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Chapter IV

Contents

Part II

COMPLICATIONS OF WOUNDS OF THE CHEST


CHAPTER IV

Complications and Sequelae

Thomas H. Burford, M.D.

Except for two or three immediate complications, such as tension pneumothorax, hemorrhage, and acute gastric dilatation, almost any of the complications of wounds of the chest might occur at any time after wounding. It was therefore necessary to be on the watch for them, and to try to forestall their occurrence, at all times.

While the attempt to separate them chronologically is somewhat academic, the complications of chest wounds may be divided, generally speaking, into (1) early and (2) late or delayed complications as follows:

Early complications included tension pneumothorax, hemorrhage, acute gastric dilatation, emphysema, pulmonary edema, atelectasis, hematoma of the lung, bronchopleural fistula, (which sometimes was persistent), wound disruption, clostridial myositis, and chylothorax.

Delayed complications included abscess of the lung, pneumonitis and pneumonia, chronic parietal sinuses, defects of the chest wall, adhesive pleuritis (infolded lung), traumatic osteomyelitis, and abscess of the mediastinum.

The important sequelae of chest injuries in World War II were diaphragmatic hernia, hernia of the lung, and a group of residual symptoms, of which pain and dyspnea were the most prominent.

TENSION PNEUMOTHORAX

General Considerations

Pathogenesis-Tension or pressure pneumothorax might be of four origins (figs. 42 and 43):

1. It might result from a pulmonary laceration in which a tangential opening in the lung acted as a check valve, so that, during inspirations, gradually increasing amounts of air were trapped in the pleural cavity. The flap of lung prevented the escape of air into the bronchial tree on expiration. Most tension pneumothoraces were of this origin.

2. It might result from small perforating associated wounds of the subglottic larynx or the cervical trachea. In the latter type of wound, air dissected along the fascial planes to the mediastinum and might break into one or both subcavities. Tension pneumothorax of this origin was infrequent.


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FIGURE 42.-Pathologic physiology of tension pneumothorax. A. Pneumothorax of moderate extent. As air escapes into the pleural cavity, the affected lung collapses, and there is moderate mediastinal shift to the unaffected  side. B. Tension pneumothorax. The uninvolved lung, as well as the involved lung, is now collapsed, as the result of mediastinal shift to the uninvolved side. Shock increases as the result of collapse of the superior and inferior venae cavae, and because of the decreased venous return to the heart associated with the marked mediastinal shift.


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FIGURE 43.-Tension pneumothorax of various origins. A. Tension pneumothorax resulting from laceration of cervical trachea and mediastinal pleura, showing: Laceration of cervical trachea (a), laceration of mediastinal pleura (b), tension pneumothrax (c), collapsed lung (d), shift of heart (e), subcutaneous emphysema (f), and partial collapse of contralateral lung (g). B. Tension pneumothorax resulting from sucking wound of valvular type, showing: Valvular sucking wound of chest wall (a), tension pneumothorax (b), collapsed lung (c), cardiac shift to intact side (d), and partial collapse of contralateral lung (e).


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FIGURE 43.-Continued. C. Tension pneumothorax resulting from pulmonary laceration following packing of sucking wound, showing: Sucking wound of airtight packing (a), laceration of lung, permitting egress of air into pleural cavity (b), collapse of the lung (c), cardiac shift to intact side (d), and partial collapse of contralateral lung (e).

3. It might result from the ingress of air through the thoracic wall in a sucking wound.

4. It might follow the emergency closure of a sucking wound in forward areas, without provision for release of trapped air or the continued escape of air into the pleural cavity.

An occasional tension pneumothorax occurred during operation for thoracoabdominal wounds (p. 103).

Incidence-Tension pneumothorax as the result of trauma was encountered only infrequently in forward hospitals, though it was somewhat more common as a postoperative or posttherapeutic complication. Its infrequency is evident in the statistics of the 2d Auxiliary Surgical Group. It was encountered by this Group only 11 times in its 2,267 thoracic and thoracoabdominal injuries. It is doubtful, furthermore, that all of these 11 cases were examples of true tension pneumothoraces, since the valvelike mechanism that produces it and that permits easy ingress, but difficult egress, of air was not always found. In occasional cases in which air was found under more than normal pressure, or even above atmospheric pressure, the explanation was usually either compression of air by intrapleural bleeding or, most often, the irregular, splinting type of respiration that was the result of pain in the chest wall.


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The infrequency of pressure pneumothorax probably has several explanations:

1. The preponderance of shell-fragment wounds, which resulted in a preponderance of large defects of the chest wall. For physical reasons, air could not be entrapped in the chest in such wounds.

2. The routine application of occlusive dressings tightly enough to end the sucking or blowing effect of the open chest wound but not so tightly that a tension pneumothorax was built up.

3. The almost routine use of a flapper-valve decompressive catheter in collecting stations or battalion aid stations.

4. The excellent screening of inductees in World War II, as a result of which preexistent restricting pleural adhesions, which were rather frequent in World War I soldiers, were extremely uncommon.

The majority of tension pneumothoraces observed in World War II resulted from continued leakage of air from the lacerated pulmonary parenchyma. If such a laceration existed and was leaking air, closure of the external chest wound converted the open pneumothorax into a progressive tension pneumothorax. This type of tension pneumothorax was also uncommon, possibly because bleeding from the pulmonary laceration usually stopped promptly and the hematoma that surrounded the torn parenchyma produced a sufficient area of nonaeration to limit the amount of air that reached the pleural cavity until the laceration was sealed over by natural processes.

Continued leakage of air occasionally had unusual explanations. A retained missile might offer a physical obstacle to natural closure of the air leak in the lung (fig. 44), or there might be a leak through a laceration in one of the larger bronchi. Two unusual cases of tension pneumothorax were observed by surgeons of the 2d Auxiliary Surgical Group:

In one case, the tension pneumothorax developed from a perforating wound of the subglottic larynx: the air dissected the fascial planes of the mediastinum and perforated into the pleura. Tracheotomy was necessary to short circuit the column of air.

In the other case, an instance of crushing injury, the patient sustained wounds of the lower esophagus, mediastinum, diaphragm, and stomach, and the air in the pleural cavity was swallowed air.

An occasional tension pneumothorax was of extreme degree (fig. 45). That it could be survived was striking proof of the tremendous respiratory reserve of the young, well-conditioned fighting men who made up the battle casualties.

Clinical picture-Extreme dyspnea was the most prominent symptom of tension pneumothorax. The patient preferred to sit upright or semierect. His worried, anxious expression indicated that he was fighting for breath.


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FIGURE 44.-Pressure (tension) pneumothorax. A. Posteroanterior roentgenogram showing pressure pneumothorax of moderate degree with retained foreign body. B. Same 24 hours later, showing prompt reexpansion of injured lung. Leakage of air continued, however, and thoracotomy 5 days after wounding showed that the presence of the missile offered a physical obstacle to natural closure. It was lying in the periphery, only partly embedded in the pulmonary parenchyma. The catheter functioned well, though it had been introduced farther than was necessary. Operation was performed without difficulty on the totally equilibrated patient, and recovery was prompt.


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FIGURE 45.-Lateral roentgenogram showing extreme degree of pressure pneumothorax with mediastinal shift. This patient recovered without complications after reduction of the tension pneumothorax.

Cyanosis, which might not be present originally, became increasingly prominent as mediastinal shift caused interference with cardiac action. The veins of the neck also became prominent. Physical examination revealed hyperresonance of the involved hemithorax, with absence of breath sounds (the so-called silent resonant chest) and a shift of the heart and mediastinum to the opposite side.

Management

The emergency management of tension pneumothorax has been discussed under resuscitation (vol. I).

If emergency measures were not required (that is, if the compression of the lung did not exceed 25 or 30 percent and if dyspnea were not a feature), the practice was merely to observe the patient carefully for 10 to 14 days. In most instances, pulmonary reexpansion had occurred by this time, and no treatment was necessary.

In cases of any consequence, pneumothorax was best handled by the prompt insertion of a water-seal intercostal catheter of sufficient size (30-36 F.) to produce immediate decompression of the chest. As a rule, this procedure was followed by prompt reexpansion of the lung (fig. 46), without which neither resuscitation nor recovery could insure.


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FIGURE 46.-Management of tension pneumothorax. A. Closed catheter drainage, with catheter high in pleural cavity.  This is the decompression procedure of choice. B. Constant decompression of chest with negative suction, which is required when leakage of air is persistent. The addition of a second bottle is important in this technique: A glass tube, open to the air, passes through the third opening in the cork, and the amount of suction varies with the distance this tube is under water.


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HEMORRHAGE

Incidence

There is surprisingly little discussion in the military literature of hemorrhage caused by wounds of the chest. The explanation is probably threefold:

1. Casualties with bleeding from one of the vessels in the pulmonary hilus or from the other great vessels of the thorax or from the heart usually died on the battlefield or in the battalion aid station. They seldom survived to reach a field hospital.

2. Bleeding from other vessels of the chest was not usually a problem.

3. Another explanation of the infrequency of severe bleeding in chest wounds was that the first effect of parenchymal bleeding into the pleural cavity was compression of the lung. In many instances, hemothorax had the mechanical effect of ending the hemorrhage by compressing the blood vessels.

There were, of course, exceptions to the generalization that all casualties with bleeding from the major thoracic vessels died promptly. In the Mediterranean theater, survivals were recorded after lacerations of the azygos and hemiazygos, and even after a laceration of the superior vena cava, but they were most unusual.

Two casualties with vascular injuries of magnitude were observed by Maj. (later Lt. Col.) Paul C. Samson, MC, in a field hospital. In the first case, a laceration of the right innominate vein was controlled by packing, but death followed a massive recurrence of the hemorrhage 24 hours later. The second patient presented massive bleeding at the left apex, presumably from the subclavian vein. His condition was critical, but rapid reflection of the clavicle permitted the blind placement of mass ligatures and control of the hemorrhage before he became exsanguinated. Recovery ensued but was complicated by a serious pleural infection.

Severe bleeding in chest wounds observed at field hospitals most often arose from one of the systemic vessels, such as the intercostal, the pericardiophrenic, or the internal mammary vessels. The most serious hemorrhages occurred from the internal mammary and the intercostal vessels, from both of which it was likely to be brisk. On the other hand, while complete division of these or any other thoracic vessels might cause severe intrapleural hemorrhage, it was unusual to find active bleeding at operation, even if from 1,000 to 2,000 cc. of blood had previously been aspirated from the chest. The explanation was physiologic: The reduction in blood pressure caused by the blood loss and the subsequent reduction in blood volume had allowed the vessels to retract and become sealed off. The most frequent source of bleeding at operation was an intercostal artery that had been incompletely divided and therefore was unable to retract.

The actual infrequency of serious bleeding in thoracic wounds is evident in the analysis of 200 penetrating and perforating wounds of the chest, including


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55 thoracoabdominal wounds, observed in forward hospitals by Maj. (later Lt. Col.) Lawrence M. Shefts, MC, and Capt. (later Maj.) Ernest A. Doud, MC. Active bleeding from the intercostal arteries was found at operation 10 times and from the internal mammary arteries, from the mediastinal vessels, and from the heart in 2 cases each. This is a combined frequency of 8 percent.

