward hospitals

Thoracic damage

Surgical procedure

Total

Thoracotomy

Thoracoabdominal surgery

Yes

No

Chest wall:

Soft tissue

56

86

25

167

Bony cage

69

23

19

111

Persistent pneumothorax

10

13

5

28

Persistent hemothorax

45

29

17

91

Foreign bodies:

Chest wall

8

18

9

35

Pleura

14

4

3

21

Lung

18

15

3

36

Mediastinum

6

1

3

10

Pulmonary laceration

38

12

11

61

Pulmonary hematoma

27

53

9

89

Mediastinal injury

7

4

2

13

Diaphragmatic injury

9

1

25

35


TABLE 21.-Associated injuries in 167 followed-up thoracic casualties according to surgical procedure

Region

Surgical procedure

Total

Thoracotomy

Thoracoabdominal surgery

Yes

No

Head

5

5

1

11

Neck

5

9

1

15

Pelvis

7

6

3

16

Extremities:

Upper

23

22

7

52

Lower

12

21

5

38

Spine

1

---

1

2

Blast

9

6

6

21


448

TABLE 22.-Intra-abdominal damage in 81 followed-up thoracic casualties according to surgical procedure

Viscera and structures injured

Surgical procedure

Total

Thoracotomy

Thoracoabdominal surgery

Diaphragm

10

21

31

Stomach

3

4

7

Small intestine

---

5

5

Large intestine

---

5

5

Liver

2

11

13

Spleen

---

6

6

Kidney

---

5

5

Pancreas

---

1

1

Vessels

3

3

6

Retroperitoneum

---

4

4


TABLE 23.- Complications in forward and fixed hospitals in 167 followed-up thoracic casualties according to surgical procedures in forward hospitals

Complications

Surgical procedures in forward hospitals

Surgical procedures in fixed hospitals

Grand total

Thoracotomy

Thoraco-
abdominal surgery

Total

Thoracotomy

Thoraco-
abdominal surgery

Total

Yes

No

Yes

No

Shock1

8

---

4

12

---

---

---

---

12

Coma

1

---

1

2

---

---

---

---

2

Wet lung

37

22

6

65

---

---

---

---

65

Hemothorax

18

5

3

26

---

---

---

---

26

Wound infection

---

---

---

---

5

2

3

10

10

Empyema

1

---

2

3

4

3

2

9

12

Pneumonitis

1

2

2

5

---

---

---

---

5

Lung abscess

2

---

---

2

---

---

---

---

2

Chronic hemothorax

2

4

5

11

---

---

---

---

11

Bronchial fistula

2

---

---

2

---

---

---

---

2

Abdominal2

---

---

1

1

4

---

6

10

11

Other3

5

7

4

16

1

3

3

7

23


1Severe only.
2Subphrenic and peritoneal abscesses, et cetera.
3Hepatitis, amputations, toxic psychoses, et cetera.


449

SUBSEQUENT SURGERY

In oversea hospitals-By the time the Italian campaign began, excellent facilities had been provided in the thoracic surgery centers in base sections of the North African theater for handling thoracic and thoracoabdominal casualties. The principles of treatment were becoming standardized. Well-trained and experienced personnel were available. Also, it was possible to keep the patients in these hospitals, when necessary, for periods up to 150 days.

Delayed primary wound closure, with or without redebridement, accounted for the largest number of operations (59) necessary in base section hospitals (table 24). No undue morbidity followed the removal of retained foreign bodies in 13 cases; in fact, the patients were then in much better condition to withstand the procedure than they were immediately after wounding.

Most of the drainage operations for infections of the chest wall and for empyema (seven each) were required because of the extent of the original wound and the serious contamination that had occurred.

Seven decortications were carried out for empyema and two for organizing hemothorax. Most of the patients in the empyema group had been treated only by debridement and thoracentesis in forward hospitals.

Colostomies were closed twice, both in patients in particularly good condition. It was always desirable to perform this operation overseas if it could be done.

As these data show, most surgery in base section hospitals, aside from delayed primary wound closure, was necessary for infections of the chest wall and pleural cavity. Persistent pneumonitis was not seen in any of these patients.

TABLE 24.- Surgery required in fixed hospitals according to surgery performed in forward hospitals

Surgery in fixed hospitals

Previous surgery in forward hospitals

Total

Thoracotomy

Thoracolaparotomy

Yes

No

Drainage of chest wall

2

3

2

7

Drainage for empyema

5

1

1

7

Removal of foreign body

5

7

1

13

Decortication

4

4

1

9

Abdominal surgery

2

---

4

6

Delayed primary wound closure

26

31

2

59

Other

8

12

6

26


450

In Zone of Interior hospitals.-Only a small amount of surgery was necessary in these casualties in Zone of Interior chest centers:

Two patients required drainage for empyema 5 and 6 months, respectively, after wounding. One had had a traumatic thoracotomy and the other a thoracoabdominal wound.

In three instances, removal of foreign bodies was necessary. In the first case, the missile was removed from the lung of a patient who had had debridement without thoracotomy in a field hospital. In the second, the missile was removed from the abdomen when a colostomy was closed. In the third case, the object was removed from the liver.

The only other thoracic surgery required was excision of an arteriovenous fistula involving the internal mammary artery.

Chest pain and dyspnea were the principal complaints of casualties who were not returned to duty from Zone of Interior chest centers. In practically all of these cases, as will be pointed out later (p. 523), physical and roentgenologic examinations showed excellent lung expansion and minimal pleural reaction.

MORTALITY AND DISPOSITION

Deaths-Four deaths occurred in base section hospitals, all in casualties with multiple wounds, all of whom had been serious problems from the moment they were carried into the shock tent of the field hospital until they died in a fixed hospital in the base. Three had thoracoabdominal wounds; hepatic infection and jaundice were factors in each fatality, and one patient also had peritonitis. The remaining casualty had a traumatic thoracotomy and a spinal cord injury with paraplegia. He died of pulmonary complications and secondary hemorrhage soon after evacuation from the field hospital.

Disposition-Two casualties, both of whom had small wounds limited to the chest, were discharged from forward hospitals directly to their units. 

In view of the multiplicity and severity of the wounds sustained by most of the remaining patients in this series, it is surprising to learn that about half of them could be returned to duty in the theater, most to limited duty but a few to active frontline combat. The larger number of casualties returned to duty, 50, were in the group in which primary thoracotomy was not necessary, but 38 patients who required thoracotomy and 5 who required thoracoabdominal surgery were also returned to duty. This was, of course, a sound policy in an oversea theater, in that it conserved manpower in the theater and reduced the need for replacement from the Zone of Interior. One reason that it was possible was that the holding time in base section hospitals, sometimes up to 5 months, was sufficient for small wounds to close by secondary intention,2 for wounds closed by delayed primary suture to heal solidly, for pleural effusions to be absorbed, and for hematomas of the lung to resolve.

2Two kinds of wounds were allowed to heal by secondary intention: (1) those in which infection was just enough of a possibility to make surgeons in the base hospitals hesitant to perform delayed primary closure, and (2) large clean wounds which for one reason or another were not suitable for delayed primary closure.


451

In the Zone of Interior, only 17 patients were returned to duty, most of them to limited duty. The group was about equally divided between those who had undergone primary thoracotomy and those who had not. The number was necessarily small, in view of the policy in the Mediterranean theater of not evacuating casualties to the Zone of Interior, unless there was a shortage of beds, until it was reasonably clear that they could not return to duty in the oversea theater.

When the group of patients returned to duty overseas is added to the group returned to duty in the Zone of Interior, it is seen that more than two-thirds (112) of the 163 patients who survived surgery in forward and base hospitals could be returned to some form of useful army service. Had the war continued and this same trend continued, there would have been an enormous saving in manpower. As it was, it is impossible to estimate the morale factor inherent in the return to duty of such a large number of seriously wounded men.

The postwar status of these casualties will be discussed later.

The case histories which follow have been selected from the histories of the 167 patients followed up after forward surgery to illustrate special conditions and complications and the methods of treatment employed for them. They are deliberately presented in some detail.

WOUNDS OF THE CHEST WALL

Although the chest wall was, of course, involved in all penetrating wounds of the chest, in 22 cases in this series, these wounds were small. They were sometimes associated with serious intrathoracic problems, but in all cases, the wounds themselves were readily managed by simple debridement.

In the remaining 145 cases, trauma to muscle masses and the bony cage was extensive enough to create challenging clinical problems. Foreign bodies were present in 35 cases, and there were 88 sucking wounds and 4 thoracoabdominal wounds in the series. The bony case was involved 101 times, the ribs 77 times, the scapula 13 times, the sternum 6 times, and the spine 5 times. 

Wound infection was not a serious problem in any field hospital, but in 10 of these 145 cases, drainage of the wound was necessary for this reason in base section hospitals. In all 10 cases, the relation between the development of infection and the time at which debridement was performed seemed clear cut; in a few cases, initial wound surgery had been delayed up to 72 hours. Empyema developed in 9 cases at the base section and in 2 others in the Zone of Interior, but in only 2 of these 11 cases did a severe wound infection exist.

Case 1

Management overseas-This 31-year-old infantryman was wounded in the chest at 1130 hours on 14 October 1944, near Hupelmont, France. Three hours later, he received a plasma transfusion of 1,000 cc. in a battalion aid station, where the sucking wound of the anterior chest wall was closed by skin


452

FIGURE 196 (case 1).-Schematic showing of large defects of chest wall. A. Wound: Large sucking wound of exit in right anterior chest wall, with destruction of portions of fourth, fifth, and sixth ribs and the corresponding costal cartilages (a), wound of entrance in left chest (b), and through-and-through wound of left upper arm (c). B. Closure of large chest wall defect by suture of mobilized pectoralis major (a) and rectus abdominis (b). C. Closure of central portion of wound with wounds of entrance (a) and exit (b) left open down to fascia, and closed drainage tube in situ (c).


453

FIGURE 196b (case 1).-Schematic showing of large defects of chest wall. A. Wound: Large sucking wound of exit in right anterior chest wall, with destruction of portions of fourth, fifth, and sixth ribs and the corresponding costal cartilages (a), wound of entrance in left chest (b), and through-and-through wound of left upper arm (c). B. Closure of large chest wall defect by suture of mobilized pectoralis major (a) and rectus abdominis (b). C. Closure of central portion of wound with wounds of entrance (a) and exit (b) left open down to fascia, and closed drainage tube in situ (c).

sutures and a sulfonamide powder was placed in it. He was given morphine gr. ¼ and, because of wet breathing, atropine gr. 1/50.

When he was received at the 11th Field Hospital at Eloyes, France, at 1545 hours, he was dyspneic and cyanotic, and his breathing was still wet. A large wound in the anterior chest wall (fig. 196A) extended from the anterior axillary line on the right at the sixth interspace across to the fourth rib in the anterior axillary line on the left. Breath sounds were heard bilaterally distant on the right, and there were numerous rales and rhonchi throughout both lung fields.

The resuscitative regimen included oxygen by nasal catheter; penicillin intramuscularly; thoracentesis, with removal of 300 cc. of bloody serous mucus from the right chest; intercostal nerve block, including the fifth through the eighth nerves; and catheter aspiration, which produced bloody serous mucus.


454

FIGURE 197 (case 1).-Serial roentgenograms in large defect of chest wall. A. Posteroanterior roentgenogram, 14 October 1944, immediately after wounding, showing fluid in lower half of right chest, with mottled infiltration above and on the left. Note air in anterior mediastinum outlining left mediastinal pleura. B. Lateral roentgenogram showing hazy lung fields and displacement of heart posteriorly by air in anterior mediastinum. C. Posteroanterior roentgenogram, 21 October 1944, showing closed drainage tube in right chest (reinserted to control pulmonary air leak), right hydropneumothorax, and subcutaneous and mediastinal emphysema. D. Posteroanterior roentgenogram, 25 October 1944, showing clearing of both lungs.


455

FIGURE 197.-Continued. E. Posteroanterior roentgenogram, 19 November 1960, 16 years after wounding, showing irregularity of fifth and sixth ribs anteriorly, slight blunting of right costophrenic angle, prominent bronchovascular markings, and fibrosis of right paracardiac region above diaphragm. F. Lateral roentgenogram on same date, showing pleural shadow anteriorly and fairly flat diaphragms.

Roentgenologic examination (fig. 197A and B) showed fluid occupying the lower half of the right chest, with a mottled infiltration above and to the left, and air in the mediastinum displacing the heart posteriorly.

When the patient was first observed, his pulse was intermittently irregular, and there were dropped beats at the radial pulse. There were also premature cardiac contractions. After 4 hours of the intensive resuscitation just described, his condition improved, and his lungs seemed entirely dry.

The sucking wound of the right chest was thoroughly debrided, and portions of the fourth, fifth, and sixth ribs, with the corresponding costal cartilages, were resected. The laceration of the right lung was repaired with interrupted sutures of fine catgut, and a drainage tube was introduced into the lower right pleural cavity and connected with a closed system.

To effect closure, it was necessary to mobilize a large pectoral flap and a rectus flap. These were sutured together and attached to the chest wall, to fill in the huge defect left by resection of the three ribs (fig. 196B). The central portion of the chest wall was closed (fig. 196C), and the wounds of entrance and exit were left open and packed with gauze down to the muscle layers. 

A wound in the left upper arm was debrided.

The patient's condition was satisfactory throughout the operation, but an hour after it was concluded, his respirations became very wet. Bronchoscopy, which was performed at once, yielded a moderate amount of bloody mucus from both bronchi. At this point, cardiac arrest occurred. The catheter was at once withdrawn and the bronchoscope was removed. Oxygen was administered by


456 

face mask, with intermittent positive pressure on the anesthetic bag. In less than 2 minutes, the heartbeat returned, the respirations also returned, and within 10 minutes, the patient regained consciousness.

Late on the second postoperative day, subcutaneous emphysema in the neck and the chest wall became quite marked. Pneumothorax, which was evident on the right, was controlled by a catheter inserted into the pleural space and fixed to a closed drainage system (fig. 197C). The inferior drainage tube ceased to function within 48 hours and was removed at this time.

The temperature was elevated to 101º F. for the first week after operation, but when the patient was evacuated to the base section on the 12th postoperative day, the emphysema had disappeared (fig. 197D), the lung was expanded, and the wound was clean.

Contrary to the usual practice, it was necessary in this case to use a tight binder during the postoperative period, because of the mobility of the chest wall. It was discarded as the wound healed and the wall became firm.