It had previously been the practice of these observers to expose the intercostal vessels routinely at operation, for fear of hemorrhage. They abandoned the practice after finding in these 200 cases, 33 lacerations or transections of these arteries in all of which bleeding had ceased by the time operation was done. In this series, all of the bleeding vessels were found in one of two areas, (1) the area extending from the origin of the vessel to the angle of the ribs or (2) the area extending approximately 6 cm. from the lateral border of the sternum.

In 4 of the 200 cases observed by Major Shefts and Captain Doud, bleeding of considerable magnitude occurred from lacerations in the upper half of the upper pulmonary lobes. It was readily controlled by suture. Hemorrhage of similar degree was not observed from lacerations of the same extent in other pulmonary lobes, probably because the injuries in the other lobes involved vessels of smaller size than the comparable lacerations in the upper lobes.

Diagnosis and Indications for Thoracotomy

Continued hemorrhage into the tracheobranchial tree was readily recognized by the reappearance of fresh blood after repeated attempts to clear the airway. Otherwise, external evidences of bleeding were few; in chest wounds, the most serious bleeding was usually internal.

It was not safe to make the diagnosis of intrathoracic bleeding solely on the basis of the pulse rate, blood pressure, respiration, and general status. Some patients with actively bleeding intercostal vessels remained in surprisingly good condition.

The most reliable guides to the existence of continued serious hemorrhage were:

1. Failure of the blood pressure to rise after apparently adequate transfusion.

2. A fall in a blood pressure that had risen to relatively normal levels.

3. Reaccumulation of 1,200 to 2,000 cc. of blood in the pleural cavity within 24 hours after the initial aspiration of similarly large amounts.

4. Persisting severe anemia, in spite of blood replacement, as determined by serial hematocrit determinations.

5. Plotting of the probable course of the missile with reference to the vascular supply.

It proved difficult to generalize on how much bleeding constituted life-endangering thoracic hemorrhage. The fact that from 1,000 to 1,500 cc. of blood could be aspirated from the pleural cavity within 12 to 18 hours after


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injury was not, in itself, an absolute index of lethal bleeding. Nearly all the patients who had lost blood in these and even larger amounts responded promptly to massive blood replacement, and subsequent aspirations produced progressively smaller amounts of bloody fluid.

Decision for or against exploratory thoracotomy on the basis of the criteria just listed proved entirely satisfactory during periods of relative quiet, when casualties were admitted in small numbers and surgeons had time for deliberate consideration and watchful delay. During rush periods, when they were confronted with large numbers of casualties, their judgment was often sorely tried. Their decisions became more accurate in proportion to the number of casualties they encountered.

The general policy was followed of exploring any injury in which there was a reasonable doubt concerning the possibility of active intrathoracic hemorrhage. In the really urgent cases, in which procrastination would have been disastrous, there was seldom any doubt of the need for surgery.

Management

The techniques employed at operation for intrapleural hemorrhage were those ordinarily employed in vascular surgery. In hemorrhage from the internal mammary artery, it was imperative that both ends of the damaged vessel be ligated, since hemorrhage could occur from either end. If emergency access to the great vessels proved necessary, it could be obtained at once by reflecting the clavicle and cutting through the manubrium sterni obliquely with a Gigli's saw. This technique, devised by Col. Johan Holtz, chief consultant in surgery to the Norwegian Forces in the United Kingdom, was preferable to section of the clavicle or to sternoclavicular disarticulation.

The prewar expectation that lobectomy would frequently be necessary in parenchymal lacerations, especially those extending into the hilus and involving large vessels, was not fulfilled, nor was the expectation that total pneumonectomy might be necessary in some cases (p. 18).

The possibility of the postoperative recurrence of a preoperative intercostal hemorrhage had always to be kept in mind when the intercostal vessels had not been exposed at operation. The experience of Major Shefts and Captain Doud (p. 153) showed that the policy of nonexposure was safe. There were no deaths from any cause in the first 35 patients in whom, on the basis of their previous experience, they did not expose the intercostal vessels at operation.

Case Histories

Case 1-A casualty wounded by a high explosive shell fragment that perforated the right upper chest had a sudden massive hemorrhage shortly after his admission to a field hospital. Blood filled the entire trachea and the primary branches of the bronchus.

Bronchoscopy cleared the trachea only temporarily. Hemorrhage continued from the orifice of the right upper lobe bronchus. The patient was taken to the operating room


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immediately. Hemorrhage could be controlled only by packing this orifice and holding the packing in place by packing the entire right main stem bronchus. It was then possible to perform a thoracotomy and suture the injuries in the bronchus and lung. The patient made a good recovery and had a fully expanded lung 1 month later.

Comment-As this case illustrates, massive hemorrhage was always a possibility in chest injuries, infrequent though it might be. This patient's life was saved by his immediate transfer to the operating room and the bold and imaginative measures by which bleeding was controlled.

Case 2-This patient was admitted to a field hospital 5 hours after he had sustained a penetrating wound of the left chest and penetrating wounds of the right upper arm and left neck. The wound of entrance in the chest injury was in the left part of the neck. Several attempts at aspiration of a large hemothorax were unsuccessful, and it was concluded that the blood had clotted. The wound of the neck was debrided, and the track was explored in the area in which it ran superior to the first rib.

Aspiration was not attempted for the first 3 days after operation. On each of the next 5 days, from 400 to 500 cc. of blood was removed. On the 11th day, the yield was 900 cc. of thin, bloody fluid. During this time, the patient received numerous transfusions.

On the 12th day after wounding, the patient suddenly went into severe shock. Neither the blood pressure nor the radial pulse could be obtained. The respiration was slightly labored, and the skin was cold and clammy. Breath sounds on the left side of the chest were distant. The patient rallied after receiving 1,000 cc. of blood. Attempts at aspiration of the left chest were not successful.

The following (13th) day, 400 cc. of blood-tinged fluid was aspirated. The pulse ranged to 148. After the aspiration, under endotracheal anesthesia, a sickle-shaped incision was made, extending from the mid third of the clavicle to the fifth costosternal junction. The first rib was excised at the sternocartilaginous junction. As the pleural cavity was entered, copious amounts of blood poured out. The second, third, and fourth ribs were severed at the sternocartilaginous junction, and through the exposure thus secured, it could be seen that the bleeding was in the region of the subclavian artery and innominate vein. The bleeding point was compressed by the finger until it could be controlled by gross clamping and mass suture of the vessels at the apex of the chest. The chest wall was closed with catgut sutures for the muscle and fascia and silk for the skin. A catheter was inserted into the eighth intercostal space.

Although blood had been started in both ankles and the right arm as the operation was begun, the blood pressure was imperceptible during most of the procedure. During the operation and the immediate preoperative period, a total of 3,750 cc. of blood was given. An hour after operation, the blood pressure was 100/60 mm. Hg, and oxygen was discontinued. Four hours later, the blood pressure was 102/80 mm. Hg.

The postoperative course was without incident for the next 13 days. Then the hospital blew down in a severe snowstorm, and this patient, along with 700 others, was evacuated to another forward hospital, and 4 days later to a general hospital. When he was received in the latter, the intercostal catheter was not draining, and he was dyspneic and distressed. Several days later, a large drainage tube was inserted in the bed of the eighth rib, to drain a well-established empyema. Recovery thereafter was uneventful.

Comment-In this case, the direction taken by the missile and the early clotting of the hemothorax pointed to the possible laceration of a large blood vessel. In the absence of shock and other evidence of gross bleeding, thoracotomy seemed to be contraindicated. Subsequent events showed that it would have been the better procedure. The subclavian artery and innominate vein had apparently been partially lacerated, and local infection completed the severance 12 days after wounding. This patient's life was unquestionably saved by the introduction of blood into three veins during the operation.


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ACUTE GASTRIC DILATATION

Acute gastric dilatation was a frequent occurrence in both thoracic and thoracoabdominal wounds and was often sufficient to cause respiratory embarrassment. Its recognition was important before operation. Unless decompression was carried out, regurgitation would occur, and gastric contents might be aspirated, with the usual serious consequence.

Routine decompression by the Miller-Abbott or Wangensteen techniques was carried out after operation in all thoracoabdominal wounds until all risk of acute dilatation was past. The same method was used if this complication developed, as it sometimes did, after surgery limited to the thorax.

EMPHYSEMA

Surgical emphysema was not frequent in World War II, probably because of the low incidence of preexisting pleuropulmonary disease in U.S. soldiers. It was of two types, superficial (subcutaneous) and mediastinal.

Subcutaneous Emphysema

The superficial variety of surgical emphysema resulted from penetration of the lung by a missile or by indriven fragments of fractured ribs. In either type of wounding, air escaped into the subcutaneous tissue (1) directly from the lung if adhesions were present, or (2) indirectly, through the medium of an interposed pneumothorax. The trapped air then spread upward to involve the tissues of the neck and face or downward to involve the abdominal wall. Occasionally, the extremities were involved.

Diagnosis was readily established by the crackling sensation felt on palpation of the involved area. Roentgenograms confirmed the presence of air in the tissues. Recognition was important because of the possible association of tension pneumothorax. The only condition which required differentiation was clostridial myositis, which is also characterized by crepitation in the tissues.

Superficial emphysema seldom required any special treatment. Once the opening in the pleura became sealed, which usually happened promptly, the air in the tissues was readily absorbed. If the pleural opening did not close and the air in the tissues increased progressively, a needle was introduced into the pleural cavity to permit the air to escape.

Mediastinal Emphysema

Mediastinal emphysema (fig. 47) was a much more serious condition than subcutaneous emphysema. Air escaped into the mediastinum because of dam-


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FIGURE 47-Schematic showing of pathologic physiology of mediastinal emphysema. A. Leakage of air through penetrating wound of trachea or bronchus, or rupture of these structures, finding its way (as shown by arrows) first into superior thoracic inlet and then upward into neck and head and downward into trunk and upper extremities. B. Tension pneumothorax, which may be rapidly fatal, caused when air in mediastinal emphysema ruptures the mediastinal pleura.


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FIGURE 47.-Continued. C. Extensive mediastinal and subcutaneous emphysema. This process, although it presents an alarming picture, is compatible with life if it is not accompanied by tension pneumothorax.

age to the extrapleural, intramediastinal segments of the tracheobronchial tree. If it could escape into the pleural cavity, a tension pneumothorax developed. If it had no route of escape, there was serious danger of compression of the great vessels and even of the esophagus.

Diagnosis was easily made by palpation of the soft swelling in the suprasternal notch. It was confirmed by roentgenograms.

As a rule, decompressive intubation of the pleural cavity was sufficient for relief of the condition (figs. 48 and 49). Tracheotomy was sometimes necessary. Radical treatment was indicated only when the symptoms of compression were severe enough to endanger life. In such cases, the swelling in the neck could be incised, or, if this measure was not effective, cervical mediastinotomy could be employed. So far as is known, this operation was not required in any patient in the Mediterranean theater.


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FIGURE 48.-Management of mediastinal emphysema. A. Decompression of air leak of moderate size by insertion of Penrose drains through transverse incision in suprasternal space. B. Tracheotomy in advanced mediastinal emphysema, to permit aspiration of secretions and facilitate administration of oxygen.


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FIGURE 49.-Management of mediastinal emphysema. A. Open repair of laceration of trachea, necessary when air leak is persistent or is associated with pneumothorax not controlled by closed suction drainage: Laceration of trachea (a), esophagus (b), azygos vein (c), vagus nerve (d), and superior vena cava (e). B. Insert showing detail of tracheal repair. Suture of laceration at right angles to long axis of trachea, to prevent obstruction is shown in (a). C. Reinforcement of repair with pedicled muscle or pleural graft.

PULMONARY EDEMA

Pulmonary edema was a possibility in all thoracic wounds and frequently occurred with wounds in other parts of the body. It was most often associated with, or caused by, one of the following conditions:

1. Severe pulmonary contusions, in which it tended to appear early.

2. Dyspnea and anoxia, in both of which, as Drinker and Warren (1) showed, pulmonary transudation is frequent.

3. Too rabid administration of intravenous fluids, or the administration of fluids in too large quantities.

4. Fat embolism, which most often was a complication of an associated fracture.

5. Lower nephron nephrosis, a condition in with pulmonary edema seldom appeared before the fifth day after wounding.

The clinical manifestations of pulmonary edema chiefly took the form of frothy pulmonary secretions in excessive amounts. If right heart failure


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FIGURE 50.-Technique of intermittent positive pressure oxygen administration in field and evacuation hospitals. A. Anesthetic machine with to-and-fro filter. B. Anesthetic face mask, held over nose and mouth by rubber sling. C. Manual compression of bag synchronous with each respiration (pressure 15-20 cm. H2O).

supervened, the symptoms and signs included: Hyperpnea, distention of the veins of the neck, and falling pulse pressure and systolic pressure.

Since pulmonary edema was usually secondary to some other pathologic process, which often was obscure itself, specific treatment was generally unsatisfactory and often failed entirely. The basis of therapy was an attempt to increase oxygenation, and oxygen given through a mask, under positive pressure (fig. 50), was sometimes distinctly beneficial. Repeated catheter suction was employed to remove the pulmonary secretions. If necessary, a small catheter was left indwelling in the trachea, and oxygen was administered between aspirations. A few patients were benefited by atropine sulfate (gr. 1/100) by vein.

Right heart failure was treated by prompt venesection of from 500 to 750 cc. of blood or by the application of tourniquets (the so-called bloodless phlebotomy). It was difficult to distinguish from shock, but the differentiation had to be made before either measure was instituted.


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FIGURE 51.-Postoperative atelectasis with complete collapse of lung. Note tracheal and mediastinal shift.

ATELECTASIS

General Considerations

Massive pulmonary collapse as the result of trauma to the chest, as well as of trauma to the abdomen, might involve all the lobes of one lung but more often involved only one or two. The precise amount of trauma seemed relatively insignificant. Collapse sometimes occurred from the pressure effects of bombs or shells. In such cases, as well as in instances of direct trauma, contrecoup collapse might occur, with only minor involvement of the homolateral side.

The frequent existence, before wounding, of bronchitis and other upper respiratory infections favored the development of atelectasis. Prolonged ether anesthesia also encouraged its development.

Postoperative atelectasis (fig. 51) was infrequent. In this variety, as well as in the traumatic variety, the basic pathologic process was excessive fluid accumulations that completely obstructed a bronchus. The explanation for its very low incidence was the routine and effective treatment of wet lung before and after operation.


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Clinically, the patient with atelectasis presented a far greater degree of dyspnea than might be expected from the collapse of a single lobe. Cyanosis, though also more than might be expected, was not so prominent as dyspnea. The trachea was deviated to the side of the collapse, and cardiac dislocation toward the affected side was usual. A sudden rise of temperature, from normal to 103 or 104 F., was typical. Physical examination of the chest revealed the usual signs of a nonaerating lobe or lobes.

Management in Forward Hospitals

It was imperative that atelectasis be treated promptly and vigorously. Persistence of the collapse was likely to result in pulmonary consolidation. Many chest surgeons, in fact, believed that the majority of postoperative pneumonias were preceded by some degree of atelectatic collapse. In this belief, a number of surgeons prescribed sulfonamide therapy as a prophylactic measure against postatelectatic pneumonia.

The treatment of established atelectasis was directed to the same end as the treatment of wet lung; that is, aiding the patient to expel obstructing fluid from the tracheobronchial tree. He was positioned with the involved side up and was made to cough at intervals of 5 to 10 minutes. If coughing was not effective, a curved, semirigid rubber catheter of the Magill type was inserted into the trachea, and sudden suction, of considerable intensity, was instituted. Often, during intubation, the patient coughed strenuously enough to clear out and aerate the involved lobe or lobes. Carbon dioxide inhalations were sometimes used to increase the depth of respiration, and back slapping and blow bottles were also sometimes used.

If these measures were not promptly effective, bronchoscopy was employed, under local anesthesia. No analgesic was applied to the vocal cords or trachea. In a surprising number of cases, aspiration of only small amounts of mucus from the orifices of the bronchi of the involved lobes corrected the atelectasis immediately. As experience increased, and especially as the efficacy of the method came to be appreciated, it became more and more the practice to resort to bronchoscopy without delay when atelectasis of any serious degree was encountered.

Typically, after spontaneous aeration or aeration following active treatment, rales appeared and persisted for several days, in spite of clinical and roentgenologic evidence of satisfactory aeration and the disappearance of dyspnea and cyanosis.

Management in Base Hospitals

Atelectasis encountered in base hospitals was also infrequent. The lobar type was occasionally encountered in the first year of the experience in North Africa and Italy but was seldom observed later. The atelectasis observed in base hospitals was frequently complicated by infection and was practically always the result of inadequate bronchial drainage. This was in contrast to


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the atelectasis seen in forward hospitals, in which the important problem was wet lung secondary to trauma and anoxia.

In the base hospital, atelectasis, like tracheobronchitis and pneumonitis, was likely to be present in casualties complaining of pain in the chest wall and the abdomen and in casualties with spinal damage. Under these circumstances, respiration was shallow and cough ineffective. When there was increased secretion of mucus or of mucopurulent sputum in bronchitis, varying degrees of tracheobronchial obstruction occurred, and atelectasis was always a possibility. Catheter suction or bronchoscopy was the correct treatment, supplemented by intercostal nerve block if pain was a feature.

In 338 wounds of the chest treated at the 21st General Hospital, Mediterranean theater, there were 2 deaths directly due to lobular pneumonia, and the same complication played a possible part in a third fatality. No instance of lobar atelectasis was observed after operation, however, because of the vigorous measures routinely instituted to prevent its development.

In the single case of total pulmonary atelectasis observed in this series, a nonspecific type of bronchitis was found by bronchoscopy on the involved side. No real improvement followed standard therapy. Pulmonary tuberculosis was suspected, but it required numerous sputum examinations to establish the diagnosis. In retrospect, it was concluded that in this case, a subclinical pulmonary tuberculosis was activated by the pyogenic infection that was responsible for the pulmonary collapse. The patient had had a normal chest roentgenogram 2 months before he sustained the severe contusion of the chest that led to atelectasis.l

HEMATOMA OF THE LUNG

General Considerations

Hematomas of the lung (figs. 52, 53, and 54), which were common, were found in association with all types of chest injuries. The degree of pathologic involvement ranged from simple contusions with small extravasations of blood into the pulmonary interstitium and, to some extent, into the alveoli, to massive interstitial hemorrhage. The latter variety of hematoma was associated with intra-alveolar hemorrhage which involved whole lobes and even the whole lung.

In general, the clinical significance of a hematoma was in direct proportion to the amount of pulmonary parenchymal tissue involved. In the majority of cases, the entity represented nothing more than a roentgenologic finding. In the more severe cases, the process involved sufficient pulmonary tissue to give rise to dyspnea and even to cyanosis.

1So far as is known, active tuberculosis did not occur after any battle injury in the Mediterranean theater, and there is no known instance in which reactivation of arrested disease could be attributed to battle trauma. These circumstances are testimony to the effectiveness of the screening methods used in the selection of combat personnel.


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FIGURE 52.-Posteroanterior roentgenogram showing hematoma and clearly defined missile track in left lung. Note foreign body in left axilla.

From a diagnostic point of view, hematomas were occasionally confused with intrapleural collections of fluid or with atelectasis. Thoracentesis and bronchoscopy were frequently required to exclude these diagnostic possibilities. An occasional hematoma was associated with a febrile response and hemoptysis, which might lead the unwary to suspect pulmonary suppuration. The diagnostic confusion might lead, in turn, to the performance of incorrect drainage procedures.

Management

Once the diagnosis of a hematoma was established, the accepted therapy was entirely nonsurgical. No lesion encountered in all the broad spectrum of thoracic trauma demonstrated more dramatically the remarkable recuperative powers of the lung than did massive pulmonary hematomas. As a rule, serial roentgenologic examinations showed slow but steady resolution of the process and complete clearing of the lung.

Hematomas associated with retained foreign bodies of considerable size of course represented a different therapeutic problem, as did those associated with long missile tracks (fig. 52) and with peripheral lacerations. In such cases, operative interference was frequently necessary for removal of the foreign body or closure of the laceration. If a foreign body was present, it was wise to wait for complete resolution of the pathologic process and for stabilization of the patient before an attempt at removal was made.


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FIGURE 53.-Posteroanterior roentgenogram showing typical intrapulmonary hematoma. Note rounded shadow.

FIGURE 54.-Posteroanterior roentgenogram showing sharply defined intrapleural hematoma.


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FIGURE 55.-Hematoma of lung. A. Posteroanterior roentgenogram 6 days after wounding showing large hematoma of the left lung. B. Same, 4 weeks later, with only small area of hematoma remaining.


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FIGURE 55.-Continued. C. Same, 6 weeks after wounding. Note almost complete disappearance of hematoma.

Case History

The following case history is typical of the progress in most hematomas of the lung:

Case 3-This patient was wounded on 24 May 1944. A large shell fragment penetrated the left chest and caused a laceration of the lung and a hemopneumothorax on that side. The wound was debrided, the sucking wound closed, and the shell fragment removed from the chest wall. Repeated thoracenteses were performed.

Roentgenologic examination 6 days after wounding showed a large hematoma of the left lung (fig. 55A). Clinically the patient's course was smooth and uneventful. Four weeks after wounding, the hematoma was very much smaller (fig. 55B), and 6 weeks later, roentgenologic examination showed almost no evidence of it (fig. 55C).

BRONCHOPLEURAL FISTULA

General Considerations

Bronchopleural fistulas of traumatic origin were of two types.

In the first group, the fistula occurred without serious parenchymal damage and without pleural infection or significant pulmonary infection. It represented a disruption of the visceral pleura and underlying peripheral lung,


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with the establishment of pleuroalveolar or pleurobronchiolar and bronchial continuity, or with both.