Management in the Zone of Interior-The patient required no active treatment in the Zone of Interior and was given a disability discharge. 

Followup.-This patient has been well since he was finally discharged from the VA outpatient clinics 5 years ago except for dyspnea on manual exertion and some pain. He has held a variety of jobs.

Roentgenologic examination on 19 November 1960, 16 years after wounding (fig. 197E and F) showed prominent bronchovascular markings, and slight fibrosis of the right paracardiac region above the diaphragm. The lateral view was clear except for blunting of the right cardiophrenic angle.

Comment-This patient presented a number of problems: A large anterior sucking wound of the right chest; fractures of the fourth through the sixth ribs and their cartilages; some evidence of blast injury to the heart, with cardiac irregularity; a moderately severe wet lung syndrome; and mediastinal emphysema. Satisfactory closure of the large defect in the chest wall was effected with flaps of pectoral and rectus muscles. Although the patient had had atropine (gr.1/200) 90 minutes earlier, cardiac standstill occurred when bronchoscopy was performed after operation. Positive pressure oxygen was effective, and there were no further difficulties in this regard. Accumulation of air in the affected hemithorax required the insertion of a second closed thoracostomy tube. The explanation of the cardiac standstill was probably a combination of hypoxia., so-called cardiac blast, and vagovagal tracheal stimulation. The use of atropine before operation may have been helpful in producing the prompt recovery.

Case 2

Management overseas-This technical sergeant, attached to a tank destroyer battalion, was wounded in the left chest by a high explosive shell fragment at 0845 hours on 3 December 1943, near Cassino, Italy. At the battalion aid station, a sucking wound of the left chest anteriorly (fig. 198A) was packed


457

FIGURE 198 (case 2).-Schematic showing of sucking wound with defect of chest wall. A. Wound in anterior aspect of chest, with sucking wound of second intercostal space packed with petrolatum-impregnated gauze. B. Schema of pathologic findings, anterior view: Foreign body in lung and pleura (a), hematoma of left upper lobe (b), wet lung (c), mucus and blood in trachea (d), and engorged superior vena cava (e).


458

FIGURE 198.-Continued. C. Findings at thoracotomy, lateral view: Sucking wound (a), laceration of left upper lobe (b), hematoma of left upper lobe (c), foreign body in pleura (d), left hemothorax (e), and wet lung (f).


459

FIGURE 198.-Continued. D. Anterior aspect of chest at conclusion of operation: Debrided pectoralis major muscle sewn together to close sucking wound (a), with fine-mesh gauze packed into wound (b), and closed intercostal drainage tube (c).

with a dressing sprinkled with powdered sulfanilamide, and morphine (gr. ½) was given.

The patient was received at the 94th Evacuation Hospital at 1100 hours the same day. Here he gave a history of having had a severe respiratory infection for the previous 4 or 5 days. At this time, he was in shock, with blood pressure of 80/60 mm. Hg, pulse of 130, and wet and labored respirations. He was extremely dyspneic. Signs of fluid were present over the entire left chest, and rales were heard over the right chest.

The chest wound was fairly clean. It was cleansed down to the pleural opening, which was 2 by 3 cm., and a fresh petrolatum-impregnated pack was inserted. Resuscitative measures included tracheal aspiration, which yielded a large amount of bloody fluid; intercostal nerve block, from the second through the eighth nerves on the left; thoracentesis, which yielded 700 cc. of bloody fluid; and a transfusion of 500 cubic centimeters.

The patient's condition improved with these measures, but respirations were wet over both lung fields, and it was obvious that he had been wounded at a time when he had a severe bronchopulmonary infection. Therefore, since


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the wound was fairly clean, it was decided that the risk of immediate surgery was greater, under the circumstances, than the development of infection of the chest wall.

Roentgenograms on the day of wounding, taken after aspiration of the chest (fig. 199A), showed a large foreign body in the left upper lobe and a hematoma in the same location.

The patient was given 4 gm. of sulfadiazine daily until 7 December 1943. During this period, he ran a low-grade temperature.

Operation was performed on 7 December 1943, under light nitrous-oxide anesthesia. The hematoma shown in the roentgenogram 4 days earlier was still present, but the foreign body was not readily accessible, and no search was made for it (fig. 198B and C). Lateral pleural drainage was instituted. The pectoralis muscle was closed (fig. 198D) and the rest of the wound was left wide open and packed.

The postoperative course was satisfactory, and the patient was evacuated to the 24th General Hospital at Bizerte, 10 days after operation. Here, 3 weeks later, elective thoracotomy was done, and a large foreign body was removed from the left pleural space and left upper lobe. Satisfactory healing followed delayed primary wound closure.

Four months after wounding, the patient was released for limited duty in the communications zone. At the end of the war, he was sent to the Zone of Interior by rotation and discharged there.

Followup-A communication from this patient on 22 November 1960 stated that he had done outside construction work since the war. His only complaints were mild dyspnea when he had chest colds and some pain in the left shoulder associated with overwork. He was married and had children.

Roentgenograms made on 21 November 1960 (fig. 199B and C) showed the left lung completely expanded and no abnormalities of consequence. 

Comment.-The interesting feature in this case is the admission of the patient to a forward hospital with a sucking wound superimposed upon a severe bronchopulmonary infection. It was decided to repack the wound daily and allow the respiratory infection to subside before surgical closure of wound was undertaken. Removal of the foreign body in the left pleura and upper lobe was performed at the base section. Recovery from this operation, as from the deferred initial wound surgery, with closure of the pectoralis muscle, in the forward hospital, was uncomplicated, and there was no residual disability.

This is the only case of the kind in this particular series, though there were a number of similar instances in the cases in this series not followed up after the war. The lesson to be learned from it is that, while general principles must be followed in wartime, they must be flexible enough to permit each case to be managed on its own merits.


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FIGURE 199 (case 2).-Serial roentgenograms in sucking wound with defect of chest wall complicated by severe bronchopulmonary infection. A. Posteroanterior roentgenogram, 3 December 1943, shortly after wounding, showing large foreign body and hematoma in left upper lung field, with haziness of both lung fields. Although the chest has been aspirated, a small amount of pleural fluid is still present on the left. B. Posteroanterior roentgenogram, 21 November 1960, 17 years after wounding, showing clear lung fields, prominent bronchovascular markings, and sharp costophrenic angles. Note healed fracture of left sixth rib, apparently the result of elective thoracotomy performed in base hospital in 1943. C. Lateral roentgenogram on same date showing clear lung fields and deep, clear costophrenic angles.


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LACERATIONS OF THE LUNG

Lacerations of the lung of sufficient magnitude to present clinical problems were present in 61 of these 167 cases. Neither blunt trauma nor spontaneous pneumothorax was an etiologic factor in any case. In each instance, the lung was torn by a penetrating missile or by fractured ribs.

Intrapleural decompression was required in all 61 cases, but thoracotomy to repair the rent was employed only selectively. The laceration, per se, was not regarded as an indication for this procedure.

In 13 cases, continuing leakage of air was treated conservatively, by aspiration or catheter drainage, and in each instance, the laceration closed spontaneously. In a number of cases not included in the group followed up, small lacerations of the lung were closed when thoracotomy was done, but whether all these repairs were necessary is another matter.

In the 48 cases in this series in which thoracotomy was done on the indication of pulmonary lacerations, direct repair of the laceration was necessary in 38 cases, in 6 of which the tear was so extensive that muscle grafting was required to effect closure. This technique proved highly successful; neither bronchopleural fistula nor empyema developed in any instance.

In only one instance in the series was pulmonary resection carried out in a forward hospital. In this case, a laceration of the lung and damage to the blood supply and the bronchus of the posterior basal segment of the right lower lobe served as a valid indication for segmental resection because the damaged area of the lung was no longer viable.

Pulmonary resection was not necessary at any hospital in the communications zone, nor was it necessary in a Zone of Interior hospital. One patient among the 61 with pulmonary lacerations developed a pneumothorax in the Zone of Interior, 3 months after wounding, and thoracotomy was necessary to remove the foreign body causing the difficulty. No other patient in the series required surgery in the Zone of Interior, and this was the only thoracotomy performed for this reason in this series in any Army general hospital in the United States.

One other point should be emphasized in connection with lacerations of the lung: Patients in this group with progressive or tension pneumothorax were not evacuated to the rear until the condition was under control unless tactical circumstances demanded movement of the installation. In 2 of these 61 cases, evacuation was necessary for this reason before the air leak was controlled, but in each instance, a trained medical technician rode in the ambulance with the patient to insure that the decompression catheter functioned properly en route. This conservative evacuation policy undoubtedly explains why recurrent pneumothorax was not a problem in base section hospitals in the Mediterranean theater.


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Case 3

Management overseas-This 19-year-old infantryman was wounded in the left chest posteriorly, the left upper arm, and the left hip at 0800 hours on 28 November 1943, in the mountains near Cassino, by an artillery shell fragment. Emergency treatment consisted of the application of an occlusive dressing sprinkled with a sulfonamide powder, sulfadiazine by mouth, and morphine. At the collecting station, a unit of plasma was given. Because of transportation difficulties, the patient did not reach a clearing station until the following day.

When he arrived at the 94th Evacuation Hospital at LePezze, he was found to have a sucking wound (fig. 200A), satisfactorily occluded, of the left posterior chest in the region of the sixth, seventh, and eighth ribs, and smaller wounds of the left arm and left chest. He was extremely short of breath. The temperature was 101° F., the pulse 90, the respirations 48, and the blood pressure 130/80. Breath sounds were absent over the left chest; the right chest was fairly clear. Roentgenograms made on 30 October 1960 (fig. 201A and B) showed almost complete collapse of the left lung; fractures of the sixth, seventh, and eighth ribs; and a foreign body apparently within the cardiac shadow. Some fluid was present in the left chest; the right lung was fairly clear.

The routine of resuscitation included bronchial aspiration per catheter, after which respirations became more satisfactory.

Operation was performed on 30 November 1943, at 0040 hours. The posterior sucking wound, which was found to be infected (fig. 200A), was very carefully debrided down to clean muscle tissue. The instruments, gloves, and drapes were changed before the remainder of the operation was proceeded with.

Fractures of the sixth, seventh, and eighth ribs were exposed and the fragments were removed. The pleural cavity was entered by extending the wound of the sixth intercostal space (fig. 200B). A metallic foreign body, 2 by 1.5 cm., was removed from the left upper lobe, along with some rib fragments. A hematoma was present in this lobe, as well as a foreign body which did not penetrate the heart. Rib fragments were also removed from the left lower lobe (fig. 200C). Lacerations in both lobes, from which air was bubbling, were easily repaired with catgut (plain O) mattress sutures. About 500 cc. of blood was aspirated from the pleural space, after which extremely thorough pleural lavage was carried out.

The chest wall was closed (fig. 200D) by suturing the trapezius and latissimus dorsi muscles over the pleural defect in the sixth intercostal space. The serratus was closed more anteriorly. The fascia and subcutaneous tissues were left wide open. Closed intercostal drainage was instituted in the eighth intercostal space.


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FIGURE 200 (case 3).-Sucking wound of left posterior chest with early infection. A. Wound. Posterior aspect of thorax showing infected sucking wound of sixth intercostal space on left, packed with gauze. B. Diagram of findings at thoracotomy showing: Collapsed lung with foreign body (a), pulmonary laceration (b), hemothorax (c), bone fragments in left lower lobe (d), and hematoma in same location (e).


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FIGURE 200.-Continued. Appearance of wound after repair of laceration of left upper lobe with removal of foreign body, leaving hematoma undisturbed (a). Closed pleural drainage has been instituted (b).

The immediate postoperative course was stormy, with the temperature ranging daily from 100° to 102° F. Roentgenologic examination on 7 December 1943 showed diffuse haziness of the left chest, and thoracentesis yielded purulent exudate.

In spite of the fever and the infection, the patient's general condition was good, and he was therefore evacuated to the base when an inordinate number of fresh casualties required that the hospital be emptied.

The left empyema was drained at the 33d General Hospital, at Bizerte, by resection of a portion of the ninth rib.

Management in the Zone of Interior-In February 1944, the patient was evacuated to the Zone of Interior. By this time, the chest wound was healed, the empyema had been controlled, and the lung was fully expanded, the only abnormality being some pleural thickening on the left. Neurolysis of the left median nerve was carried out at Walter Reed General Hospital, Wash-


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FIGURE 200.-Continued. D. Airtight closure of deep muscles of chest wall: Packing of superficial wound above closure (a), and closed pleural drainage (b).

ington, D.C. After a period of limited duty, the patient was discharged from the Army on 14 March 1946.

Followup-A communication from the patient in November 1960 stated that he had worked in the post office as a mail clerk since his discharge from the Army. He was married and had two children. He had no symptoms referable to the chest. Roentgenograms made on 21 November 1960 (fig. 201C and D) showed an essentially clear left lung field. The only abnormality was regeneration and fusion of the sixth, seventh, eighth, and ninth ribs.

Comment-This casualty was in serious condition when he was first seen, with an infected sucking wound of the left chest posteriorly, an almost complete collapse of the lung, some fluid in the left chest, and a foreign body at first thought to lie within the cardiac shadow. A hematoma was present in the left upper lobe, and there were fragments of fractured ribs in this lobe and in the left lower lobe. Conservative management included bronchial aspiration per catheter as part of the resuscitative regimen, debridement, removal of the


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FIGURE 201 (case 3).-Serial roentgenograms of sucking wound with early infection. A. Posteroanterior roentgenogram, 30 October 1943, shortly after wounding, showing collapse of left lung and fracture of sixth, seventh, and eighth ribs. Note that in this view a foreign body appears to be within the cardiac outline. B. Left lateral roentgenogram, showing foreign body within lung and not penetrating heart. C. Posteroanterior roentgenogram of chest, 21 November 1960, 17 years after wounding, showing regeneration and bridging of sixth, seventh, eighth, and ninth ribs; slight blunting of left costophrenic angle; and slight pleural reaction on left. Otherwise, the lung fields are clear. D. Lateral roentgenogram on same date, showing clear lung fields and sharp posterior costophrenic sulci.


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foreign body and the rib fragments, repair of lacerations in the involved pulmonary lobes, closure of the chest wall, and closed intercostal drainage. 

Although the patient developed an empyema, it was readily controlled by correct rib-resection drainage, and the damaged lung was fully expanded when he was received in a Zone of Interior hospital. At the present time, 17 years after wounding, he is leading an active life, with no residua from his chest injury and no significant roentgenologic abnormalities.