These fistulas, which were usually small, might be caused in several ways:

1. By erosion or laceration of the lung from sharp, fixed rib fragments.

2. By the reopening of peripheral lacerations of the pulmonary parenchyma.

3. By the avulsion of the line of repair of a pulmonary laceration that had previously been sutured.

4. By necrosis around metallic foreign bodies or indriven costal spicules.

5. By denudation of lung tissue as the result of its being stripped from an adherent area, either by collapse of the lung because of the accumulation of exudates or transudates or by expansion of the lung after thoracentesis.

In the second group of bronchopleural fistulas, the fistula was part of a serious total situation, and the surgical measures necessary to correct it were part of the major surgery required to cane for whatever pleural or pulmonary damage might be present. The procedure most often included drainage of an empyema by rib resection, decortication of the lung (occasionally with segmental pulmonary resection), and, in very occasional instances, drainage of a lung abscess.

Although bronchopleural fistulas were always a potential cause of tension pneumothorax, they were seldom associated with it. A few patients complained of a tight feeling in the chest, but most of them were unaware of what had happened. In a small number of cases observed in the Mediterranean theater, in which the fistulas developed during evacuation from forward to base hospitals, the tension pneumothorax was of considerable proportions, and the patients arrived dyspneic and in generally poor condition. Removal of the air by needle resulted in only temporary relief, but permanent relief of symptoms and prompt healing followed the use of water-seal intercostal drainage.

Diagnosis was made by the discovery of a pneumothorax, either by physical examination or roentgenologic examination, or by both, in a patient whose chest was previously free of pleural air and who had had no breakdown of a chest wall wound to cause an open pneumothorax.

Management

Treatment of bronchopleural fistulas had three purposes: (1) To bring about prompt removal of the air in the chest, (2) to obtain complete reexpansion of the lung, and (3) to close the fistula so that firm and permanent healing would follow. Treatment was instituted as soon as the diagnosis was made.

After manometric determinations of the intrapleural pressure, a small intercostal catheter was inserted under local analgesia and via trocar into the chest at the site of the pneumothorax. Since most bronchopleural fistulas gave rise to apical air pockets, the most usual site of insertion was the second inter-


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space in the midclavicular line. The site, however, corresponded with the location of the air pocket, which, because of adhesions, might be restricted to some other portion of the chest. The catheter was connected to a long rubber tube, the end of which was kept under water, to provide closed drainage. This arrangement permitted air to escape from the pleural cavity only when the pressure in it rose above atmospheric pressure. The lung was thus allowed to expand slowly. At the end of 48 hours, and sometimes by the end of 24 hours, the catheter could be withdrawn. If the fistula reopened, as occasionally happened, the catheter was reinserted.

The conservative method of treatment just described was always given a fair trial, even though catheter drainage had to be instituted more than once. It gave very satisfactory results. In 870 penetrating wounds of the chest analyzed by Maj. Thomas H. Burford, MC, from the 2d Auxiliary Surgical Group experience, there were 22 bronchopleural fistulas of the type just described. Twenty-one were closed permanently by the conservative method outlined, though one patient experienced three recurrences of the fistula before solid sealing was obtained. In the remaining case, operation was resorted to after repeated attempts at catheter suction had proved unsuccessful. No patient in the group developed a pleural infection, which is highly significant, since in several instances, the fistula persisted for 2 weeks or more. It was the general experience that fistulas not associated with significant parenchymal damage were not a source of pleural infection if the pleural cavity did not contain blood.

If intrapleural infection did occur, operation was performed at once. Otherwise, thoracotomy for repair of the fistula was not instituted until the full possibilities of thoracentesis and intercostal water-seal drainage had been exhausted.

In some cases, operation was necessary to smooth dangerously sharp rib ends or remove indriven rib spicules or metallic foreign bodies. Only occasionally was it necessary to operate for the fistula alone. This was fortunate, for the difficulties of finding a small fistula at an open operation were often considerable.

The management of bronchopleural fistulas that were a part of other major pathologic processes did not usually furnish problems referable to them alone. Occasionally, however, pressure pneumothorax appeared suddenly in patients with empyema, before dependent drainage had been instituted. Intercostal catheter drainage was instituted at once, by the technique just described.

Case History

A typical instance of bronchopleural fistula treated by the method just described follows.

Case 4-This soldier, who was wounded in action on 17 September 1944, sustained a perforating wound of the right thorax, with lacerations of the right lung, right diaphragm, and liver. A hemothorax developed promptly. He was treated by thoracolaparotomy,


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FIGURE 56.-Bronchopleural fistula. A. Posteroanterior roentgenogram showing delayed right bronchopleural fistula with pneumothorax. B. Same, showing complete reexpansion of lung after closure of fistula which occurred 48 hours after insertion of intercostal catheter.


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with suture of the diaphragm and subcostal drainage of the hepatic laceration. The pulmonary laceration was not leaking and was therefore not sutured.

The immediate postoperative course was uneventful. Biliary drainage ceased, and the drains were removed. The chest also cleared, but 2 weeks after wounding, the patient began to complain of tightness in the right hemithorax, in which physical examination revealed the presence of air. Roentgenologic examination (fig. 56A) confirmed this finding. Manometric studies also furnished evidence of a small bronchopleural fistula of the right lung.

A small catheter was inserted into the pneumothoracic space, through the second intercostal space in the midclavicular line, and was attached to a water-seal bottle. Twenty-four hours later, the tube had ceased to bubble air. At the end of 48 hours, the water column had ceased to oscillate, and the tube was removed. Examination at this time revealed total disappearance of the pneumothorax and complete reexpansion of the right pulmonary apex. These findings were corroborated by roentgenograms (fig. 56B). The fistula did not recur.

WOUND DISRUPTION

General Considerations

The causes of wound disruption in thoracic injuries and the consequences of the accident are best presented in an analysis of 10 cases observed at the 21st General Hospital in the Continental Advance Section after the invasion of southern France.

The 10 disruptions occurred in 74 sucking wounds, which occurred, in turn, in 338 battle casualties admitted to the thoracic service of this hospital. All but one of the patients had been treated in U.S. Army field hospitals. This man had received his initial treatment in a German hospital.

Analysis of these 10 cases of wound disruption revealed the following data:

1. In eight cases, the damage to the chest wall was severe, and there had been considerable loss of soft tissue.

2. Rib fractures were present in all cases, the number of fractures ranging from one to five.

3. Pulmonary damage was severe in all cases.

4. In two cases, the wound of the chest wall had been contaminated by intestinal contents from a thoracoabdominal wound.

5. Six wounds were in the anterior chest wall, in which muscles are thin and difficult to draw together. Three were located laterally, and the remaining injury was close to the spine.

6. Debridement had obviously been inadequate in the two small wounds in the series and in another large wound, the latter treated at the German hospital.

7. The wound had been left open in two cases. One of these patients had been treated at the German hospital.

8. Thoracentesis had been performed after operation in only three cases.

9. Eight patients had bronchopleural fistulas, bronchitis, and severe wet coughs. In none of these cases had any measures been instituted to improve bronchial drainage.


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10. Empyema was present in every patient, and in only three instances had there been an attempt to drain the pleural cavity. Infection in the pleural cavity and lung, as well as in the chest wall, was thus an important factor in all of these disruptions.

11. In six instances, respiratory embarrassment was the result of mobility of the mediastinum.

12. All but one patient had had penicillin systemically, and at least three had had it intrapleurally also.

Management

When these patients were received in the base hospital, disruption of the chest wound had, in every instance, produced, or reproduced, a sucking wound. Many patients were admitted in severe respiratory distress as a result of the anoxia which had developed during evacuation. Closure of the wound was a secondary consideration in every instance. All the patients needed other treatment far more urgently.

The following treatment was instituted:

1. The wound was occluded with an airtight, petrolatum-impregnated gauze dressing, kept in place by strips of adhesive tape or by an Ace type of bandage. Because of its elasticity, this type of bandage permitted expansion of the lung while at the same time it furnished necessary support to the paradoxically moving chest wall.

2. Intercostal nerve block was carried out if respiration was painful or paradoxical.

3. Oxygen was administered to all patients.

4. Tracheobronchial suction was used if the cough was ineffective.

5. Adequate pleural drainage, which was the keystone of treatment, was instituted as soon as these emergency measures had been carried out.

In six cases, the pleura sealed over without other treatment. In three cases, redebridement was necessary because the wounds contained necrotic muscle tissue. Muscle flaps were developed and the wounds closed in layers with interrupted silk sutures. The remaining patient, whose wound had been secondarily closed at an evacuation hospital, had a second rupture, which was satisfactorily closed by the same measures.

In other words, when the multiple etiologic factors of wound disruption in these 10 cases were under control, wound closure was possible, either by surgical closure or by spontaneous closure of the pleura after satisfactory drainage of the intrapleural infection. The chest wall defect in the latter cases was allowed to heal by granulation, after which the skin edges were drawn together by adhesive tape. With proper initial management, it is doubtful that any of these wound ruptures would have occurred.


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CLOSTRIDIAL MYOSITIS

Clostridial myositis was extremely infrequent in wounds of the chest. When it did occur, the etiologic factors and clinical manifestations were essentially the same as in clostridial infections in civil life. The principles of management were also the same.

A point of great importance was that subcutaneous emphysema be clearly distinguished from clostridial infections. The chief point of differentiation was that in emphysema, except in the more extreme cases, air was confined to subcutaneous tissues, while in clostridial infections, it was within the muscle plane.

CHYLOTHORAX

There was no instance of chylothorax in any of the thoracic or thoracoabdominal wounds cared for by surgeons of the 2d Auxiliary Surgical Group. The assumption is that most patients with these injuries died on the battlefield from their severe wounds.

LUNG ABSCESS

Incidence

The incidence of lung abscess in World War II was extremely low. Preliminary figures compiled by the Medical Statistics Division, Office of The Surgeon General, Army, based on sample tabulations of individual medical records (table 10), show only 541 cases for the entire war, 382 in the continental United States and 159 outside of the United States. There were 16 deaths, 10 in the continental United States. Of 255 cases of lung abscess (based on 20 percent sample tabulations of individual medical records) classified as secondary (table 11), 130 occurred outside the continental United States. The figures include both battle and nonbattle cases, and not all of the abscesses secondary to battle wounds were related to wounds of the chest.

The statistical evidence of the infrequency of lung abscess as a complication of battle wounds of the chest supports its infrequency in individual studies and also supports the clinical impression of the World War II chest surgeons. In one analysis of 870 battle wounds of the chest, by Major Burford and eventually included in the total figures of the 2d Auxiliary Surgical Group, there were only 5 instances of lung abscess. Maj. (later Lt. Col.) John Burke, MC, and Capt. (later Maj.) Theodore T. Jacobs, MC, in an analysis of 122 penetrating wounds of the chest at the 23d General Hospital in the European theater, encountered only 2 lung abscesses. Other observers had similar experiences.

The explanation of the infrequency of this complication in battle-incurred wounds of the chest is twofold, (1) penicillin therapy and (2) the intensive efforts immediately after wounding to restore the normal respiratory physi-


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TABLE 10.-Number of admissions1 and deaths2for lung abscess in the U.S. Army, by area of admission and year, 1942-45

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

 

Area

1942-45

1942

1943

1944

1945

Continental United States

ADMISSIONS

382

81

132

89

80

Overseas:

 

 

 

 

 

Europe

60

2

8

15

35

Mediterranean4

25

1

13

6

5

Middle East

5

---

5

---

---

China-Burma-India

14

1

2

1

10

Southwest Pacific

24

2

4

13

5

Central and South Pacific

22

1

6

5

10

North America5

4

1

2

1

---

Latin America

5

2

3

---

---

Total overseas

159

10

43

41

65

Total Army

541

91

175

130

145

Continental United States

DEATHS

10

1

7

1

1

Overseas:

 

 

 

 

 

Europe

4

1

1

1

1

Mediterranean4

1

---

1

---

---

Middle East

1

---

1

---

---

China-Burma-India

---

---

---

---

---

Southwest Pacific

---

---

---

---

---

Central and South Pacific

---

---

---

---

---

North America5

---

---

---

---

---

Latin America

---

---

---

---

---

Total overseas

6

1

3

1

1

Total Army

16

2

10

2

2


1It is estimated that virtually none were CRO (carded for record only) cases. For the 2 years, 1943 and 1945, in which the number of CRO cases was known, the 320 admissions included but 1 CRO case.
2Underlying cause of death; year of death.
3
Complete files of records used for deaths, 1942 admissions, and oversea admissions in 1943. Samples of admissions were: 20 percent for 1945, U.S. 1943, and Europe 1944; 80 percent for 1944, excluding Europe.
4Includes North Africa.
5
Includes Alaska and Iceland.


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TABLE 11.-Number of secondary cases1 of long abscess in the U.S. Army, by area and year,1944-45

[Preliminary data based on 20 percent sample tabulations of individual medical records]

Area

1944-45

1944

1945

 

Number

Number

Number

Continental United States

125

75

50

Overseas:

 

 

 

Europe

60

15

45

Mediterranean2

20

15

5

Middle East

---

---

---

China-Burma-India

---

---

---

Southwest Pacific

45

20

25

Central and South Pacific

---

---

--- 

North America3

---

---

---

Latin America

5

---

5

Total overseas

130

50

80

Total Army

255

125

130


1Battle and nonbattle cases. 2
Includes North Africa. 3
Includes Alaska and Iceland.

ology. Since lung abscesses were infrequent even before penicillin became available in the spring of 1944, the second of these explanations must be considered the more important.

The low incidence of lung abscess can also be interpreted as further evidence of the remarkable recuperative capacity of the lung, particularly when, as just mentioned, its inherent capacity was supported by prompt measures to assure a patent airway and total pulmonary reexpansion. Consistent with the infrequency of localized intrapulmonary suppuration was the observation that bacteria were seldom cultured from missile cavities when foreign bodies were removed in uncomplicated cases (p. 327).

There was no explanation, however, of why pulmonary abscesses developed about an occasional foreign body and not about others. One explanation advanced was that while the heat of shell fragments might be sufficient to sterilize most pathogenic bacteria, bits of clothing driven into the lung along with the missile might carry infecting micro-organisms in with them. This is not an acceptable theory, partly because this occurrence was so frequent and lung abscesses so infrequent, and partly because the infecting micro-organisms found in lung abscesses were usually resident respiratory flora. The number of cases is too small to permit anything beyond the mere statement of facts, but it might be mentioned that the abscess formed about a foreign body with recognizable bits of cloth attached to it in three of the five cases reported by Major Burford. Other, isolated observations were to the same effect.


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Management

The type of lung abscess seen in battle-incurred injuries differed from the type seen in civilian practice. In civilian practice, the abscess begins with a diffuse area of pneumonitis, and, if progress is favorable, as it usually is, the process proceeds to localization. In the traumatic type of abscess, the localized phase was the first phase. This was a distinction of fundamental importance from the standpoint of treatment: In the traumatic type of abscess, the earlier the attack, the simpler the procedure, and the better the results.

In four of the five cases studied by Major Burford, the abscess was excised, the excision including the foreign body in the three cases in which the missile was retained. Drainage was instituted in the remaining case. All five patients eventually recovered, though in two instances, the abscess recurred and required secondary drainage. Drainage of an associated empyema was necessary in both of these cases.

Penicillin therapy and the intelligent use of whole blood were important parts of the routine of management, but good surgery was the basis of treatment.

Massive gangrene of the lung was not observed by surgeons of the 2d Auxiliary Surgical Group, but in two instances, extensive suppuration developed, apparently on the basis of extensive vascular damage. The process in both cases went on to multilobar areas of pneumomalacia with multiple bronchopleural fistulas and widespread pleuropulmonary sepsis. One patient recovered after multiple drainage operations. The other died after total pneumonectomy.

MEDIASTINAL ABSCESS

Surgeons of the 2d Auxiliary Surgical Group encountered abscess formation of the anterior mediastinum in only one instance. The infection developed about a retained foreign body, and the organism recovered was a pure strain of hemolytic streptococcus. Complete and prompt recovery, without complications, occurred after thoracotomy, removal of the foreign body, evacuation of the abscess, and intrapleural instillation of penicillin.

An occasional patient was observed in forward hospitals with localized abscesses of the posterior mediastinum or diffuse posterior mediastinitis. These infections were considered the only indication for posterior extrapleural mediastinotomy in war wounds of the thorax. None of this small group of patients survived to reach base hospitals.

PNEUMONITIS AND PNEUMONIA

Infectious pulmonary complications, chiefly pneumonitis and the pneumonias, were considerably more infrequent in chest injuries than had been expected, in view of the World War I experience. The low incidence, which was


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practically the same in thoracic and thoracoabdominal wounds, could be explained in several ways:

l. The attention devoted to the correction of wet lung both before and after operation. Measures that drastically reduced the incidence of atelectasis, as the correction of wet lung and maintenance of a patent airway reduced it, also drastically reduced the incidence of pneumonitis and subsequent pneumonia.

2. The postoperative routine which emphasized coughing, frequent turning in bed immediately after operation, and early ambulation.

3. Perhaps the unwitting prophylaxis instituted by the administration of sulfonamides and later of penicillin as part of the routine of management of all wounds.

Pneumonitis almost always developed on the basis of atelectasis or of stagnation of excessive bronchial fluids. Pneumonia was more frequent in the winter months, when it was often superimposed on a preexisting purulent bronchitis. An occasional lobar pneumonia was a primary pathologic process.

Diagnosis of pneumonitis and pneumonia was by the usual symptoms and signs (toxicity, increased fever, pulmonary consolidation) supplemented by roentgenologic examination.

Sulfadiazine was the drug of choice. It was frequently observed that a pneumonia that had developed under penicillin therapy responded promptly to sulfonamide therapy. If stagnation of bronchial secretions was a persistent feature of the disease, and if the patient could not or would not cough effectively, either catheter suction or bronchoscopy was employed, even when pulmonary infection was clearly established. No undesirable consequences followed this practice.

Atelectasis and pneumonia caused by inadequate bronchial drainage were fairly common on neurosurgical and general surgical wards. The staffs of the thoracic surgical wards saw many of these patients in consultation and assisted in their care, particularly in the performance of catheter suction and bronchoscopy.

TRAUMATIC OSTEOMYELITIS

Neither osteomyelitis nor osteochondritis was frequent after trauma in World War II, in contrast to their relative frequency in World War I. Both were managed by removal of the involved segments under systemic penicillin protection. The wound was left widely open for 4 to 10 days. Then secondary suture or staged closure was carried out, depending upon the rapidity with which the wound cleared up. To await sequestration of the bone was not in harmony with modern surgical principles.

Osteomyelitis of the scapula was seen at least 10 times more frequently in the early fighting in North Africa than later. The explanation was that in


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the early months of the war, debridement about the scapula was not sufficiently radical. Later, there was a better realization of the importance of adequate initial wound surgery. Free incision with removal of sequestra usually resulted in prompt cure.

CHRONIC SINUSES OF THE CHEST WALL

General Considerations

Chronic sinuses of the parietes were encountered in a small number of patients in the base area and in a larger number in Zone of Interior hospitals. The causes were chiefly as follows:

1. Injury to the costal cartilage, caused by the so-called gutter type of wound, with destruction of the cartilage as a result. Sinuses of this origin continued to drain until all diseased cartilage had sloughed off, or, better, had been excised.

2. Retained foreign bodies. Sinuses were particularly frequent when bits of clothing or other foreign organic material had collected around retained metallic fragments, but metallic fragments alone could be responsible for the sinuses.

3. An unwise selection of suture material. In closing particularly large defects of the chest wall, it was sometimes necessary to use pericostal or perichondral sutures to pull the ribs and cartilages together. Experience proved that the use of heavy silk or wire or other nonabsorbable suture material was unwise; healing was sometimes satisfactory, but many times these materials acted as retained foreign bodies. As the war progressed, pericostal and perichondral sutures were not used if they could be avoided. If they could not be avoided, absorbable suture material was used.

4. Un-united fractures or fractures that had healed with excessive scar tissue and callus formation. These were infrequent causes of parietal sinuses and were seldom an indication for surgery.

5. Osteomyelitis of the ribs or other bones (fig. 57).

Management

The basis of management of these sinuses of the chest wall was the removal of the offending retained material, whatever it might be. The removal of retained foreign bodies and unabsorbed suture material offered no difficulties. If bone or cartilage was responsible for the sinus, the infected area was excised. Numerous exceptions were noted to the opinion that infection involving cartilages in the fused portion of the thoracic cage requires complete excision of the involved fused cartilage for permanent cure. As experience accrued, it was found that a less radical resection, involving only the infected segment,


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FIGURE 57.-Sinus of chest wall resulting from traumatic osteomyelitis of clavicle. Note swelling of tissues just below pointer.

was all that was necessary in most cases. If there was a recrudescence of the infection, the more radical operation could be done as a secondary procedure.

At operation, the wound was opened widely and the offending material removed. The extent of the debridement depended upon the circumstances in the individual case. Since all of these wounds were infected, the skin and subcutaneous tissues were left open, as at initial wound surgery. Secondary closure of the incision was usually possible under penicillin protection from 5 to 7 days later.

DEFECTS OF THE CHEST WALL

Wounds causing large defects of the chest wall were frequent. They reflected, in a dramatic fashion, the effectiveness of modern weapons. They were also observed frequently because adequate debridement of an initially large wound resulted in a sizable opening in the chest wall. This was particularly true at Anzio, where many patients with large traumatic thoracotomies would


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FIGURE 58.-Defect of anterior chest wall. A. Large defect, with typical loss of substance, sketched before debridement. B. Result 1 month after repair of defect by swinging down small muscle flap from pectoralis major. This picture was taken 7 days after delayed primary wound closure in a base hospital. The patient recovered uneventfully. Note absence of lung hernia.