This case is another illustration of the excellent results achieved by strict adherence to the principles and practices of thoracic surgery developed in the Mediterranean theater during World War II.

MEDIASTINAL INJURIES

Injuries to the mediastinum were recorded only 13 times in these 167 cases. This might be expected. As pointed out several times earlier in this history, because the heart, great vessels, esophagus, trachea, and bronchi are located in this area, most casualties with severe penetrating mediastinal wounds do not survive to reach any hospital.

The casualties in this series who survived mediastinal injuries all had wounds produced by small foreign bodies, whose driving force was spent. Bleeding into the mediastinum sufficient to produce a widened mediastinal shadow was present in five instances, but in all, the blood was absorbed without sequelae.

Although this is a small group and the mediastinal injury was not always the most important lesion, six of the casualties had traumatic thoracotomies, and others had considerable trauma to the thoracic cage and the lungs. Small foreign bodies were removed in four instances and allowed to remain in the others.

At the base section, five patients were returned to limited duty. The other five were evacuated to the Zone of Interior, where all received disability discharges, in one instance on the basis of psychoneurosis.

The problems encountered in the treatment of mediastinal injuries are illustrated in the following case history:

Case 4

Management overseas-This 19-year-old Japanese-American infantryman received a high explosive shell-fragment wound of the left chest (fig. 202A) at 1100 hours on 8 November 1944, at Biffontaine, France. He received two units of plasma at the battalion aid station, where the wound was packed with a dressing sprinkled with sulfanilamide.

When the casualty was received at the 11th Field Hospital at 1345 hours, he was in deep shock. The blood pressure was 80/70 mm. Hg, the pulse 128, and the respirations 40. The massive sucking wound of the left anterior chest was occluded by an airtight packing.


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FIGURE 202 (case 4).-Anterolateral sucking wound of left chest. A. Anterolateral aspect of left chest after removal of petrolatum-impregnated gauze pack: Large, dirty wound, 5 by 8 inches, involving pectoralis major and serratus magnus (a), stump of fifth rib (b), defect in pleura 2.5 by 3 inches (c), and stump of fifth costal cartilage (d). B. Findings at thoracotomy: Tense hemopericardium (a), nonopaque foreign bodies (dirt, bone, cloth) in pericardium (b), hematoma of pericardium (c), hematoma of entire left lower lobe (d), laceration and hematoma of lingula of left upper lobe (e), accessory lobe (f) and hemothorax (3,000 cc.) (g).


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FIGURE 202.-Continued. C. First step in wound closure: Residual defect in pleura, 1 by 1.5 inches, impossible to close (a), closure of intercostal muscles (b), and anterior stump of fifth cartilage (c). D. Closure of muscles of anterior chest wall over pleural defect: Upper portion of pectoralis major (a), lower portion (b), serratus magnus (c), and pleural defect (d). E. Wound closure: Anterior reinforcement of closure by skin suture (a), skin wound left open posteriorly (b), posterior inferior closed intercostal drainage tube (c), and anterior intercostal closed drainage tube (d).


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After 200 cc. of plasma had been given, pulmonary edema occurred, and no more plasma was given. Tracheal suction, repeated several times, produced quantities of thin, pinkish fluid. When only 20 cc. of fluid could be obtained by thoracentesis, the pack in the wound was temporarily loosened, whereupon a large amount of bloody fluid escaped. An attempt at blood transfusion precipitated pulmonary edema, and endotracheal suction was again applied, with positive pressure oxygen therapy, the anesthetic bag being squeezed with each inspiration.

Roentgenologic examination (fig. 203A and B) showed haziness of the entire left lung field, a shift of the heart to the right, and subcutaneous emphysema. The right lung was fairly clear.

At the end of 8 hours of the regimen described, the patient's condition was still precarious. Blood transfusion was again attempted, while at the same time, measures were carried out to combat wet lung. The blood pressure was imperceptible at times, but eventually, after intercostal nerve block and the administration of atropine gr. 1/150, it rose to 96/60 mm. Hg.

After the patient's condition had improved sufficiently and his lungs had been dry for several hours, operation was undertaken at 0130 hours on 9 November, on the indications of continued intrathoracic hemorrhage; the necessity of closing the sucking wound; and the possibility of both diaphragmatic and cardiac injury. The operation began with debridement of the chest wall. The pectoralis and serratus muscles were extensively involved (fig. 202A), the defect measuring 5 by 8 inches. The fifth rib was shattered, and had to be removed down to the cartilage. There was an opening 2.5 by 3 inches in the fourth and fifth intercostal spaces.

Excellent exposure of the pleural cavity (fig. 202B) was obtained by opening the fifth intercostal space posteriorly. A massive hematoma occupied the lower lobe of the left lung and the lingula of the upper lobe, but the accessory lobe was not involved. About 90 cc. of bloody fluid was aspirated from the pericardium, which was extremely tense. After dirt, cloth, and fragments of rib were removed from the pericardium, it was seen to contain a large hematoma. A window was made in the pericardial sac, to permit drainage into the pleural cavity, which contained about 3,000 cc. of blood. After the blood had been removed, the cavity was thoroughly washed out with physiologic salt solution. A laceration in the upper lobe of the left lung had almost completely sealed over.

Pleural drainage was effected in the second intercostal space anteriorly and in the base posteriorly and was connected with a closed-drainage system.

By this time, the lung had expanded satisfactorily and there was no further evidence of bleeding. The chest wall was closed (fig. 202C and D) by partial closure of the intercostal bundles of the fifth interspace. The pectoralis major was mobilized from above and brought down over the pleural defect, and the serratus magnus was brought up behind. Since the muscles were abnormally thin, it was necessary to close the skin and subcutaneous tissues with mattress


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FIGURE 203 (case 4).-Serial roentgenograms in mediastinal injury with intrapericardial foreign bodies and hematoma. A. Posteroanterior roentgenogram, 7 November 1944, immediately after wounding, showing massive left hemothorax, with slight shift of mediastinum to right, and extensive emphysema of left chest wall. Right lung is fairly clear. B. Lateral roentgenogram on same date showing diffuse haziness. No radiopague foreign body is seen. C. Posteroanterior roentgenogram, 22 November 1960, 16 years after wounding, showing clear lung fields and normal heart shadow. Note muscular defect of left anterior chest wall, with resection of anterior portion of fifth rib, and tenting of left diaphragm. D. Lateral roentgenogram on same date showing defect of left anterior chest wall with pleural reaction posterior to it and high anterior tenting of left diaphragm. Otherwise, the findings are within the normal range.


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sutures anteriorly; both posterior limbs of the wound were left open (fig. 202E).

The wound in the left arm was then debrided. The ulnar nerve had been traumatized but not completely lacerated. The brachial artery, however, had been lacerated. After the clot which occluded it had been milked out and a free flow of blood had been reestablished, repair was accomplished with No. 00000 silk sutures. The pulse, which had not previously been present in the left wrist, could now be felt.

The patient made a satisfactory recovery.

Management in the Zone of Interior-When the patient reached the Zone of Interior, no further surgery on the chest was necessary. Repair of the ulnar nerve was carried out at DeWitt General Hospital, Auburn, Calif. He was discharged from the Army on 17 August 1946.

Followup-A communication from this patient on 23 November 1960 revealed that he was working 40 hours a week as a building materials salesman. He had no difficulty in breathing and no other complaints. Roentgenograms made on 22 November 1960 (fig. 203C and D) showed the left lung to be completely expanded and the lung fields clear. The chest wall defect was apparent on the film, both laterally and anteriorly, and the left diaphragm was tented, but there were no other abnormalities.

Comment-This patient was observed at a field hospital in eastern France with a large sucking wound of the anterior chest wall, which undoubtedly involved both the lung and the heart. Stabilization was extremely difficult and occupied some 10 hours. Although surgery was taxing, he withstood it well; it included removal of foreign bodies from the pericardium, pericardial drainage, and the structural problem inherent in the reconstruction of the anterior chest wall. The pectoralis and serratus muscles were used to cover the defect, and the weakest portion of the repair was reinforced by closure of the skin over it. The associated wound in the arm, which involved both the ulnar nerve and the brachial artery, also required a taxing repair.

The fact that this patient is well and working without complaints referable to the chest 16 years after wounding is heartening when one considers the severity of the original wound and the complex problems involved in both resuscitation and initial surgery. The presence of clear lung fields, except for diaphragmatic tenting, at the end of this period of time also speaks well for the staged management employed in this case.

BLAST INJURIES

Generalized blast injury, caused by a wave of generalized positive pressure followed by a wave of negative pressure, was a factor in 21 cases in this series. In three instances, there was no external wound except for powder and dirt burns of the skin. Perforated eardrums were present in four cases,


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and transient cardiac irregularities and evidences of cerebral anoxia were characteristic of the early stages in practically all cases.

All 21 patients were evacuated to the base section, where 3 patients died of wounds not directly due to the blast injury. After periods of up to 5 months, six patients were returned to limited duty in the communications zone. The other 12 patients were returned to the Zone of Interior. None of them was released for active duty, and all of them eventually received disability discharges, two with the diagnosis of psychoneurosis as the principal cause. Followup studies showed slight pulmonary emphysema, but no instance of clinical dyspnea was reported.

Localized blast effect, due to the impact force of high explosive shell fragments upon the chest wall and thoracic organs, was a factor in practically every patient in the series who had a severe injury of the chest wall.

The following case history illustrates the problems of blast injuries and the typical followup status of those who sustained them:

Case 5

Management overseas-This 21-year-old infantryman was 20 feet away from an aerial bomb blast which occurred at 1330 hours on 10 November 1943, near Venafro, Italy. He was unconscious for a short period of time. When he regained consciousness, he found that he had been sprayed with dirt and had suffered facial burns. He was picked up by a corpsman shortly after the blast and taken to a battalion aid station, where he was given 250 cc. of plasma and morphine gr. ½.

When he was admitted to the 94th Evacuation Hospital at LePezze at 1530 hours, he complained of severe dyspnea, orthopnea, wheezing, choking, slight dysphagia, and severe chest pains. Coughing produced bloody sputum.

Examination showed a second degree burn of the face, involving the left cornea and conjunctiva, but no other external wounds. The veins in the neck were full. The patient was cyanotic, and his breathing was extremely difficult. Breath sounds were decreased, and in some areas almost absent, over the right chest, and scattered rales were also heard on the left. The heart sounds were distant and slightly irregular.

The left tympanic membrane was ruptured. Hearing was impaired on this side, and later there was slight drainage from the ear.

Roentgenologic examination on 11 November 1943, the day after injury (fig. 204A), showed diffuse bilateral haziness and infiltration, which were taken to indicate petechial pulmonary hemorrhage and edema.

Treatment consisted of oxygen administration by nasal catheter, repeated catheter bronchial aspiration, restriction of fluids by mouth, and control of the chest pain by small doses of morphine. The patient was not digitalized, and he was not given intravenous fluids.

The lungs gradually cleared (fig. 204B), and 14 days after wounding, he was evacuated to a base hospital.


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FIGURE 204 (case 5).-Serial roentgenograms in blast injury. A. Posteroanterior roentgenogram, 11 November 1943, 24 hours after injury, showing diffuse bilateral haziness and infiltration indicative of petechial pulmonary hemorrhage and edema. B. Posteroanterior roentgenogram, 17 November 1943, showing clearing of lung field. C. Posteroanterior roentgenogram, 7 January 1960, 16 years after severe blast injury. The only abnormality is slight emphysema of upper lobes. The diaphragms are at level of the eleventh ribs; their contours are rounded. Heart is also normal.

Management in the Zone of Interior-In the Zone of Interior, the patient required no treatment for the blast injury. The considerable facial scarring left by the powder burns was treated by plastic surgery at Valley Forge General Hospital, Phoenixville, Pa., in March 1944. On 28 November, he was returned to limited duty and served without difficulty until his discharge on 1 September 1945.

Followup-Since his discharge from the Army, the patient has been followed up in the Veterans' Administration. His only complaint is brief, mild headaches, about three times a week, relieved by simple medication. They are


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thought by the neurologist to be evidence of an early, mild, chronic brain syndrome as a result of the blast injury.

Roentgenologic examination on 7 January 1960, 16 years after the blast injury (fig. 204C), showed no abnormality except mild pulmonary emphysema of the upper lobes.

Comment-This case history illustrates a typical blast injury, produced by a powerful wave of positive, followed by a wave of negative, air pressure, from a bomb apparently of considerable size. The infantryman was about 20 feet from the bomb, his nearness to it being shown by the superficial burns and dirt wounds of the skin of the face. The symptoms and signs were those usually observed in serious blast injuries. They included unconsciousness, severe dyspnea, hypoxia, severe chest pain, and rupture of an eardrum. The dilatation of the veins of the neck indicated increased venous pressure, and the wet lung syndrome was characterized by the presence of persistent rales and rhonchi.

Treatment included maintenance of a clear airway by repeated catheter aspirations; the administration of oxygen, to provide adequate oxygenation of the blood while the lung was healing; restriction of fluids by mouth; and avoidance of administration of fluids by vein. With these measures, digitalization was not necessary.

This casualty could be returned to active duty, and 16 years after the blast injury, he is in good health and is leading an active life. He has no pulmonary symptoms and there are no significant roentgenologic findings. The only (minimal) evidence of the injury takes the form of occasional mild headaches.

THORACOABDOMINAL WOUNDS

Thoracoabdominal wounds, which occurred 25 times in these 167 thoracic wounds, represented the combined problems encountered when two major serous cavities were involved. The seriousness of these problems is evident in certain facts:

1. Three casualties, as already mentioned (p. 450), died of late complications in base hospitals.

2. No patient in this group was returned to duty from the forward area, although four performed limited duty in base sections of the Mediterranean or European theaters within 2 months after wounding.

3. Secondary surgery was required in six cases, three times for drainage or empyema, twice for drainage of subphrenic infections, and once for removal of a foreign body which was left in situ in the forward area because of the urgency of the abdominal wounds.

4. All patients who returned to the Zone of Interior eventually received disability discharges, in one instance almost 10 years after wounding.

The following case histories illustrate the course of, and the problems involved in, thoracoabdominal wounds:


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Case 6

Management overseas-This 22-year-old infantryman was wounded in the left lower chest anteriorly (fig. 205A) at 1200 hours on 28 September 1944, at Faucompierre, France. He was standing about 100 feet from an 88-mm. shell explosion. He was knocked down but did not lose consciousness. Within 15 minutes, he was taken to a battalion aid station, where he was given eight sulfonamide tablets by mouth and a unit of plasma intravenously. The wound was sprinkled with a sulfonamide powder and dressed.

When he was admitted to the 11th Field Hospital at Eloyes, France, the wound was bleeding moderately. He complained of moderate pain in the chest and severe pain in the left upper quadrant of the abdomen. The blood pressure was 120/78 mm. Hg, the pulse 80, and the respirations 20.

The wound in the lower left chest was close to the costal margin in the eighth intercostal space. It was packed because movement of the chest wall caused sucking. Breath sounds on the left were decreased, but the right lung showed no abnormalities.

The patient complained of increased pain in the abdomen immediately after admission to the field hospital. Examination revealed tenderness in the left upper quadrant; pressure on any portion of the abdomen produced pain in this area.

Roentgenologic examination (fig. 206A) showed a large metallic foreign body below the left diaphragm, at the level of the eleventh rib. The lung fields were hazy.

The patient had eaten a K-ration 5 hours before wounding, and gastric lavage produced undigested food along with bloody fluid.

Obviously, peritoneal contamination had occurred from a wound of the gastrointestinal tract, and operation was urgent. At 1530 hours, when the anesthesiologist began induction, the blood pressure fell to 40/0 mm. Hg. After a transfusion of 500 cc. was given, the systolic pressure rose to 90 mm. Hg, and operation was restarted at 1630 hours.

The wound at the eighth intercostal space was debrided and the incision was extended along this interpace (fig. 205A), to expose the pleural cavity. The diaphragm was found widely torn. The omentum had herniated into the left pleural cavity, which also contained gastric contents. When the diaphragm was opened posteriorly, providing excellent exposure of the upper abdomen (fig. 205B and C), an 8-cm. tear was found in the stomach. Both the spleen and the pancreas were lacerated. The foreign body responsible for these wounds, which was 4 by 1 by 2 cm., had dropped back into the stomach. It was removed, after which the gastric laceration was repaired and the spleen was removed. Blood in the amount of 1,000 cc. was aspirated from the peritoneal cavity, which also contained a small amount of gastric contents. The rent in the gastrocolic omentum was repaired. The diaphragm was closed with a double layer of interrupted silk sutures. The chest wall was closed in layers with similar suture material. Closed intrapleural drainage was instituted.


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FIGURE 205 (case 6).-Schematic showing of thoracoabdominal wound. A. Wound of entrance: Shell fragment wound in anterior eighth intercostal space (a), metallic foreign body (b), and incision in eighth intercostal space (c). B. Diagram of course of missile: Wound of chest wall (a), laceration of diaphragm and stomach (b), foreign body (c), and laceration of spleen and pancreas (d).


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FIGURE 205.-Continued. C. Excellent exposure of left upper abdomen at operation, with diaphragm opened and rib spreaders in place: Anterior wound in stomach (a), posterior wound in stomach (b), foreign body (c) responsible for lacerations of pancreas (d), spleen (e), and left lower lobe of lung (f).

The immediate postoperative recovery was satisfactory, but on the following morning, the patient was dyspneic and cyanotic, and diffuse rales were heard over both lungs. Thoracentesis produced 500 cc. of bloody fluid. Because the hematocrit showed hemoconcentration, an intravenous infusion of glucose and physiologic salt solution was given, together with 250 cc. of plasma. Bilateral intercostal nerve block was carried out from the sixth through the twelfth nerves. The penicillin therapy begun before operation was continued. Thereafter, the patient coughed and raised sputum, and the lungs cleared.

On the eighth postoperative day, peristalsis was active, and fluids were permitted by mouth. On the 10th postoperative day, signs of consolidation were demonstrable in the right lower lobe, and some fluid was present. Bronchoscopy produced thick mucus from the right lower, middle, and upper lobes, and a small amount from the left side. The temperature ranged from 100° to 101° F.

Roentgenologic examination on the 13th day (fig. 206B) revealed fluid and infiltration in the lower two-fifths of the right lung field and fluid in the left costophrenic angle. Because of the pneumonitis and fluid on the right side, subphrenic abscess was considered a paramount diagnostic possibility. On the 19th postoperative day, thoracentesis produced 700 cc. of clear fluid from the right pleural cavity. Roentgenologic examination (fig. 206C) after this procedure still showed pleural fluid bilaterally, especially on the right.


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FIGURE 206 (case 6).-Serial roentgenograms in thoracoabdominal wound. A. Posteroanterior roentgenogram, 28 September 1944, immediately after wounding, showing large metallic foreign body below left diaphragm, at level of eleventh rib, with haziness of both lung fields. B. Posteroanterior roentgenogram, 11 October 1944, showing fluid in left costophrenic angle and fluid and infiltrative process in lower two-fifths of right lung field. C. Posteroanterior roentgenogram, 19 October 1944, showing fluid in both pleural cavities, more marked on right.

On the following day, the patient was evacuated to the 36th General Hospital at Dijon, France. Here the pleural effusion on the right gradually resolved. On the left side, the fluid became purulent and rib-resection drainage was required. A subphrenic infection did not develop.

Management in the Zone of Interior-At Fitzsimons General Hospital, Denver, Colo., to which the patient was evacuated, the empyema pocket on the left side gradually became obliterated without further surgery. The patient was considered for limited duty, but with the end of the war in Europe and the reduced necessity for manpower, he was given a disability discharge on 28 May 1945.


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FIGURE 206. Continued. D. Posteroanterior roentgenogram, 19 November 1960, 16 years after wounding, showing lung fields clear except for pleural shadow above diaphragm and deformity of rib in lower left costophrenic angle as result of rib resection for empyema. E. Lateral roentgenogram on same date, showing blunting of anterior cardiophrenic sulcus. Posterior sulci are sharp, and lungs are clear.

Followup.-Following his discharge, the patient returned to an active civilian life. At this time (November 1960), he is still working hard as a maintenance worker in a large city. The work at times involves manual labor, but he wrote that he had "no ill effects from his injury" and considered himself perfectly well.

Roentgenologic examination on 19 November 1960, 16 years after wounding (fig. 206D and E), showed clear lung fields except for blunting of the lower left costophrenic angle as a result of rib resection for empyema, with some blunting of the anterior cardiophrenic sulcus.

Comment-This casualty had serious injuries, including a sucking wound of the chest; a tear of the diaphragm; and lacerations of the stomach, spleen, and pancreas. Severe blood loss and early contamination of the pleura and peritoneal cavities with gastric contents made resuscitation difficult. The spleen was removed, and the stomach, pancreas, and diaphragm were repaired. The course after operation was stormy, as a result of bilateral pleural effusion and pneumonitis. The right side cleared under penicillin and sulfonamide therapy, combined with aspiration of the chest. Empyema developed on the left side, as a result of early soiling of the pleura with gastrict contents. Recovery followed drainage of the left empyema, with a complete return to health. At the end of 16 years, this man has no residual symptoms and is hard at work.

Case 7

Management overseas-This 23-year-old sergeant in a chemical warfare battalion sustained bilateral shell-fragment wounds of the posterior chest at 2130 hours on 10 December 1944, at Enchenberg, France. He was given four 


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FIGURE 207 (case 7) .-Schematic showing of thoracoabdominal wound. A. Wounds: Sucking wound over left eleventh rib posteriorly (a), fracture of eleventh rib (b), and nonsucking wound in right chest posteriorly (c).

units of plasma and two injections of morphine at a battalion aid station. The sucking wound in the left chest was packed.

When he was admitted to the 54th Field Hospital at 0200 hours on 11 December, he was comatose, apparently from shock and from the two injections of morphine. The blood pressure was 90/60 mm. Hg, the pulse 130, and the respirations 36. His respirations were wet and labored.

Examination revealed shell-fragment wounds of the right and left chest posteriorly. The wound on the left side was sucking (fig. 207A). Roentgenologic examination (fig. 208A) revealed massive opacity of the left chest, haziness of the right lung, and a large amount of gas in the stomach. After gastric decompression, another examination (fig. 208B) showed a foreign body in the upper part of the left upper lobe.

Resuscitation was begun immediately and continued for 14 hours. It included, in addition to gastric decompression, catheter suction of the tracheobronchial tree, intratracheal oxygen administration under positive pressure, and the slow transfusion of 1,000 cc. of blood.

At the end of this period, the lungs were clear and the blood pressure had stabilized at 112/72 mg. Hg. The patient was therefore taken to the operating room and, under endotracheal anesthesia, the pack was removed from the sucking wound of the left lower posterior chest. The wound was debrided down to the pleura, after which it was extended upward and laterally along the eleventh intercostal space. The eleventh rib was divided to improve exposure (fig. 207B). The kidney capsule was torn, and there was a rent 3 by


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FIGURE 207.-Continued. B. Diagram of course of shell fragment in abdomen and thorax: Sucking wound of entrance (a), laceration of upper pole of kidney (b), severe laceration of spleen (c), laceration of diaphragm (d), laceration and hematoma of left lower lobe (e), laceration of left upper lobe (f), shell fragment in lung (g), and massive hemothorax (h).


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FIGURE 207.-Continued. C. Posterior view of chest: Central portion of wound packed down to sutured muscle layers (a), closure of skin at both ends of incision (b), wound in right posterior chest wall after debridement and packing with fine-mesh gauze (c), Penrose drain to left kidney (d), and closed thoracostomy drainage tube (e).

1 cm. in the posterior lateral portion of the upper pole. A catheterized specimen had shown blood. Bleeding was controlled with catgut sutures, so that it was not necessary to remove the kidney. The spleen, which was badly torn and bleeding, was removed; the artery and vein were controlled with mattress sutures of No. 00 silk. The diaphragm, which was torn near the dome, was opened anteriorly, to provide adequate exposure of the inferior pleural cavity. The lower left pulmonary lobe, which was lacerated and the site of a hematoma, was oozing moderately; it was repaired with fine catgut sutures. About 800 cc. of blood was aspirated from the pleural cavity.

Since the upper pulmonary lobe expanded fairly well at this point, it was decided to remove the foreign body. It was left in situ, however, when exposure proved inadequate and there was no evidence of leakage of air or bleeding from the affected area. Closed catheter drainage was instituted in the eighth intercostal space.

The diaphragm was debrided and closed with interrupted sutures of No. 00 silk. Sulfanilamide (3 gm.) and penicillin (100,000 units) were left in the upper abdominal cavity. The kidney was drained with a Penrose sheath drain through a stab wound in the flank.

The latissimus dorsi was closed over the defect in the eleventh intercostal space in the central portion of the wound, which had been debrided, and this area was packed with gauze down to the muscle layer (fig. 207C). The anterior and posterior extensions of the wound were closed in layers.


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FIGURE 208 (case 7).-Serial roentgenograms in thoracoabdominal wound. A. Posteroanterior roentgenogram, 11 December 1944, immediately after wounding, showing massive opacity of left chest, haziness of right lung, and large amount of gas in stomach. B. Oblique roentgenogram after gastric decompression, with Levin tube still in stomach. A foreign body is now visible in left upper lung. Left chest is hazy. C. Posteroanterior roentgenogram on sixth postoperative day, showing expansion of left lung but somewhat hazy lung field. Retained shell fragment is clearly seen in left mid lung field.


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FIGURE 208.-Continued. D. Posteroanterior roentgenogram, 19 November 1960, almost 16 years after wounding, showing few adhesions along left diaphragm, healed fracture of eighth rib, and clear lung field. E. Lateral roentgenogram, on same date, showing clear lung fields and sharp costophrenic angles.

The right posterior wound did not extend through the muscle layers and did not involve the pleura, so it required only debridement. It was packed with fine-mesh gauze.

The patient received 1,000 cc. of blood during the operation, which he tolerated well. His temperature was elevated for the first 6 days, but otherwise his recovery was satisfactory. Roentgenologic examination (fig. 208C) on the sixth postoperative day showed the left lung to be well expanded.

The patient was evacuated to the 23d General Hospital at Vittel, France, on the seventh day after operation. Here an elective thoracotomy was performed, with removal of the foreign body in the left upper lobe.

Management in the Zone of Interior-After satisfactory recovery from this operation, the patient was evacuated to the Zone of Interior. After hospitalization at Kennedy General Hospital, Memphis, Tenn., where he was found to require no further active treatment, he was sent to a reconditioning center on 28 July 1945. He was discharged shortly after V-J Day. 

Followup.-A communication from the patient on 26 November 1960 stated that he was working as a carpenter's helper, was married, and had two children. He suffered from occasional attacks of nausea and vomiting, which responded to simple medication. He had no breathing difficulties except on strenuous exertion, when he became somewhat dyspneic.

Roentgenologic examination (fig. 208D and E) on 19 November 1960 showed the left lung to be well expanded. Two pleural streaks were seen at the left base in the posteroanterior view, but the costophrenic angles were sharp in the lateral film. The lung fields were normal except for prominence of the bronchovascular markings.


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Comment-This patient was admitted to a field hospital in serious condition, with a severe thoracoabdominal wound. He was in shock, which was complicated by both the wet lung syndrome and morphine poisoning, and resuscitation required 14 hours. At operation, it was found possible to save the damaged kidney. Since the foreign body in the left upper lobe could not be reached through the low thoracoabdominal incision being used, it was left in situ at the original operation and removed later at the base. The hematoma of the left lower lobe resolved spontaneously. Only reconditioning was needed in a Zone of Interior hospital.

At the present time, the patient is living an essentially normal life, with only occasional minor gastrointestinal symptoms and some dyspnea on strenuous exertion. His condition immediately after wounding was so precarious that the additional surgery necessary to remove the foreign body at the original operation might well have been fatal. Vigorous resuscitation, staging of surgery, and limitation of initial wound surgery were important factors in the successful result and in the patient's excellent state of health 16 years after wounding.

Case 8

Management overseas-This 21-year-old infantryman sustained shell-fragment wounds of the left chest (fig. 209A), shoulder, upper arm, and the scalp at 1400 hours on 22 September 1944. He was given sulfonamide tablets and two units of plasma at the battalion aid station.

When he was admitted to the 11th Field Hospital at Plombières, France, shortly afterward, he was not in shock. The blood pressure was 130/80 mm. Hg, the pulse 80, and the respirations 36. He complained of severe pain in the chest and the abdomen.

Breath sounds were depressed on the left, apparently chiefly from pain; there was improvement when intercostal nerve block was done. Tenderness and rebound tenderness in the left upper quadrant, however, persisted, and peritoneal contamination had evidently occurred.