183

not have survived except for immediate surgery in hospitals close to the frontlines.

These large defects presented special problems of management. The necessary intrathoracic procedures were carried out with dispatch, particular attention being paid to removal of fragments of ribs and clothing, which were found more often, and in larger amounts, than in any other type of chest wound. Debridement had to be even more thorough than usual, because it was often advisable to close the skin primarily, to enhance the security of repair.

Satisfactory restoration of the chest wall often required patience and ingenuity. The procedures utilized to accomplish closure without dangerous tension varied with the number and location of the defects. Pericostal sutures, though generally undesirable, had to be used in some cases to approximate the ribs and thus reduce the size of the defect. In flail segments of the ribs, it was occasionally feasible to use wire to fix the ends. Muscle flaps were very useful, particularly in the anterior chest (fig. 58), in which tissues for repair were sparse. The paraspinalis group of muscles was used for flaps low in the posterior chest, where there was a similar paucity of tissue. In an occasional case, the subscapularis was used, as suggested by Maj. (later Lt. Col.) Reeve H. Betts, MC, and Capt. (later Maj.) William M. Lees, MC, with the arm positioned to bring the scapula over the opening. If nothing else was possible, closure was effected by reattachment of the hemidiaphragm.

ADHESIVE PLEURITIS

Pathologic Process

Deforming adhesive pleuritis, also known as infolded lung, was a fairly common complication of chest injuries. Its mechanism was not clearly understood but could be postulated as follows:

1. The blood present in the pleural cavity after wounding resulted in compression of the lung.

2. The lung was additionally compressed by an associated pneumothorax.

3. If the pleural blood clotted, it occupied a considerable portion of the pleural space.

4. In the simplest type of infolded lung (fig. 59), as a result of the thoracic wound, the associated hemothorax, and the resulting deflation of the lung, the diaphragm was elevated and splinted. The costophrenic fringe of the lung was dragged along the dome of the diaphragm and presumably became retracted. Since blood was invariably present in some amount in all thoracic wounds, symphysis occurred between the costophrenic fringe of the lung and the diaphragmatic pleura at what might be termed the high watermark.

5. Eventually, as the result of absorption of air, or of aspiration of blood or air, or of both processes, the lung began to reexpand, filling the pleural space that remained by rolling out over the area of the pleural symphysis and expand-


184

FIGURE 59.-Diagrammatic representation of infolded lung (adhesive pleuritis). A. Rapid massive intrapleural hemorrhage. B. Lung infolding as it is compressed by massive bleeding. C. Captive infolded lung (a), held by pleural membrane (b), resulting from organizing hemothorax (c).

ing those portions of its contour that could most conveniently occupy the available space. The upper portions of the lung were free to expand and fill the apex of the chest. The peripheral portion of the base could be filled only by adaptation of the lung to the available space.

The process just postulated furnished a satisfactory explanation for slight degrees of pulmonary infolding. They were of no great clinical significance, and they probably occurred much more often than they were recognized. On the other hand, extensive degrees of infolding and distortion were serious. They sometimes occurred as the result of adhesions between the visceral and parietal pleural coats or between opposed portions of the visceral pleura (fig. 59). Bizarre distortions were occasionally observed, as the result of a symphysis between the lateral costophrenic fringe and the mediastinum, along its diaphragmatic border.

Though the mechanism of infolded lung was not clearly understood, the consequences were evident. Because the hemithorax was not completely filled by the lung, areas within it that were not adequately filled by lung tissue were likely to be filled by recurrent accumulations of pleural fluid. This fluid, after the blood in the chest had been removed, was uniformly serous. It formed only in small amounts, but it had a tendency to reaccumulate after it was removed by aspiration.

If the adhesive process involved large areas of lung, pulmonary expansion was considerably slower than when an uncomplicated hemothorax was present, and filling of the hemothorax was considerably delayed. These observations


185

explained the contracture of the chest wall observed in such cases; it was merely Nature's attempt to reduce the size of the hemithorax.

Some degree of infolding was uniformly seen in association with massive intrapleural clotting. Most observers thought that if roentgenologic examination showed obscuration shortly after wounding and showed clearing within a period of weeks of expectant treatment and vigorous breathing exercises, the patient had had an infolded lung and not an organizing hemothorax. An organizing hemothorax was likely to be irreversible without more active therapy.

Diagnosis

The only condition easily confused with deforming adhesive pleuritis was organizing hemothorax. The differentiation was extremely important: An organizing hemothorax of any extent constituted a definite indication for thoracotomy and decortication; an infolded lung did not.

The differentiation was usually readily accomplished by roentgenologic examination, but certain clinical features were also helpful. In organizing hemothorax, but not in infolded lung, the physical findings usually included dullness on percussion over the affected area; decreased tactile fremitus; suppression of breath sounds; narrowing of the interspaces; and possibly retraction of the mediastinum toward the affected side, with elevation and relative immobility of the corresponding hemidiaphragm. Blood was usually obtained by thoracentesis.

Roentgenograms taken in infolded lung showed a generalized obscuration of the pleural space in the posteroanterior projection. In lateral films, there was a triangular posterior obscuration generally regarded as typical of the process. The opacity was produced by the infolding and malaeration of the affected pulmonary area, as well as by the small, irregular, and usually intercommunicating collections of pleural fluid. It was the findings in the lateral roentgenograms which differentiated adhesive pleuritis from organizing hemothorax. In the former, the obscuration was patchy and diffuse because the process was not localized. In the latter, the opacity was posterior and basal.

Management

If within 3 or 4 weeks after wounding, an infolded lung had expanded sufficiently to fill the hemithorax, expectant treatment was continued. Even though the chest was somewhat contracted, it was thought that return of function to the chest wall by the practice of breathing exercises would eventually correct the deformity. Conservative management was indicated whenever serial roentgenograms showed that pulmonary reexpansion had been shared proportionately by all the lobes, so that the patient would not be left, for example, with a fully expanded upper lobe and a seriously contracted lower lobe.

On the other hand, release of limiting adhesions by surgery was considered justified if, within 3 or 4 weeks after wounding, the lung had not expanded


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sufficiently to fill most of the hemithorax or if serial roentgenograms showed that the filling had been accomplished predominantly by one portion of the lung at the expense of other portions. In most cases, though not in all, when filling of the hemithorax was long delayed, it was much more likely that failure of pulmonary expansion was the result not so much of infolding of the lung, even if it was present to some degree, as of compression of the lung by the peel or rind of an organizing hemothorax. In that type of case, decortication of the lung was clearly indicated.

DIAPHRAGMATIC HERNIA

Up to 1944, the Medical Statistics Division, Office of The Surgeon General, Army, coded diaphragmatic hernia with a residual group of hernia conditions. The data for 1944 and 1945, when diaphragmatic hernia was coded separately, show a total of 449 cases and 9 deaths (table 12). In 230 cases, diaphragmatic hernia was the secondary diagnosis.

Data on deaths were obtained from a complete file of records. Admissions in 1945 and for the European theater in 1944 were derived from a 20-percent sample of records. Admissions in 1944 for areas other than the European theater were derived from an 80-percent sample. Data on secondary diagnoses were derived from a 20-percent sample. Not all of the hernias associated with battle-incurred wounds were related to wounds of the chest.

Oversea Experience

The small samples from which the statistics just cited are derived do not permit generalizations. They are in correspondence, however, with the impressions of surgeons both overseas and in the Zone of Interior that traumatic diaphragmatic hernias were decidedly infrequent. Only 2, for instance, were observed in 1,028 intrathoracic wounds analyzed by Major Burford from the 2d Auxiliary Surgical Group experience.

In the first of these cases, the hernia was not suspected before thoracotomy, which was undertaken for removal of a missile from the left lower pulmonary lobe. In the second case (fig. 60), which was not a combat injury, the casualty sustained a crushing injury to the upper abdomen when a jeep was blown off the road, by the explosion of a mortar shell, and was overturned. Early thoracotomy revealed that the stomach and colon had herniated through a large tear in the left leaf of the diaphragm. The tear extended to, but not through, the left crus of the hiatus. Convalescence was uncomplicated, and postoperative roentgenologic examination showed normal configuration of the diaphragm and stomach. Both of these patients were returned to duty in the theater.

So far as is known, no instance of diaphragmatic herniation was observed in the Mediterranean theater in a battle wound in which the diaphragm had been sutured. The early experience had demonstrated the risk of suturing the


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TABLE 12.-Number of total cases (incidence), admissions, secondary diagnoses, and deaths from diaphragmatic hernia1 by area of admission and year, 1944-45

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

Area

1944

Incidence2

Admissions3

Secondary diagnoses4

Deaths5

Continental United States

146

86

60

4

Overseas:

 

 

 

 

Europe

40

10

30

---

Mediterranean6

18

8

10

---

Middle East

9

4

5

1

China-Burma-India

---

---

---

---

Southwest Pacific

18

3

15

---

Central and South Pacific

3

3

---

---

North America7

---

---

---

1

Latin America

5

---

5

---

Total overseas

93

28

65

2

Total Army

239

114

125

6

1945

Continental United States

115

70

45

2

Overseas:

 

 

 

 

Europe

40

5

35

---

Mediterranean6

15

5

10

---

Middle East

---

---

---

---

China-Burma-India

5

---

5

---

Southwest Pacific

20

10

10

---

Central and South Pacific

10

10

---

1

North America7

5

5

---

---

Latin America

---

---

---

---

Total overseas

95

35

60

1

Total Army

210

105

105

3


1Battle and nonbattle cases.
2
Sum of admissions and secondary diagnoses.
3
Cases in which diaphragmatic hernia was the primary cause of admission to a medical treatment facility.
4Cases of diaphragmatic hernia secondary to, or concurrent with, some other admission diagnosis.
5
Underlying cause of death, year of death, and theater of admission.
6
Includes North Africa.
7
Includes Alaska and Iceland.


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FIGURE 60.-Traumatic diaphragmatic hernia. A. Posteroanterior roentgenogram 4 hours after crushing injury of lower chest and upper abdomen. At operation, both stomach and large bowel were found in chest. B. Same, 10 days after thoracotomy, reduction of hernia, and repair of diaphragm.


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FIGURE 60.-Continued. C. Detail film after barium meal demonstrating normal stomach pattern and intact diaphragm. Patient made an uneventful recovery.

diaphragm with catgut whenever there was any risk of bile leakage. Sutures of silk, cotton, or nylon held consistently. Bile, free of its normal confines, always makes trouble, and the success of diaphragmatic suture was in large part due to recognition of this fact and provision of adequate drainage for a sufficiently long period (p. 118).

Zone of Interior Experience

Diaphragmatic hernia of traumatic origin was seen only slightly snore frequently in the Zone of the Interior than overseas. The 28 patients observed at the Kennedy General Hospital chest center, Memphis, Tenn., during the 3-year period of its operation may be taken as typical, and the analysis of these cases is the simplest method of presenting the main points in the clinical picture and management of this condition.2

2This analysis was made by Maj. Felix A. Hughes, Jr., MC; Maj. Earle B. Kay, MC; Lt. Col. Richard H. Meade, Jr., MC; Maj. Theodore R. Hudson, MC; and Maj. (later Lt. Col.) Julian Johnson, MC. All of these officers served at various times in the thoracic surgery center, Kennedy General Hospital.