Roentgenologic examination of the chest (fig. 210A and B) showed the lungs to be comparatively clear. There was a small amount of fluid at the left base, and a small fragment in the left upper quadrant of the abdomen was seen on both posteroanterior and lateral films.

Resuscitation consisted, in addition to intercostal nerve block, of the slow administration of 500 cc. of blood and evacuation of the stomach through a Levin tube. No food had been taken that day, and there was little gastric content.

When the patient was taken to the operating tent at 1815 hours, the blood pressure was 90/50 mm. Hg and the pulse 114. Chest involvement was found to be minimal. The small 2-cm. wound of the eighth intercostal space (fig. 209A)


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FIGURE 209 (case 8).-Schematic showing of thoracoabdominal wound. A. Small penetrating wound in left eighth intercostal space in midaxillary line. B. Pathologic findings: Laceration of lung (a), omentum plugging laceration of diaphragm (b), intact stomach (c), laceration of splenic flexure of colon (d), and foreign body (e).


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FIGURE 209.-Continued. C. Anterolateral chest wall at conclusion of operation: Closed thoracotomy incision (a), closed pleural drainage tube (b), and exteriorized loop of colon over glass rod (c).

could have been handled through either the chest or the abdomen, but the location of the foreign body indicated an approach through the thorax. After debridement of the chest wall, the incision was extended along the eighth intercostal space and the pleural cavity was opened. A moderate amount of bloody fluid was aspirated. The lower lobe of the left lung was lacerated (fig. 209B). A plug of omentum had herniated through a perforation in the diaphragm and sealed off the pleural cavity.

Excellent exposure of the upper abdomen (fig. 209B) was secured through an anterolateral incision in the diaphragm. The spleen and the stomach were intact. A 1-cm. laceration in the antimesenteric border of the transverse colon was repaired with fine silk sutures. Localized peritonitis was present in this area only. The foreign body seen on the roentgenograms (fig. 210A and B) was about 1 cm. in diameter and was adjacent to the colon. It was removed. The colon was exteriorized through a counterincision in the left upper quadrant and brought out over a glass rod. Exploration revealed no other injured organs. 

The diaphragm was closed with interrupted silk sutures. Closed drainage was instituted in the ninth intercostal space posteriorly. The chest wall was closed tightly in layers (fig. 209C), primary closure being considered safe because of the small size of the wound.

The wounds of the shoulder, upper arm, and scalp were debrided.

The postoperative course was benign. The highest temperature was 100.8° F. The exteriorized loop of colon healed well, and gas was passed after the glass rod had been removed. The lungs remained clear throughout (fig. 210C).


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FIGURE 210 (case 8).-Serial roentgenograms in thoracoabdominal wound. A. Posteroanterior roentgenogram of chest, 22 September 1944, shortly after wounding, showing relatively clear lung fields, small amount of fluid in left pleural cavity, and small metallic foreign body in left upper quadrant of abdomen. Levin tube in esophagus is shown by arrow. B. Lateral roentgenogram on same date, showing small metallic foreign body in left upper quadrant of abdomen and haziness of lungs. Note that an artifact present in posteroanterior view is not seen in lateral view. C. Posteroanterior roentgenogram showing expansion of left lung on sixth postoperative day.


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FIGURE 210.-Continued. D. Posteroanterior roentgenogram of chest, 14 February 1961, 16 years and 5 months after wounding, showing clear lung fields. Left diaphragm is flat and costophrenic sinus is blunted laterally. E. Lateral roentgenogram on same date, showing prominent bronchovascular markings, tenting of diaphragm anteriorly, and sharp posterior diaphragmatic sulcus.

The patient was evacuated to the 46th General Hospital on the 10th postoperative day. Here the loop colostomy was opened when some distention developed. It was closed shortly afterward.

Management in the Zone of Interior-When the patient was evacuated to Battey General Hospital, Rome, Ga., on 29 December 1944, he required only rehabilitation. After a period of service on limited duty, he was discharged in August 1945.

Followup-A communication from this patient on 14 February 1961 stated that he had worked as a truck driver since the war. He was married and had children. He had no digestive symptoms and no dyspnea and considered himself well except for occasional pain in the left chest. Roentgenograms at this time (fig. 210D and E) showed no abnormalities of consequence. 

Comment.-This patient had a satisfactory recovery after severe thoracoabdominal wounds and multiple other injuries. Several reasons may be given: He was admitted to a field hospital 75 minutes after wounding. The gastrointestinal tract was almost empty, since he had taken no food that day. Minimal contamination occurred because of the prompt handling of the lacerations of the lung, diaphragm, and colon. The pleura was spared serious contamination because the omentum partly blocked off the wound of the colon and also plugged the diaphragmatic wound. Had the war continued, this man could have gone back to full duty. He is well at this time, more than 16 years after wounding, and is leading an active civilian life.


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FIGURE 211 (case 9).-Schematic showing of thoracoabdominal wound. A. Lateral aspect of chest and abdomen showing 8-cm. sucking wound of sixth intercostal space (a) and foreign body in abdominal wall (b). B. Pathologic findings: Laceration of left lower lobe of lung (a), laceration of diaphragm (b), laceration of spleen (c), laceration of stomach (d), laceration of colon (e), and small foreign body in abdomen (f). C. Anterolateral aspect of left chest and abdomen at conclusion of operation: Central portion of chest wound packed with fine-mesh gauze (a), closed intrapleural drainage tube (b), exteriorized colon (c), and counterincision for removal of foreign body in abdominal wall (d).


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Case 9

Management overseas.-This 21-year-old infantryman sustained a high explosive shell-fragment wound of the left chest at 1625 hours on 30 October 1944 in the mountains of northern France. At the battalion aid station, the sucking wound was packed (fig. 211A), and he was given morphine gr. ¼. 

When he was admitted to the 11th Field Hospital at Eloyes at 1825 hours, he was in shock, with a blood pressure of 80/50 mm. Hg. He complained of severe chest and abdominal pain and was spitting up blood. Breath sounds were absent on the left. The right chest was clear. Tenderness, spasm, and rebound tenderness were present in the left upper quadrant of the abdomen. Roentgenograms are shown in figure 212. The right chest was fairly clear, and the cardiac shadow was not enlarged. A small foreign body was discerned in the region of the left upper quadrant of the abdomen. On further examination (fig. 212A and B), it was seen that two foreign bodies were present, one deep in the left upper quadrant and the other apparently in the abdominal wall. Roentgenogram (fig. 212C) showed haziness over the left chest.

Two units of plasma were given as soon as the patient was admitted, and transfusions of 1,500 cc. of blood were given over the next 3 hours. By the end of this time, the blood pressure was stabilized. Since there was no improvement in the abdominal symptoms and signs, the patient was taken to the operating room at 2125 hours.

The sucking wound in the sixth intercostal space was debrided, and the incision was extended in this interspace down to the costal margin. The left lower lobe of the lung was lacerated (fig. 211B) and was the site of a small hematoma. The diaphragm, which was torn, was opened at the dome anterolaterally. This provided excellent exposure of the upper abdomen. The spleen, which was badly torn, was bleeding and was removed. Two perforations in the stomach were repaired easily, as was a through-and-through wound of the splenic flexure of the left colon. A small foreign body was found in this region, and a larger object, palpated in the anterior abdominal wall, was removed through a counterincision. The splenic flexure of the colon was mobilized, the perforations in it closed, and the involved area brought out through a stab wound in the left upper quadrant of the abdomen, over a glass rod.

The diaphragm was repaired with interrupted No. 00 silk sutures. Closed pleural drainage was instituted in the eighth intercostal space; the catheter was connected to a closed system. After the pleural cavity had been thoroughly lavaged with physiologic salt solution, the chest wall was closed in layers. The central portion of the wound was left open (fig. 211C) and was packed with fine-mesh gauze down to the muscle layer.

For the first week after operation, the temperature rose daily to 101° F. Peristalsis was observed on the second day. The colostomy was opened, and fluids by mouth were permitted. The lung expanded well and there was only a moderate pleural reaction when the patient was evacuated to the 23d General


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FIGURE 212 (case 9).-Serial roentgenograms in thoracoabdominal wound. A. Anteroposterior roentgenogram of abdomen showing two intra-abdominal foreign bodies. B. Lateral roentgenogram of chest and abdomen on same date, showing two metallic foreign bodies in left upper quadrant. C. Posteroanterior roentgenogram of chest, 30 October 1944, immediately after wounding, showing haziness of left hemothorax, diffuse pleural fluid, and small metallic foreign body in left upper quadrant. Right lung is fairly clear.


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FIGURE 212.-Continued. D. Posteroanterior roentgenogram, 29 December 1960, 16 years after wounding, showing flat left diaphragm and relatively clear lung fields. E. Lateral roentgenogram on same date, showing sharp costophrenic angles.

Hospital, Vittel, France, on the 10th day. He had, however, complained of some pain and distention in the left upper quadrant. Later, swelling, tenderness in the left costal margin, and fever indicated the development of a subphrenic abscess, which was drained successfully on 30 November 1944.

Management in the Zone of Interior-The patient was evacuated to Barnes General Hospital, Vancouver, Wash., on 29 December 1944. The colostomy, which functioned well, was closed in April 1945. He received a disability discharge on 11 August 1945.

Followup-On 28 December 1960, the patient reported that he had worked as a printer since his discharge from the army. He was married and had six children. He had no digestive or other complaints and considered himself well. Roentgenograms made on 29 December 1960 (fig. 212D and E) revealed clear lung fields, with prominent bronchovascular markings.

Comment.-This was a patient with an extremely severe thoracoabdominal wound, which was treated promptly, though before his admission to the field hospital, spillage of contents into the upper abdomen from wounds of the stomach and colon had produced severe shock. Prompt surgery was lifesaving in this case. Colostomy prevented further contamination of the upper abdomen. The subphrenic abscess which developed was promptly drained at the base section hospital, and healing was satisfactory. The colostomy was closed without difficulty in a Zone of Interior hospital. Although the chest trauma in this case was moderately severe, the would could perhaps have been handled from below. Exposure, however, would have been more difficult, and it was


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thought better to handle the sucking wound of the chest and the wound of the diaphragm in a single operation. The excellent health of the patient 16 years after operation points up the value of the staged treatment that he received.

HEMATOMA

The diagnosis of intrapulmonary hemorrhage or hematoma was made in forward hospitals in 89 cases in this series. When the chest was not opened and only a debridement of the chest wall was done, the diagnosis was made on clinical grounds. When pneumonitis and atelectasis could be ruled out, the presence of hemoptysis and a pulmonary parenchymal shadow, with slow resolution of the shadow, was regarded as confirmation of the diagnosis.

Hematoma of the lung is a pathologic process in which there is extravasation of blood into the alveoli and interalveolar tissue of the pulmonary parenchyma. Observations at base section hospitals in the communications zone showed that these lesions resolved slowly within 4 to 6 weeks, according to their severity. No mention is made of their persistence in any of the roentgenologic reports in this series at Zone of Interior hospitals from 2 to 5 months or longer after wounding.

In other words, all 89 hematomas resolved spontaneously and without morbidity. No resection of any type was performed for them, nor did lung abscess or other secondary infection develop in any instance, even when a massive hematoma of an entire lobe might liquefy to produce a cystlike shadow on the roentgenogram.

The evidence from these 89 cases thus clearly indicates that there is no reason to perform lobectomy or segmental resection of a lung that at initial wound surgery is tense and boggy and contains large amounts of extravasated blood. As alarming as such a lung may appear to a surgeon who is viewing his first pulmonary hematoma, there should be no surgical interference. The lung has tremendous recuperative power because of its dual blood supply from the bronchial and pulmonary arteries, and recovery can be expected without complications when this natural power is supplemented by vigorous measures to keep the bronchial tree clear of blood and mucus and the pleural cavity dry.

The concept of noninterference in pulmonary hematoma formation is one of the important advances in thoracic surgery developed in World War II.

Case 10

Management overseas-This 31-year-old infantryman was wounded by a fragment of a 20-mm. missile from a German airplane at 1500 hours on 24 April 1945, at Amerbach, Germany. After a delay of 25 minutes, the ensuing sucking wound was packed with petrolatum-impregnated gauze at a battalion aid station, and sulfonamide crystals were placed in the wound.


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FIGURE 213 (case 10).-Schematic showing of thoracic wound with massive hematoma of the right lung. A. Course of missile: Anterolateral wound of entrance in eighth right intercostal space, with resulting sucking wound (a), passage of missile through lung to lodge close to mediastinum posteriorly (b), and high explosive shell fragment (c). Location of the wound introduced the possibility of diaphragmatic laceration.

When he was admitted to the 66th Field Hospital at Gunzenhausen, Germany, at 1855 hours, he was cyanotic and dyspneic, and his respirations were wet and labored and were 40 to the minute. The blood pressure was 150/72 mm. Hg and the pulse 120.

Examination revealed a large anterolateral sucking wound of the eighth intercostal space (fig. 213A), packed with an airtight dressing. There were signs of fluid and air in the right chest (fig. 214A and B), and numerous wet rales over both lung fields, but no cardiac shift.

Resuscitation occupied 16 hours. It consisted of the administration of oxygen; the immediate slow administration of 500 cc. of blood and the deferred, very slow, administration of 1,000 cc. of blood; evacuation of the pleural cavity by loosening the gauze packing and tipping the patient so that the wound drained about 500 cc. of blood; intercostal nerve block (T4 -T8); and bronchial


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FIGURE 213-Continued. B. Findings at thoracotomy: Laceration of right lower lobe of lung (a), with massive hematoma of entire lobe (b), wet lung of adjacent lobes (c), clots (500 cc.) and blood (300 cc.) in right pleural cavity (d), and foreign body resting in right lower lobe and pleural cavity (e).


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aspiration per catheter. The patient coughed voluntarily after the nerve block and the catheter aspiration, and the lung gradually cleared of rales.

The wound in the right thoracic wall was thoroughly debrided under endotracheal anesthesia. Fragments of the fractured eighth rib were resected and the incision was extended in the intercostal space to make a formal thoracotomy (fig. 213B). The diaphragm was found intact. The right lower lobe of the right lung was lacerated and was the site of a massive hematoma which resembled the liver in appearance. A foreign body free in the posterior pleural cavity (fig. 214B) was removed, and 500 cc. of blood clot and 300 cc. of fluid blood were evacuated.

Although the lung was lacerated, it was not blowing air, and no attempt was made to place sutures in the boggy, engorged right lower lobe.