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FIGURE 61.-Diaphragmatic hernia. This patient, a prisoner of war, was injured in France in 1944, and then worked in the United States for a year without symptoms. A. Posteroanterior roentgenogram made after onset of symptoms induced by carrying heavy sacks. The greatly distended stomach, partly filled with barium, occupies the left pleural cavity. B. Same, after reduction of hernia and repair of diaphragm. Recovery was uneventful.


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Etiology and pathogenesis-In 16 of the 28 cases, the wounds were caused by shell fragments, or machinegun, rifle, or pistol bullets. In the remaining 12 cases, the hernias, which were not combat-incurred, were variously caused or precipitated by traffic accidents (9), a stab wound, a fall, and jumping from a truck. In five of the combat-incurred hernias, the injured diaphragm had been repaired overseas at the time of wounding.

In the 11 combat-incurred wounds in which the diaphragm had not been repaired overseas, the defect was so small that no herniation occurred until sudden strain or prolonged strain caused it to enlarge. One soldier, for instance, had sustained a penetrating wound 13 months before, for which thoracotomy was not considered necessary. Suddenly, while carrying heavy sacks, he was seized with severe upper abdominal pain. At operation, the entire stomach was found in the chest (fig. 61). Another patient had sudden, acute symptoms after he jumped from a truck. At operation, the colon was found herniated through a defect only 1.5 cm. in diameter, and gangrene had already set in. Three other patients with known hernias of several months' duration also developed acute intestinal obstruction while under observation in the hospital. Emergency operation was successful in all three cases.

The first patient with a diaphragmatic hernia observed at the chest center at Kennedy General Hospital furnished a useful lesson. He had sustained a bullet wound of the right chest in May 1943. A few weeks later, he showed no abnormalities of any consequence on roentgenologic examination (fig. 62A) and had no symptoms of any kind. He continued well for a year. Then he began to complain of pain in the right lower chest, and roentgenograms showed a rounded mass overlying the diaphragm (fig. 62B). Exploratory thoracotomy was performed, and the mass was found to be a herniated portion of the right lobe of the liver. Undoubtedly, many cases of this kind have been observed in veterans' hospitals and in private practice since the war. If there is no hemorrhage, gangrene, or perforation of the gastrointestinal tract, patients may accustom themselves to living with a surprising degree of diaphragmatic herniation.

In no instance was it possible to correlate the hernia, either in size or location (fig. 63), with the anatomic areas of weakness in which such hernias are prone to occur. Obviously, however, increased abdominal pressure, produced by strain, as a number of cases in this series show, may be the immediate cause of herniations through previously created defects, even when the defect is small.

Pathologic process-A definite sac was demonstrable in only two of the hernias in the series. A membrane frequently covered a part of the herniated structure, but it was not complete. The adhesions present in practically all cases between the affected structures varied in extent and character. At times, it was impossible to separate the herniated structures from the lung without some pulmonary damage. The size of the opening in the diaphragm varied from a defect 1.5 cm. in diameter to one that involved the entire dome and extended into the pericardium.


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FIGURE 62.-Diaphragmatic hernia. A. Posteroanterior roentgenogram 4 months after penetrating wound of right chest. There is no evidence of herniation in this film, and the patient was asymptomatic. B. Same, 1 year later, showing herniation of right lobe of liver.


193

The dome of the left diaphragm was the site of the hernia in 12 of the 28 cases (fig. 63). Contusion defects were located more peripherally and penetrating defects more centrally.

At operation, practically all the organs in the peritoneal cavity were found herniated through the diaphragm, either singly or in various combinations. At one extreme were asymptomatic herniations of the omentum, discovered accidentally at operation for other conditions. At the other extreme were two herniations, each consisting of the kidney, spleen, stomach, small bowel, colon, and omentum. In one of these cases, the structures were densely adherent and completely covered the lateral portion of the diaphragm. In the other, there was an 8-inch tear in the pericardium.

In one case, there was a constricting ring defect around the herniated stomach (fig. 64); if diagnosis had been delayed, ischemic changes, followed by perforation, would undoubtedly have ensued. In one instance, in which previous repair had been done elsewhere, the diaphragm had been severed from its attachments to the posterior chest wall, and a hydronephrotic, congenital bifid kidney had herniated through the defect. It was necessary to mobilize and remove the kidney before repair could be accomplished.

In one case, incarceration of the stomach resulted in progressive gastric distention, and eventually the entire left pleural space was filled with the herniated organ, the lung on that side being completely atelectatic. After the defect in the diaphragm had been enlarged, it was possible to express the air from the stomach through the nasal tube inserted before operation. When this had been accomplished, the adhesions could be separated and the hernia reduced.

Clinical picture and diagnosis-Herniation of solid viscera was associated with vague pain in the lower chest but usually with no other symptoms. Herniation of hollow viscera gave rise to more varied symptoms. In 11 cases, all of combat origin, the initial symptoms were epigastric pain, especially after meals and during recumbency; flatulence; indigestion; and dyspnea, which was practically always present when there was considerable collapse of the lung. Several patients stated that they could hear and feel gurgles in the chest.

If a hollow viscus suddenly herniated through the diaphragmatic defect, the symptoms were more dramatic. In two instances, unconsciousness occurred, not to be accounted for by associated injuries. The degree of pain and the presence of nausea and vomiting depended upon the extent of the herniation and the amount of obstruction it produced.

In some cases, as already mentioned, herniation of the omentum through the diaphragm was discovered unexpectedly, at operation for other conditions. In the four cases in which the liver was the herniating organ, only a presumptive preoperative diagnosis was possible. In one of these cases, the herniation, which was recurrent, was found in the course of exploration of a draining sinus of the chest wall. In two cases, the chest was aspirated, in the belief that the fluid in the herniated stomach and intestines was pleural fluid. No evidence of damage or infection was found at operation in either case.


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FIGURE 63.-Anatomic distribution of 28 diaphrammatic hernias. A. Location of 17 hernias after penetrating chest wounds. B. Location of 11 hernias after contused chest wounds.


195

FIGURE 64.-Diaphragmatic hernia. This hernia was found after a forced march with a heavy field pack overseas; it may have originated in an automobile accident several years earlier. A. Posteroanterior roentgenogram showing hernia. B. Same, showing herniated, barium-filled stomach. Note constricting ring.


196

Surgical repair-All 28 hernias in this series were successfully repaired through a transthoracic approach, usually under endotracheal anesthesia. The excellent exposure so easily obtained by this approach made it preferable to the abdominal approach. In a number of instances, the herniated structures extended up to the dome of the thorax, and the adhesions present could have been handled only with great difficulty through an abdominal incision.

Closure was eventually accomplished in every case in the series, though in some, at first glance, it was doubtful that enough diaphragmatic tissue remained to be useful. After careful dissection, however, enough tissue was developed to permit satisfactory closure in every such case, though it was sometimes necessary to dissect the extension of the diaphragm into the transversalis muscle before closure could be accomplished without tension. Two rows of silk sutures were used, the second burying the first. When the diaphragm was detached from the thoracic wall, secure closure was achieved by using mattress sutures through the chest wall. The sutures were tied over tubes, and another row of interrupted intrapleural sutures was placed.

In the first cases in this series, the phrenic nerve was not crushed unless the line of the defect was such that contraction of the diaphragmatic fibers would exert a pull on the suture line. This technique was later made routine because, in a case in which it had been omitted, a hernia recurred 5 hours after operation, presumably because of excessive movements of the diaphragm during tracheal aspiration. Successful secondary repair was carried out several months later. There was no evidence that paralysis of the diaphragm retarded healing, and earlier experimental evidence by Meade (2) had shown that it did not decrease the tensile strength of the diaphragm.

Drainage was employed only three times, once when a gangrenous colon had to be resected and twice when empyema had preceded the hernia. Water-seal drainage was used in these three cases until the lung had fully reexpanded and obliterated the pleural space. There were varying degrees of pulmonary collapse in all cases in this series, but the lung reexpanded in all without difficulty, no matter how long the collapse had been present.

Postoperative management-The usual routine of postoperative management was employed in these cases. Gastric suction was always instituted, usually for 72 hours. If the patient could not keep the airway clear by his own efforts, endotracheal aspiration was used.

Postoperative complications-There were only three postoperative complications of any consequence. In one case, as already mentioned, there was an immediate recurrence of the hernia. In one case, in which the lung was damaged while it was being separated from the herniated liver, a temporary pneumothorax developed. In one case, there was a postoperative recurrence of the empyema which had complicated the original injury and which had to be treated before repair of the hernia could be undertaken. In three other cases transient pleural effusions appeared, but they disappeared promptly and did not delay recovery.


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HERNIA OF THE LUNG

General Considerations

Hernia of the lung was an extremely infrequent complication of combat-incurred wounds, probably because of the inherent elasticity of pulmonary tissue. This property causes the tissue to contract and retract from the chest wall when intrapleural and intrapulmonary pressures become equal in the presence of the opening into the pleural cavity caused by a chest wound. The concomitant pneumothorax and hemothorax that occur after wounding also act to prevent pulmonary hernias. On the other hand, in view of the considerable number of large chest wall defects observed in forward hospitals, the rarity of pulmonary herniations is remarkable.

According to Funk (3), who made a comprehensive review of the literature in 1918, only three hernias of the lung were reported in the Civil War, and none were recorded in the Crimean War or in World War I. In the South African War (1899-1900), Makins (4), in an extensive experience, observed only one case. Adams (5) found only 5 pulmonary hernias in 20,000 wounds of the chest in the Russo-Japanese War. Up to 1945, only 185 cases had been recorded, most of which were combat-incurred.

Occasional instances of hernias involving single pulmonary lobes were observed, but there was only one instance of true pulmonary hernia (fig. 65) in the 2,267 thoracic and thoracoabdominal wounds in the 2d Auxiliary Surgical Group experience. Of the seven cases recorded from the section of thoracic surgery, Walter Reed General Hospital, Washington, D.C., by Capt. (later Maj.) Elmer P. R. Maurer, MC, and Lt. Col. (later Col.) Brian Blades, MC, six were combat-incurred, and the other was the result of trauma.

Traumatic hernias represent the largest group of pulmonary hernias. They have been reported after crushing wounds, stab wounds, and perforating wounds caused by rifle bullets and shell fragments. They occasionally appear after surgical procedures. The congenital and spontaneous varieties are decidedly infrequent.

In traumatic hernias, the first manifestation is the appearance, usually from several weeks to several months after injury, of a tender swelling in the chest wall, which increases in size on forced expiration and disappears on inspiration. In acute traumatic hernias, the symptoms referable to the hernia are obscured by the symptoms arising from the injury itself.