At this point, it is typical of conditions under which much war surgery was done in the Mediterranean theater that a small bug flew into the pleural space. It was not seen again, but the cavity was thoroughly lavaged with 1,500 cc. of physiologic salt solution.

The muscles were closed in layers with interrupted sutures of fine silk. The posterior wound of entry was left open and was packed with fine-mesh gauze down to the muscle layer. Closed intrapleural drainage was instituted in the eighth intercostal space posteriorly. Penicillin (500,000 units) was injected into the tube, which was clamped off for 3 hours.

Bronchoscopy immediately after operation produced a large amount of blood and mucus from the right main bronchus and the right lower lobe bronchus.

The patient ran a febrile course (101°-102° F.) for the first 5 days, after which his temperature gradually dropped to 99° F. Intercostal nerve block was repeated twice, with relief of pain and effective cough. Roentgenograms on the third postoperative day (fig. 214C) showed a small cyst with a fluid level, the result of liquefaction of the hematoma in the right lower lobe of the lung. 

The patient was evacuated to a base hospital on the eighth postoperative day and thence to the Zone of Interior.

Management in the Zone of Interior-When the patient was received at Walter Reed General Hospital 2 months after wounding, his only complaint was pain in the right chest, with intercostal neuritis. Roentgenograms were essentially negative. He was returned to duty in the Zone of Interior but eventually was discharged for disability.

Followup-The patient now works as a manager of a store, with no apparent disability.

Roentgenograms 15 years and 10 months after wounding (fig. 214D and E) showed clear lung fields and no evidence of the massive hematoma or the cyst with fluid level seen shortly after wounding.

Comment-The problems in this case were (1) a sucking wound, (2) a massive hematoma of the right lower lobe of the lung, (3) a foreign body in the pleura, and (4) the wet lung syndrome. Significant factors in the history are


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FIGURE 214 (case 10).-Serial roentgenograms of hematoma of right lower lobe of lung. A. Posteroanterior roentgenogram, 24 April 1945, immediately after wounding, showing fracture of eighth rib at diaphragm and foreign body in right lower lung close to hilus. Note haziness of right lung field and shift of heart to left. B. Lateral roentgenogram on same date, showing foreign body lying posteriorly in pleural cavity. C. Posteroanterior roentgenogram on 27 April 1945 (third postoperative day) showing cyst with fluid level, result of liquefaction of hematoma of right lower lobe.


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FIGURE 214.-Continued. D. Posteroanterior roentgenogram of chest, 2 February 1961, 15 years and 10 months after wounding, showing complete absorption of massive hematoma of right lower pulmonary lobe. There is no evidence of cyst with fluid level seen in April 1945. The diaphragmatic shadows are flattened laterally. E. Lateral roentgenogram on same date, showing flattened diaphragms anteriorly and fairly deep sulci posteriorly. Lung fields are clear.

the 16-hour preoperative preparation, the delay being caused by the wet lung syndrome; the necessity for traumatic thoracotomy because of the sucking wound, with removal of the readily accessible intrapleural foreign body; and the conservative management of the massive hematoma of the right lower lobe. Although the hematoma eventually liquefied and formed a pseudocyst, there are no apparent residua and the lung fields are essentially clear more than 15 years after injury.

In this case, the performance of lobectomy at initial wound surgery to correct the hematoma might have been more than this dangerously wounded casualty could have endured. His course since wounding indicates that the surgery was not necessary.

WET LUNG

Since the concepts and management of traumatic wet lung were developed in the Mediterranean theater (p. 208), it is important to assess the results of the incidence and management of this complication of thoracic injuries. It was extremely troublesome in forward hospitals, in which initial surgery was performed. It was a major problem in 65 of the 167 cases in this series.

In general, it was the policy to treat these casualties intensively in forward hospitals (p. 217) and not attempt to evacuate them, regardless of the nature of their wounds, until their lungs were comparatively dry. As a matter of fact., they withstood transportation very poorly. It was therefore the policy to


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retain them at the primary installation to which they were admitted unless, as sometimes happened, the tactical situation required the evacuation of the whole hospital. At the Battle of the Bulge, at Christmas 1944, the Seventh U.S. Army was serving as the southern anchor of the front, and as a precautionary measure, all noncombat personnel were evacuated from the frontlines. The clearing station which had been supported by a platoon of the 66th Field Hospital was moved 6 miles to the rear, but the platoon itself could not move for another week because it was holding nontransportable casualties who had undergone thoracotomy or thoracolaparotomy and who could not be moved because of serious wet lung complications.

When wet lung was properly managed in forward hospitals, few complications arising from it were encountered in base hospitals. When the reverse was true, complications were numerous. In this series, only two patients showed a late pneumonitis which might have been connected with the original wet lung syndrome. This low incidence is in sharp contrast to the earlier experience: In three of the four deaths in this series, already described (p. 450), the wet lung syndrome had been a major problem in the resuscitative regimen, and in the patient with a spinal cord injury, the problem was never completely solved. This patient, who had multiple wounds, was, however, the only one in the group in whom the wet lung factor was an important cause of death.

By the time casualties reached the Zone of Interior, there was never any clinical problem traced to the original wet lung syndrome if it had been properly handled in the forward hospital. Chronic pneumonitis, bronchitis, and bronchiectasis were seldom recorded-never in this series-nor was the massive atelectasis so frequent in World War I casualties seen in the thoracic casualties of World War II. This, no doubt, reflects the careful attention paid in forward installations to the correction of the wet lung.

The following case report illustrates various aspects of this condition.

Case 11

Management overseas-A 32-year-old infantry major was wounded in the left chest by a shell fragment on 22 January 1944, while he was crossing the Rapido River during the assault on Cassino. He took the sulfonamide tablets in his own first aid kit, and the corpsman applied a pressure dressing and gave him a unit of plasma. Thirty minutes later, he was given morphine gr. ½ in a battalion aid station, for severe chest pain.

When the casualty arrived at the 11th Field Hospital in Mignano Monte Lungo, Italy, at 1615 hours, the wound (fig. 215A) was bleeding externally and he had been coughing up blood. He was extremely dyspneic and was disoriented and in shock, with a blood pressure of 55/35 mm. Hg. The pulse, which was difficult to count, was 130, and the respirations 40. Immediate resuscitative measures consisted of the administration of nasal oxygen; the administration of three units of plasma and 500 cc. of blood; repacking of the


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FIGURE 215 (case 11).-Schematic showing of large sucking wound of chest. A. Wound after debridement of chest wall: Wound of entrance in left chest (a), large shell fragment in right pleura and axilla (b), laceration of right upper lobe of lung (c), and open apical segmental bronchus (d). B. Technique of bronchial closure. Blowing segmental bronchus sutured with fine silk and reinforced with pedicle muscle graft.


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FIGURE 215.-Continued. C. Appearance of wound at end of operation: Gauze pack in chest wall and lung (a), Penrose sheath drain in right axilla (b), closed pleural drainage (c), and closure of muscles to superficial fascia (d).

wound, which was oozing and sucking, with petrolatum-impregnated gauze, repeated bronchial suction, with aspiration of blood and mucus, as bubbly rales continued present over both lungs; and the very slow administration of another 500 cc. of blood.

Roentgenograms (fig. 216A) showed a large foreign body (4 by 2 cm.) in the right pleura and axilla and haziness of both lung fields, more marked on the right. There was no mediastinal shift.

Traumatic thoracotomy was performed 10 hours after resuscitation had been begun. The wound was debrided across the sternum, after which the shattered second and third costal cartilages were resected, with portions of the second and third ribs on the right (fig. 215B). The wound was thoroughly debrided, and the foreign body in the pleura and right axilla was removed. The lung was partly adherent near the apex and badly torn below. Lobectomy would have been necessary to close it completely. The fistula in the apical segmental bronchus was closed with silk, and the closure was reinforced with a graft of pectoralis minor.

The wound in the lung, pleura, and chest wall was packed tightly with fine-mesh gauze (fig. 215C) over an area 4 by 6 centimeters. The remainder of the wound and the muscles were pulled together with interrupted sutures but left open from the fascial layer outward.


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FIGURE 216 (case 11).-Serial roentgenograms of sucking wound of chest with wet lung syndrome. A. Posteroanterior roentgenogram, 22 January 1944, immediately after wounding, showing large foreign body in right axilla and pleura, with diffuse haziness of both lungs, more marked on right. B. Posteroanterior roentgenogram first postoperative day, showing severe bilateral pulmonary edema. Note gauze pack in right mid lung field. C. Posteroanterior roentgenogram, 7 February 1944, showing clearing of lungs. Dotted line outlines site and extent of gauze pack; 1-cm. right lateral pleural shadow indicates loculated pleural fluid. D. Posteroanterior roentgenogram, 3 May 1960, 16 years after wounding, showing essentially clear lung fields. Note anterior stumps of second and third right ribs.


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A Penrose drain was left in the left axilla, and closed pleural drainage was instituted. Bronchoscopy immediately after operation produced a large amount of bloody mucus, chiefly from the right upper lobe.

The postoperative course was extremely stormy because of pulmonary edema. Roentgenograms made the day after operation (fig. 216B) showed massive edema of both lungs, with the pack in the right anterior chest wall and the lung. Treatment consisted of nasal oxygen, supplemented by brief periods of positive pressure oxygen, administered with each voluntary inspiration by means of an anesthetic machine and manual pressure on the bag (fig. 50, p. 162); intercostal nerve block; and repeated bronchial suction. Because of some blowing from the wound, which did not end until a week after operation, it was necessary to repack portions of the chest wall. Thoracentesis was done twice after closed drainage was terminated; about 1,000 cc. of bloody fluid was aspirated each time.

When the patient was evacuated on the 14th postoperative day, the cavity in the lung had decreased to about the size of an egg and was granulating well, and the right had expanded (fig. 216C).

At the 36th Evacuation Hospital, which was then operating as a forward thoracic surgery center, Maj. Thomas H. Burford, MC, performed a fat graft of the pulmonary cavity with delayed primary closure of the large anterior wound.

Followup-This patient required no active treatment in the Zone of Interior, where he was eventually given a disability discharge. Since that time, he has been working as a rural mail carrier and has been followed by a private physician. Roentgenograms made on 3 May 1960 (fig. 216D) showed the resected ends of the second and third ribs on the right. Vascular markings in the lung fields were prominent, but the fields were essentially clear.

Comment-This patient had a very large sucking wound, complicated by a wet lung syndrome of such severity that he was delirious from hypoxia for the first 4 days after wounding. The lacerated upper lobe of the right lung was not sacrificed; a muscle graft closed the major bronchial fistula, and packing of the lung and the chest wall was a successful complementary procedure. Right upper lobe lobectomy would never have been feasible in this patient until he reached the base hospital, and there, a skillfully performed fat graft and delayed primary wound closure made further surgery unnecessary. The wet lung syndrome and massive bilateral pulmonary edema made his early care extremely difficult.

HEMOTHORAX

Hemothorax is the most common complication of thoracic wounds, which might be expected, since in every penetrating wound of the chest in which the pleural space is involved there is some degree of extravasation of blood into the cavity. A small amount of blood is of little clinical significance if infection


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does not occur; it is well tolerated by the pleura, and absorption is the rule. If larger amounts are present, preoperative aspiration is necessary to expand the lung and increase the vital capacity, as well as to supply an accurate index of the amount of hemorrhage which has occurred into the pleural space. After operation, the cavity must be kept empty by the use of intercostal closed drainage and repeated thoracenteses.

In World War II, when these principles were employed, the goal was to evacuate the casualty to the base section with the pleural cavity completely dry. This was not always possible. In spite of diligent aspiration of blood from the chest, a lung which has been traumatized and collapsed temporarily loses its elastic recoil and its ability to expand. During the period in which it is regaining its elasticity, a pleural effusion develops and there is a deposit of fibrin that forms a pleural membrane. This membrane is often quite inelastic, and in some cases, the process includes massive clotting, which can be handled only by decortication.

In this series of 167 chest wounds, bleeding into the pleural cavity was sufficiently persistent and of sufficient magnitude, in 91 instances, to create a considerable clinical problem. In 77 of these patients, repeated thoracenteses before operation, repeated after operation and supplemented by closed intercostal drainage, were successful in expanding the lung. Only 14 of the casualties were evacuated to the rear with persistent or clotted hemothorax and pulmonary collapse. These figures would seem to support the policy of repeated, prompt aspiration of the pleural cavity in hemothoraces.

At the base, decortication was carried out in nine cases, seven times for organizing hemothorax and twice for hemothoracic empyema. The other seven casualties who developed empyema were treated by drainage. This means that decortication was necessary in only 10 percent of the patients in this series with severe hemothorax and in only about 5.3 percent of the total series. No patient who underwent decortication on any indication was returned to duty overseas.

In the Zone of Interior, 2 of the 91 patients with persistent hemothorax developed late empyemas which had to be drained. No additional decortications were necessary. There were no deaths in this group of patients and no major disabilities due either to chronic empyema or to major collapse of a so-called captive lung. No patient had a chronic draining sinus of the chest wall.

These results are in sharp contrast to the results in World War I, after which the thoracic wards in Veterans' Administration hospitals were full of patients with collapsed lungs, chronic empyemas, and persistent sinuses of the chest wall following hemothorax and hemothoracic empyema. The excellent results in the World War II patients, of which the results in this series are typical, were attributable not only to adherence to the principles established for forward surgery but also to the proper timing and staging of surgery in base hospitals before the casualties were transferred to the Zone of Interior.


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Case 12

Management overseas-This 23-year-old infantry sergeant received a shell-fragment wound of the posterior left chest at 1400 hours on 21 September 1944, at Remiremont, France. He also received a wound of the scalp. Immediate treatment consisted of a pressure dressing, on which sulfanilamide powder had been sprinkled, and the subcutaneous administration of morphine gr. ½.  A unit of plasma was given later at a clearing station.

When the patient was admitted to the 11th Field Hospital at Plombières at 1710 hours, he was comatose and in shock, with wet respirations and pinpoint pupils. The blood pressure was 90/40 mm. Hg, the pulse very rapid and difficult to count, and the respirations 14. Although the record did not indicate it, further inquiry produced the information that another half grain of morphine had been administered at the battalion aid station.

The patient was obviously in morphine poisoning. Shortly after he was admitted to the hospital, the blood pressure began to drop further, and he was given a unit of plasma and 500 cc. of blood. An intratracheal catheter was introduced, and repeated aspirations were carried out; oxygen was administered through the catheter between the aspirations. When the respirations fell to 12, three ampules of Coramine (nikethamide) were administered intravenously. When the sucking wound of the left chest (fig. 217A) was inspected, a small amount of blood drained from it.

At 1900 hours, the patient coughed out the catheter, after which he coughed up bloody mucus voluntarily. Oxygen was administered by nasal catheter. When thoracentesis of the left chest was done posteriorly, only 5 cc. of blood and 20 cc. of air were aspirated; there was no evidence of tension pneumothorax. Penicillin was given intramuscularly.

In spite of the active therapy carried out, the lungs remained wet. Over the next 18 hours, however, there was gradual improvement, in spite of evidence, by the results of thoracentesis, of continued hemorrhage into the left chest. Over this period, treatment consisted of two additional blood transfusions, intercostal nerve block, and the administration of oxygen by positive pressure.

At 1400 hours on 22 September 1943, the patient was considered sufficiently prepared to withstand surgery, which was performed under endotracheal anesthesia, in the right posterolateral position. The wound of the scalp was debrided, together with the extensive wound of the left chest and the back. The large wound over the left scapula (fig. 217B) was found to connect with the right shoulder. On the left side, there were extensive lacerations of the trapezius, latissimus dorsi, subscapularis, and rhomboid muscles. A large part of the central portion of the left scapula was destroyed. The involved area was debrided, which left a portion of the tip in situ, together with the intact upper portion.


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FIGURE 217 (case 12).-Schematic drawings of chest wound with massive chest wall and intrapleural trauma. A. Posterior aspect of chest showing: Wound of entrance in right shoulder (a), large sucking wound with destruction of inferior portion of scapula and fifth rib (b), portion of wound bridged by skin (c), and second wound in left shoulder, with two small foreign bodies (d).

The pleural cavity was opened by resection of the comminuted fifth rib. Intrapleural bleeding was occurring from the fifth intercostal artery (fig. 217B), which was secured at once; 500 cc. of blood was aspirated from the pleural cavity. A huge hematoma occupied the left upper pulmonary lobe. The bone fragments in the lung were removed, and a small laceration was closed, but no pulmonary tissue was resected.

Closed catheter drainage was instituted posterolaterally in the left eighth intercostal space. The wound and the pleural cavity were lavaged with physiologic salt solution. The pleura was closed by suturing the subscapularis and posterior serratus, and then closing the trapezius and latissimus dorsi over this suture line, as a reinforcing layer (fig. 217C). The trapezius on the right was debrided and closed. The whole wound was left open down to the muscle layers.

Bronchoscopy was performed at the conclusion of the operation. A small amount of bloody mucus was aspirated from the trachea, and larger amounts from both main bronchi.


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FIGURE 217.-Continued. B. Findings at thoracotomy: Massive hemopneumothorax, with hemorrhage from fifth intercostal vessels (a), rib fragments in left lung (b), laceration of left lower lobe of lung (c), hematoma formation (d), wet lung diagramed on right side (e), and superficial wound of left shoulder (f.).

The patient was given 550 cc. of blood during the operation. Immediately after it was concluded, his pulse was irregular, but thereafter the major postoperative problem was keeping the tracheobronchial tree clear.

Roentgenograms before operation (fig. 218A) had showed massive left hemothorax and haziness of the right lung. There was some improvement in expansion of the left lung after thoracentesis (fig. 218B). On the ninth postoperative day, the left lung had almost completely expanded, and both lungs were dry.

After operation, there was considerable drainage (about 500 cc. daily) for the first 2 days; the loss of blood was covered by transfusions.

Delayed primary closure of all wounds was carried out at the 46th General Hospital in the base.

Management in the Zone of Interior-When the patient was evacuated to the United States on 18 October 1944, the lung had completely expanded, and the hematoma had completely resolved. He was given a disability discharge on 8 May 1945, at Madigan General Hospital, Tacoma, Wash., limitation of motion of the scapula being the main problem.


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FIGURE 217.-Continued. C. Diagram depicting types of muscle closure: Right trapezius closure demonstrating simple interrupted sutures (a), left trapezius closure demonstrating mattress type sutures (b), left latissimus dorsi (erector spinae group not closed) (c), infraspinatus, skin and superficial fascia left open, wound packed down to muscle layer (d), closure of superficial left shoulder wound (e), and closed intrapleural drainage tube (f).

Followup-A personal communication from this patient on 6 December 1960 stated that he had been employed as a truck driver for the past 14 years. He complained of soreness and stiffness around the left scapula, of lack of much grip in the left hand for heavy lifting, and of inability to do work involving raising the hand to the level of the shoulder. Although the chief complaint was referable to the shoulder, the patient stated that when he jumped from a truck platform, a distance of 2 or 3 feet, he sometimes spat up blood the following day. He had trouble sleeping on the left side, because of pain in the left shoulder, but he had no difficulty in breathing, and the occasional hemoptysis, the cause of which is not known, was so slight that he had never bothered to seek medical attention for it.

Comment-This patient had an extensive sucking wound of the chest wall, with continued hemorrhage into the left pleural cavity. The original trauma was complicated by the wet lung syndrome, with bilateral pulmonary edema, and was further complicated by morphine poisoning. Resuscitation


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FIGURE 218 (case 12).-Serial roentgenograms in thoracic wound complicated by massive hemothorax. A. Posteroanterior roentgenogram, 21 September 1943, immediately after wounding, showing massive left hemothorax, with slight shift of mediastinum, and haziness of right lung, due to wet lung syndrome. A defect in left scapula is faintly seen. B. Posteroanterior roentgenogram, showing some improvement in expansion of left lung after aspiration of blood in left pleural cavity. Appearance of right lung is not materially altered. Two small foreign bodies are now visible in left shoulder. C. Posteroanterior roentgenogram, 23 November 1960, 17 years after wounding, showing clear lung fields, except for prominent bronchovascular markings. Note bridging of fourth, fifth, and sixth ribs. Heart and mediastinum are normal, and diaphragmatic angle is clear. D. Lateral roentgenogram, 23 November 1960, showing sharp costophrenic angles. These findings are approximately normal and do not explain occasional hemoptyses reported by this patient.


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covered 21 hours, but the time occupied in stabilizing him was well spent, for he tolerated corrective surgery well. It is gratifying that for the past 14 years he has been able to work as a truck driver, and that his residual disability is only minor. This is the only patient in the 163 survivors followed up who gave a history of occasional blood-streaked sputum. Roentgenograms (fig. 218 C and D) offer no explanation.

RETAINED FOREIGN BODIES

Retained foreign bodies were observed in 102 of these 167 cases. In 35 instances, they were in the chest wall, in 21 in the pleura, in 36 in the lung, and in 10 in the mediastinum.

These objects always presented a difficult problem in forward hospitals, for the decision as to their removal was frequently delicate. Those in the chest wall were most often removed during debridement at the field hospital. They were usually accessible without a prolonged search, and if they were not in the original wound of entry, they could be removed by a simple counter-incision.

Foreign bodies in the lung and the pleura were not removed as part of traumatic thoracotomy at field hospitals unless they were readily accessible or were believed to lie so close to vital thoracic organs as to constitute a potential danger to them.

Only 13 operations were done for the removal of foreign bodies in base section hospitals, in only 1 instance because of pulmonary hemorrhage. One patient, after an uneventful immediate postoperative course, died 2 months later of hepatitis and jaundice. He had multiple wounds of the head and trunk, and the sucking wound of the chest was complicated by the wet lung syndrome. In this case, a foreign body in the pericardium was removed when the sucking wound was closed. The pulmonary object was not accessible, and its removal would have meant an additional incision and undue prolongation of the operation. It is possible, though highly unlikely, that the retained object was a factor in the fatal outcome.

Only two foreign bodies were removed in this series in Zone of Interior hospitals. One was removed because of a delayed air leak, and the other was removed during closure of a colostomy. Of the 41 patients with retained metallic foreign bodies who were evacuated to the Zone of Interior, only the patient just mentioned, with the delayed air leak, developed symptoms that required its removal.

Case 13

Management overseas-This 29-year-old artilleryman was wounded in the left shoulder by a high explosive shell fragment at 1146 hours on 29 November 1943 near Ardo, Italy. The wound was dressed with sulfonamide powder at a battalion aid station, where the patient was also given morphine (gr. ½) and sulfadiazine (15 gr.) by mouth.


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FIGURE 219 (case 13).-Schematic showing of chest wound with retained foreign body. A. Wound: Penetrating shell-fragment wound of left shoulder, with fracture of left humerus (a), passage of missile through chest wall and lung with lodgment in left mid thorax (b), and incision for elective thoracotomy (c). B. Findings at thoracotomy: Large hematoma of left upper lobe (a), hematoma and laceration, left lower chest wall extending down to diaphragm (b), and foreign body in lung adjacent to heart (c).


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FIGURE 219.-Continued. C. Diagram of left lung at conclusion of operation following removal of shell fragment. Repair of laceration of left lower lobe with two layers of interrupted sutures of fine silk (a), hematoma of upper portion of left upper lobe, which was not disturbed (b), and water-seal intrapleural drainage tube (c).

When he was admitted to the 94th Evacuation Hospital at LePezze at 1410 hours, examination revealed a 2-cm. penetrating wound of the left deltoid region (fig. 219A) but no other thoracic injuries. He complained of considerable chest pain and was dyspneic, orthopneic, and coughing up blood. The blood pressure was 128/60 mm. Hg, the pulse 128, and the respirations 38. Breath sounds were absent over the left chest, and the heart was shifted slightly to the right. The right lung was clear. Roentgenograms (fig. 220A) showed a left hydropneumothorax, with a foreign body in the left cardiac shadow, fractures of the sixth, seventh, and eighth ribs, and haziness of the right lung. There was also a fracture of the left humerus.


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FIGURE 220 (case 13).-Serial roentgenograms in wound with intrapulmonary foreign body. A. Posterolateral roentgenogram, 29 November 1943, immediately after wounding, showing foreign body in left cardiac shadow; extensive collapse of left lung; fractures of sixth, seventh, and eighth ribs on left; fracture of left humerus; and haziness of right lung. B. Posterolateral roentgenogram, 7 December 1943, showing expanding left lung and resection of segments of sixth, seventh, and eighth ribs. Right lung and cardiac shadows are normal. C. Posteroanterior roentgenogram, 2 December 1960, 17 years after wounding, showing healed fractures of sixth, seventh, and eighth ribs on left; tenting of left diaphragm and blunting of left costophrenic angle. Note prominent bronchovascular markings. D. Lateral roentgenogram on same date, showing left pleural shadow anteriorly and deep posterior costophrenic angle. Note clear lung field.


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After thoracentesis, which yielded 800 cc. of air and 800 cc. of blood, a transfusion of 500 cc. was given. A second thoracentesis, performed because of signs indicating a reaccumulation of fluid and air in the left pleural space, yielded 500 cc. of blood.

Thoracotomy was carried out through an elective incision 7 hours after admission, through a left posterolateral incision over the seventh rib, because of the continued reaccumulation of air and blood in the left hemithorax and also because the foreign body was in the region of the cardiac shadow. Fragments of the sixth, seventh, and eighth ribs were resected, and the pleural cavity was opened through the bed of the eighth rib. The sixth intercostal muscles were bleeding and were ligated, and fragments of ribs were removed from the lung. A huge hematoma (fig. 219B) occupied the upper portion of the left lower lobe. The laceration in the lung extended down to the diaphragm, where the foreign body was felt in the pulmonary substance next to the pericardium, which was not involved. The foreign body was removed (fig. 219C) and the lung was repaired with two layers of mattress sutures of fine silk. The hematoma was not disturbed. The chest wall was closed in layers from the pleura to the skin, and closed intrapleural catheter drainage was instituted.

The wound in the deltoid was debrided, and a small sequestrum of the left humerus was excised. The wound was packed open with fine-mesh gauze.

At the conclusion of the operation, bronchoscopy was performed and a large amount of bloody mucus was obtained from both bronchial trees.

The postoperative course was uneventful. Roentgenograms 8 days after wounding (fig. 220B) showed satisfactory expansion of the left lung. The patient was evacuated to the base on the 13th postoperative day. The shoulder wound healed by second intention.

Management in the Zone of Interior-The only active therapy which the patient required in the Zone of Interior was physiotherapy to the left arm. He received a disability discharge.

Followup-The patient has worked as a salesman since his discharge from the Army and has no complaints referable to the chest wound. 

Roentgenograms (fig. 220C and D) made in December 1960, 17 years after wounding, showed no abnormality except for some obliteration of the costophrenic angle and the thickening of the axillary pleura.

Comment-In this case, a wound of the shoulder was associated with extensive damage to the chest wall and the left lung. Thoracotomy through an elective incision was performed on the indication of continued bleeding, leakage of air into the left pleural cavity, and the possibility of cardiac damage from a retained foreign body. At operation, the intercostal vessels were found to be the source of the intrapleural hemorrhage. The intrapulmonary foreign body was removed at operation, but the large hematoma was not disturbed, and satisfactory healing of the lung followed.


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FIGURE 221 (case 14).-Schematic showing of chest wound with retained foreign bodies (rib fragments) in lung. A. Wound: Wound of entrance in left lateral chest wall (a), fracture of left scapula (b), fracture of spine of fourth dorsal vertebra (c), and wound of exit (d).

Case 14

Management overseas.-A 20-year-old infantryman received a bullet wound of the left chest at 0800 hours on 12 January 1943. A sulfonamide-powdered dressing was applied to the wound at a battalion aid station at 0830 hours, and he was given a half grain of morphine and a unit of plasma. Two additional units of plasma were given at a collecting station because of persisting shock.

When he was admitted to the 94th Evacuation Hospital at 1130 hours, he was orthopneic and somewhat comatose and was coughing up blood. He complained of severe pain in the left chest, neck, and abdomen. The blood pressure was 102/70 mm. Hg, the pulse 142, and the respirations 42. There was considerable external bleeding. There was a 3-cm. sucking wound in the left


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FIGURE 221.-Continued. B. Findings at thoracotomy: Laceration of lung (a) and fragments of fractured rib in hematoma occupying apex of left lower lobe (b) .

lateral chest wall (fig. 221A) and a 4- by 5-cm. wound at the base of the neck posteriorly on the right. The sucking wound was immediately packed. 

Further examination revealed much crepitus over the posterior chest wall, absent breath sounds on the left, and dullness and signs of fluid in the lower half of the left chest (fig. 222A). The right lung was fairly clear except for occasional rales.