The diagnosis is usually made without difficulty because of the characteristic behavior of the air-containing tissue. In four cases observed at Walter Reed General Hospital, however, the classical signs and symptoms of pulmonary hernia were present, but at operation no lung tissue was found in the defect in the chest wall. In three of these cases, the liver had herniated into the defect. The clostridial infections which occur in crushing injuries of the chest wall may produce crepitant bulging in soft tissues, but the circumstances make it unlikely that the infection will be confused with a true hernia of the lung.


198

FIGURE 65.-True hernia of lung. A. Anterior view showing retraction of chest wall when patient holds breath. B. Anterolateral view showing bulging on forced expiration. This patient sustained a penetrating shell-fragment wound through the anterior chest wall, with loss, by injury and subsequent debridement, of the third and fourth costal cartilages and the anterior segments of the corresponding ribs. Three weeks after injury, protrusion and retraction of air-conditioning tissue were noted through the defect in the chest wall. The phenomenon was not attended with symptoms. When the patient was evacuated to the Zone of Interior, roentgenograms showed periosteal regeneration and it was thought that, with stabilization of the chest wall, the pulmonary hernia would undergo spontaneous cure.

Management

Because of the infrequency of hernias of the lung, it is not possible to make many definitive statements about their management. Emergency measures were not necessary, and there was no indication for operation overseas. The symptoms could be easily controlled by pressure dressings over the defect, and spontaneous healing was always a possibility.


199

Except for such complications as might be introduced by the wound, there was nothing in the management of pulmonary hernias of traumatic origin encountered in wartime that differed from the management of similar hernias in civilian practice. Operation was always performed under endotracheal anesthesia, to avoid risk when the pleura was opened widely, as well as to leave the lung in the desired state of inflation after operation.

At Walter Reed General Hospital, tantalum plates were employed tentatively, but the method had to be abandoned because of the impossibility of maintaining immobility of the plate on the constantly moving thorax. In the five true hernias in which operation was performed at this hospital, plastic repair was accomplished with structures of the chest wall only (rib, periosteum, and muscle.) The most important feature of the repair was coverage of the defect in the chest wall with sturdy bone or with periosteum that would produce bone. After appropriately located ribs had been divided and released from their periosteal envelopes, they could be shifted until the gap was bridged. They were then anchored in the desired position by pericostal fixation, by suture to the fascia or adjoining periosteum, or by fastening the mobilized rib to an adjacent rib with absorbable sutures threaded through drill holes.

An essential point of repair was the creation of a local pneumothorax, so to speak, by freeing of adhesions and of lung tissue about the margins of the hernia orifice. The pneumothorax thus produced acted as a cushion between the lung and the freshly repaired chest wall and reduced to a minimum the chances that the lung would be forced into the chest wall if the patient coughed or strained immediately after operation, when the repair was weakest.

Case History

Case 5-This 25-year-old soldier sustained a penetrating shell-fragment wound of the right chest on 15 January 1945. Treatment consisted of closure of the wound by suture, intercostal water-seal drainage for 3 or 4 days, and three aspirations of the chest.

When he was admitted to Walter Reed General Hospital about 6 weeks later, his only complaint was mild pain in the right chest, not associated with hemoptysis or cough. A well-healed linear scar, 11 cm. long, was present in the right anterolateral chest. A second, well-healed scar, 9 cm. in length, was present along the vertebral border of the right scapula. Percussion and auscultation of the chest revealed no abnormalities. Roentgenologic examination revealed a metallic foreign body, 7 by 7 mm., and several smaller metallic foreign bodies, in the right lung. A defect in the right sixth rib laterally measured 8 centimeters. It was possible to insert three fingers into this defect for about 1 centimeter. When the patient coughed, as well as on forced expiration, with the glottis closed, there was a definite bulging through the defect.

Operation was performed on 8 June 1945, under endotracheal ether anesthesia, by the following technique (fig. 66):

An incision was made over the defect in the right anterolateral chest wall at the level of the sixth rib. The skin and muscles were divided. When the muscles were dissected free, the lung was exposed. It was found adherent to the chest wall. The adhesions were divided and the lung was separated from the chest wall over an area 10 cm. in diameter.


200

FIGURE 66.-Technique of repair of pulmonary hernia. A. Division of muscles of chest wall (a), disclosing margins of defect (b), adherent lung, and pleural sac (c). B. Release of lung (a) and pleural sac from margins of defect.


201

FIGURE 66.-Continued. C. Development of intercostal muscle bundles, to be used as first layer in closure of defect. D. Approximation of intercostal muscle bundles with medium silk sutures. Development of periosteal flaps from ribs above and below margins of defect.


202

FIGURE 66.-Continued. E. Suture of periosteal flaps over intercostal muscles to form second layer of closure and complete repair.

The periosteum of the fifth and seventh ribs was developed into flaps, which were sutured in place to bridge the defect. The first layer of closure consisted of intercostal muscles brought together with interrupted sutures of medium silk. The ribs were then approximated with retractors, and the two flaps of periosteum were joined with interrupted sutures of medium silk. No effort was made to reinflate the lung, because, as just pointed out, it was desirable to maintain a residual localized pneumothorax for a time. The muscles of the chest wall were brought together with interrupted sutures of fine silk, and the skin was similarly closed, without drainage.

Convalescence was entirely uneventful. The wound healed per primam. The soldier was sent on a convalescent furlough 4 weeks after operation, and when he was reexamined on 14 August 1945, the area of the defect was firm, and there was no evidence of recurrence of the hernia.

RESIDUAL SYMPTOMS

General Considerations

A large number of patients who had sustained chest injuries presented a triad of residual symptoms, consisting of shortness of breath, soreness of the chest, and paresthesias or pains in the affected side. These symptoms were observed at various times after wounding, in both oversea and Zone of Interior hospitals. At the Walter Reed General Hospital, they constituted the most serious obstacle to returning men with chest injuries to full duty within a short period of time.

Dyspnea was usually mild, but it appeared on very little physical exertion, and most patients complained of reduced exercise tolerance. It was often necessary for them to fall out of ranks.


203

Pain was usually vague and usually paresthetic in nature. The patient distinguished it from soreness, which most of them complained of at night, when they tried to sleep on the affected side.

Except for variations in degree, the symptoms were consistent. They bore no discernible relation to the type of injury sustained. They were as frequent in simple penetrating wounds of the chest with no consequences beyond hemothorax as they were in more severe injuries. They occurred whether or not thoracotomy had been performed. They also occurred whether the soldiers were returned to combat duty or were given limited-duty assignments.

Special Studies

When this problem became of importance in thoracic surgery centers in the Zone of Interior in chest casualties who otherwise could have been returned to duty, it was found that very little was known about it. There were no subjective studies of dyspnea on exertion in such cases, and no objective studies by determinations of the vital capacity to investigate possible permanent damage.

At the Walter Reed General Hospital, a study of the intercostal pain and numbness which followed thoracic injury was undertaken by Maj. Donald L. Rose, MC. Three methods were used:

1. The patient was asked to outline the painful area on his chest wall.

2. A complete neurologic examination was made.

3. Skin resistance tests were carried out by the Richter technique, to check the impressions gained by other examinations.

With few exceptions, the patient's own zoning of pain points on his chest wall corresponded with the results of the skin resistance tests. In the few cases in which the results of the examinations did not coincide, it was thought safe to discount the symptoms.

These studies established three practical points:

1. There was no satisfactory treatment for damaged intercostal nerves once they had been injured. Intercostal nerve block provided temporary relief, but, once the immediate effects had disappeared, the pain was sometimes more severe than it had been originally.

2. Injury to a single intercostal nerve did not cause serious residuals.

3. If three consecutive nerves were crushed or cut, prolonged discomfort followed, and it was serious from the standpoint of future vigorous activity.

Major Rose's study showed that residuals from the bruising of a single nerve were of little consequence, whether it was damaged during rib resection or in the course of an intercostal incision. Injury of at least two nerves was necessary to produce symptoms. Pressure transmitted from the rib-spreading retractor was apparently of little consequence.


204

Management

This problem was of extreme importance in military medicine. In civilian practice, it would have been considerably less serious. A civilian with discomfort after a chest injury could generally avoid activity which might aggravate it. The situation was quite different in military service, in which the soldier who was ordered to drill, carry a pack, or perform some other activity had no recourse but to obey orders as long as he was on active duty.

In military practice, furthermore, the medical officer was obliged to make a decision as to the validity of the patient's complaint. He had to consider seriously whether the pain was genuine and severe, or whether the soldier was motivated by a desire to escape active duty or to be separated from service. If the surgeon discounted the symptoms and sent the soldier off to duty when he was really unfit for it, he might do him a serious injustice.

Since the etiologic factors in postwounding discomfort were not clarified during the war, treatment was unsatisfactory. The variable results in nerve block have already been mentioned. Psychotherapy was useful in some cases.

As a result of the study conducted at Walter Reed General Hospital, it was concluded that the solution of the problem was preventive, to exercise extreme care in handling intercostal nerves at operation and to avoid, as far as possible, any surgical technique that might traumatize them unnecessarily. The corollary of this reasoning was that pericostal and perichondral sutures should not be used. Encircling sutures of this kind had been used in a number of the patients observed, with resultant temporary destruction of two or more nerves.

Surgeons at Walter Reed General Hospital believed that it was seldom necessary to employ pericostal and perichondral sutures to accomplish a satisfactory closure of the chest wall. If the wound was posterior, particularly if a segment of rib had been resected, it was not necessary to hold the ribs together by sutures. Even when an intercostal incision was employed, there was usually sufficient tissue to close the defect without fixing the exposed portion of the thoracic cage with encircling ties.

The following technique was found satisfactory for the closure of practically all surgical wounds of the chest:

Interrupted sutures were placed in the intercostal muscles while the ribs or cartilages were brought together with retractors. The placing of the instruments was important: The lower retractor must be placed not in the interspace adjacent to the wound but at least one interspace lower. The pressure from this retractor would be transmitted directly against the nerve on the inferior edge of the rib if it were placed in the adjacent interspace. By placing it one or two interspaces lower, injury to two or three consecutive intercostal nerves, which this study had shown to be responsible for painful sequelae, could be avoided.3

3The reader is referred to chapter XI (p. 441) for long-term followup studies on casualties with a number of the complications of thoracic wounds described in this chapter.


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References

1. Drinker, C. K., and Warren, M. F.: The Genesis and Resolution of Pulmonary Transudates and Exudates. J.A.M.A. 122: 269-273, 29 May 1943.

2. Meade, R. H., Jr.: The Tensile Strength of the Paralyzed Diaphragm. Preliminary Report. J. Thoracic Surg. 2: 503-516, June 1933.

3. Funk, E. H.: Hernia of the Lung, With Report of Case of Spontaneous Hernia of the Right Lung. Internat. Clin. series 28, 1: 102-107, 1918.

4. Makins, George Henry:  Surgical Experiences in South Africa, 1899-1900. London: Smith, Elder, & Co., 1901.

5. Adams, E.: Hernia of the Lung, With Report of a Case of Spontaneous Hernia of the Right Lung. Am. Med. 6 (n.s.): 41-43, January 1911.

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