Oxygen was administered and bronchial catheter suction begun. Aspiration of the left chest produced 500 cc. of air and 800 cc. of blood. A slow transfusion of 1,000 cc. of blood was given.

At 2020 hours, about 9 hours after the patient's admission, his blood pressure was stable, the pulse had dropped to 110 and the respirations to 28. He was considered fit for surgery.

The wound of entrance was debrided along the left lateral chest wall, and the incision was extended upward across the chest to the base of the neck on


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FIGURE 221.-Continued. C. Appearance of wound at conclusion of operation: Wound of entrance (a) and wound of exit (b). Wound has been left open down to deep muscle layer and packed with fine-mesh gauze (c). Closed pleural drainage tube is in situ (d).

the right. The muscles were debrided. The spinous process of the fourth dorsal vertebra, which was fractured, was excised, as was the extensively fractured lower third of the left scapula. Fragments of the fractured fifth rib were also excised. The pleura was then opened through the bed and interspace of the fifth rib, and three bony fragments were removed from the apex of the left lower lobe, which was occupied by a large hematoma (fig. 221B). The lung was slightly debrided, and all air leaks were closed with interrupted sutures of fine catgut. The pleural cavity was lavaged with 1,500 cc. of physiologic saline, after which a catheter was placed in the eighth intercostal space and connected with a closed system. The deep muscle layers were approximated with interrupted sutures of fine cotton. The remainder of the wound was left open and was packed with fine-mesh gauze (fig. 221C).


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FIGURE 222 (case 14).-Serial roentgenograms of thoracic wound with retained foreign bodies (rib fragments) in lung. A. Posteroanterior roentgenogram of chest, 1 January 1943, immediately after wounding, showing diffuse haziness and fluid in left chest; shift of heart to right; and fractures of fifth and sixth ribs and left scapula. B. Posteroanterior roentgenogram of chest, 12 January 1943, after resection of portion of fifth rib and scapula on left. Note hematoma still evident in lower lobe of expanded left lung. C. Posteroanterior roentgenogram, 18 November 1960, more than 17 years after wounding, showing partial absence of fifth and sixth ribs; slight blunting of left costophrenic angle; and increased bronchovascular markings in lung, which otherwise is clear. D. Lateral roentgenogram on same date, showing sharp costophrenic angles and prominent bronchovascular markings.


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At the conclusion of the operation, considerable blood and mucus were aspirated from both major bronchi through the bronchoscope.

The postoperative course was satisfactory. When the intercostal tube was removed on the fourth day, after it had ceased to function, the temperature was 100° F., the pulse 90, and the respirations 22. When the patient was evacuated to the base section on the 12th day, roentgenograms (fig. 222B) showed good expansion of the left lung.

Management in the Zone of Interior-The patient was evacuated to the Zone of Interior after delayed primary wound closure in a base section hospital. He required no active treatment there, and was given a disability discharge.

Followup-This patient reported in November 1960 that he was working as a diesel railroad engineer and was in good health. He was married and had two children. Roentgenograms made at this time (fig. 222 C and D), 17 years after wounding, showed essentially negative lung findings.

Comment-In addition to a sucking wound and extensive damage to the muscles of the posterior chest wall, this patient had extensive fractures of the ribs, scapula, and a spinous process, which resulted in numerous bony foreign bodies. Although this is an area in which anaerobic cellulitis is always a possibility, healing of the lung and the chest wall occurred without pneumonitis, abscess formation, or other infection. Early, careful debridement, with removal of the bony fragments, undoubtedly was the most important factor in the good recovery and subsequent absence of serious disability. The role of sulfanilamide, which was applied locally and given by mouth, is much less certain.

POSTDISCHARGE FOLLOWUP

It has been possible to follow the course in civilian life of 119 of the 163 survivors in this series of combat casualties with chest wounds since their discharge from the Zone of Interior hospitals in which they were kept until their wounds had healed and their lungs had expanded. When they were released, their chest roentgenograms usually showed good healing of the bony cage and clear lung fields except for pleural adhesions and thickening. The followup periods ranged from 3 to 17 years and averaged 5.6 years.

Roentgenologic Observations

Subsequent roentgenograms usually revealed substantially the same findings as the predischarge films, although there had often been further clearing of the pleural shadows. The most frequent abnormal findings in the current roentgenograms consisted of pleural adhesions or tenting of the diaphragm, which occurred in 57 cases. These roentgenologic findings are exactly what one would expect to find in civilian patients after thoracotomy for pulmonary, mediastinal, or cardiac surgery.


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Other roentgenologic observations included thickening of the pleura in 20 cases, slightly increased or prominent bronchovascular markings in 8 cases, and pulmonary emphysema in 5 cases. The generally inconsequential abnormalities in the roentgenograms described in the 14 case histories just recorded, all of which were taken 16 or 17 years after wounding, are typical of almost all the cases in this series.

Retained Foreign Bodies

Of the 119 patients followed up in civilian life, 41 harbored retained foreign bodies, 35 times in the lung, 4 times in the chest wall, and once each in the liver and in the region of the right diaphragm. All these objects were less than 1 cm. in diameter, and in no instance was a pleural or pulmonary reaction noted about them on roentgenograms.

All of these patients had been observed in all echelons of U.S. Army hospitals, from the combat zone to the Zone of Interior, and in every case it had been predicted that the retained missiles would cause no further difficulties. The prophecy proved correct in all but 1 of the 41 patients. The exception was a 32-year-old infantryman, who had sustained multiple wounds of the arms, legs, and chest at Anzio on 29 May 1944. He was treated at the 11th Field Hospital, where the wounds of the extremities were debrided. The two penetrating wounds of the left chest were also debrided, and a foreign body was removed from the chest wall. On 14 July 1944, a drainage operation was performed for hemothoracic empyema at the 23d General Hospital at Naples, and on 9 February 1945, a chest abscess was drained at Walter Reed General Hospital.

The patient remained well until 3 October 1951, when hemoptysis and a recurrent infection of the lung and the pleura required wedge resection of the left lower pulmonary lobe, which was the site of the retained foreign body. Both operations in the Zone of Interior were performed by Dr. Brian Blades. 

This was the only case in this series in which a retained intrathoracic foreign body gave rise to delayed difficulties. The patient represents about 0.6 percent of the 163 casualties who survived to be evacuated from hospitals in the communications zone. From the purely clinical standpoint, therefore, there seems to be no reason for early removal of small (less than 1-cm.) asymptomatic missiles. All such objects, of course, should be removed whenever this can be conveniently done in the course of surgery on other indications.

Symptoms Referable to the Chest

Most of the patients followed up in civilian life had no symptoms referable to the chest. The few who had symptoms complained chiefly of pain and dyspnea. The evaluation of any posttraumatic pain is notoriously difficult, particularly when industrial compensation is part of the picture. Since dis-


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ability and pensions were involved in all of these chest injuries, the problem was much the same as in civilian compensation cases.

Hemoptysis was recorded only twice. In one case, just described, the bleeding could be attributed to a retained foreign body. In the other, there was occasional slight streaking of blood when a driver jumped off his truck (case 12, p. 508). The origin of the bleeding in this case is not apparent; the roentgenogram, taken 16 years after wounding, shows no significant findings. 

Severe chronic cough, chronic bronchopulmonary infection, bronchiectasis, and chronic lung abscess, the heritage of so many thoracic casualties of World War I, did not appear in any of these 119 patients.

Psychoneuroses

There is thus a gratifying paucity of physical complaints in these 119 patients followed up in civilian life. In another area, however, unhappy dividends of battle wounds are apparent. In 18 cases, reports in Veterans' Administration files indicated some form of psychoneurosis. These were probably the most serious posttraumatic sequelae observed. In two instances, the patients had sustained blast injuries and had had severe cerebral symptoms immediately afterward, but all of these symptoms had cleared up before their discharge from Zone of Interior hospitals.

It seems highly likely that the psychoneuroses in these 18 cases are far more closely related to the total experience of war and of wounding than to the chest wound in itself. They are also both a factor in, and an index of, the casualty's postwar adjustment to civilian life.

Development of Thoracic Disease

Whether the postdischarge development of thoracic disease is related to thoracic trauma is a matter still to be settled. This is the present situation in these 117 men:

1. A number were hospitalized at various times for pneumonia and other acute respiratory infections, but the number was probably no greater proportionately than would be expected in the general population.

2. Two patients developed pulmonary tuberculosis, one after reenlistment during the Korean War. Both cleared well.

3. One patient, in 1952, developed a bronchogenic carcinoma on the same side as the penetrating wound of the chest. He died a year after pneumonectomy.

The incidence of posttraumatic thoracic disease was thus very small in these 119 patients. Whether the figures can be taken at their face value is another matter. The number of patients followed up is small, and the series is not representative in one sense, that it includes only a few patients who were not cared for in the Veterans' Administration hospitals and clinics. Further-


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more, carcinoma of the lung will undoubtedly be seen in other patients, even in this small group, as they pass into the age range in which this and other forms of malignancy are more common.

SUMMARY AND CONCLUSIONS

The patients in the series reported in this chapter, like all patients with chest wounds encountered after March 1944, were treated by policies of management developed, for the first time in medicomilitary history, in the Mediterranean theater. In general, these policies were conservative, and it is fair to say that no patient in the series who was treated without thoracotomy at initial wound surgery because he was not considered to need that operation suffered in any way because his chest was not widely opened.

In summary, these policies and practices were as follows:

1. Careful stabilization of the cardiorespiratory physiology was the first principle of management and was vital to the success of every procedure from simple debridement of the chest wall to extensive intrathoracic surgery. That is, no matter what the wound, the first attention was directed to its effect on the lung and the heart. The single possible exception to this generalization was thoracoabdominal wounds associated with shock caused by peritoneal contamination.

2. Debridement of the wound was the first procedure in thoracic wounds. In those limited to the chest wall, nothing else was required.

3. The indications for primary thoracotomy in forward echelons were strictly limited. They included traumatic thoracotomy (sucking wound), thoracoabdominal wounds, continued intrathoracic hemorrhage, leakage of air from the respiratory tract, and injury to vital mediastinal structures (esophagus, trachea, heart, great vessels, and thoracic duct). In retrospect, there seems to be no valid reason to widen these indications. Their standardization, in fact, represented a major contribution to thoracic surgery in World War II.

4. Immediate recognition and intensive treatment of the wet lung syndrome not only reduced the initial surgical mortality but prevented the late sequelae of pulmonary atelectasis and bronchopulmonary suppuration. These were frequent sequelae of chest wounds in World War I. There were no complications of this sort in this series.

5. In severe wet lung, in which pain in the chest wall was an important factor, treatment consisted of intercostal nerve block, tracheobronchial aspiration, and the administration of oxygen under intermittent positive pressure. All of these techniques have been carried over to civilian thoracic surgery since the war. In fact, intermittent positive pressure oxygen therapy, which was used in the Mediterranean theater for the first time in medical history, in the management of severely wounded thoracic casualties before and after opera-


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tion, is now almost standard in the management of many pulmonary and cardiac conditions for which thoracic surgery is done.

6. Prompt aspiration of hemothoraces increased the vital capacity of the lung and permitted the evaluation of the degree of intrapleural hemorrhage. In some instances, this measure undoubtedly prevented the deposition of fibrin and the development of the so-called captive lung. In no instance was there any evidence that bleeding into the chest was increased by this technique, as many surgeons, before the war, had predicted.

7. Hematomas, even if they involved an entire pulmonary lobe, responded well to conservative treatment and furnished no indications for resection of the involved tissue. These hematomas resolved with almost no pathologic pulmonary residua.

8. Pulmonary lacerations usually responded to intercostal decompression by the closed technique. If they did not, thoracotomy, with simple suture, was the indicated treatment. Neither lobectomy nor resection was required. In fact, these followup studies, as well as other studies, show that such operations had no place in the initial surgery of war casualties. Even localized (segmental or less) resections were almost never indicated; only one was performed in this series. The explanation is the tremendous recuperative powers of the lung together with its dual blood supply and elaborate lymph drainage.

9. Sucking wounds of the chest required immediate occlusion of the chest wall defect. After resuscitation of the patient from the cardiorespiratory point of view, traumatic thoracotomy could be performed with a low mortality and generally excellent results.

10. Patients with blast injuries who survived their stay in forward hospital could be returned to civilian life with few cardiorespiratory symptoms and only moderate residua caused by damage to the cerebrum or tympanum.

11. Retained foreign bodies, if they were not producing hemorrhage, persistent air leaks, or esophageal trauma, were best handled at the base section, where the patient was in better condition to tolerate the necessary procedures. Asymptomatic foreign bodies in the lung, pleura, and mediastinum which were less than 1 cm. in diameter were usually well tolerated, if the evidence of this series is to be believed.

12. Patients with thoracoabdominal wounds handled by the principles employed for thoracic and abdominal surgery in the Mediterranean theater were returned to civilian life with few or no cardiorespiratory or gastrointestinal symptoms.

13. Patients with mediastinal injuries seldom survived to reach forward hospitals. When they did, gratifying long-term results were achieved if they were managed by the principles and practices just described.

The postwar followup of the patients in this series furnishes every cause for encouragement as to the general results of these principles and practices. The series is small, it is true, but it is entirely unselective except in the sense that the patients were included in it because the original information concern-


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ing their wounds was available and their subsequent records were complete enough to be useful.

Only 4 of the 167 severely wounded casualties in this series who survived initial wound surgery in forward hospitals died in base hospitals, and no deaths attributable to thoracic wounds occurred in casualties followed up in Zone of Interior hospitals or in those traced in civilian life.

From the records, and from personal correspondence with a number of men in the group, it was evident that practically all of them were gainfully employed, usually full time; that they were married and had families; that they were leading useful civilian lives; and that, with few exceptions, they considered themselves well from the standpoint of their chest wounds.

The assumption also seems warranted, as already intimated, that the majority of patients in the original panel of casualties (822) do not appear in this followup because they regarded themselves well. Those who reported to the Veterans' Administration are a group with more persistent ill effects from their wounds-frequently not their thoracic wounds-or a group of psychoneurotic patients whose attention was focused on their old chest injuries.

One emerges, therefore, from an analysis of these records with the impression that if the patients in the series may be assumed to be representative, the great majority of casualties who survived chest wounds were really rehabilitated and restored to normal, useful lives. If this impression is correct (and there are no data to the contrary), it furnishes strong evidence of the validity of the principles and practices of thoracic surgery developed in the Mediterranean theater in World War II and recorded in detail in these volumes.

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