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Chapter VII

Contents

CHAPTER VII

Management of Retained Intrathoracic Foreign Bodies, Mediterranean (Formerly North African) Theater of Operations

Lyman A. Brewer III, M.D., and Thomas H. Bur ford, M.D.

INCIDENCE

Experience in the Mediterranean Theater of Operations, U.S. Army, during World War II showed that, exclusive of those in the heart and pericardium, which are discussed separately (p. 49), retained intrathoracic foreign bodies could be anticipated in approximately one out of every four penetrating chest wounds.

The remarkable paucity of recorded cases of retained foreign bodies after World War I leads to two possible assumptions, (1) that the majority of patients from whom missiles were not removed remained symptom-free, or (2) that they were unaware of their condition. In view of the general apprehension known to be felt when casualties were aware that they were harboring foreign bodies, the second assumption seems likely as the explanation of a considerable number of cases.

INDICATIONS FOR SURGERY

Experience with retained intrathoracic foreign bodies in civilian practice was not of great help to military surgeons because in civilian practice, the patient could be observed and the object removed electively if it became symptomatic. In military practice, the surgeon had to decide with reasonable promptness whether the patient could be safely returned to duty with the foreign body in situ, which meant that he had to predict the chances of the development of future complications, including infection.

Wounding agents-Generally speaking, if the foreign body was a bullet, it was less likely to cause complications than if it were a shell fragment or rib fragments.

Bone fragments from fractured ribs furnished a special problem. Such fragments, set in motion by the impact of the missile, were far more apt to produce lung damage, because of their irregular, jagged surfaces, than metallic foreign bodies. They were more frequently found in the lung than were metal-


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lic objects. They were not usually seen on preoperative roentgenograms, and unless they presented themselves on inspection or palpation, they were often not recognized at operation. A prolonged search for them, such as might be undertaken for known metallic objects, was therefore seldom carried out. If, however, they were seen in the lung through the pleural defect after debridement had been completed, particularly if there were extensive lacerations of the pulmonary parenchyma, it was best to remove the fragments and repair the damage without delay.

This was particularly true when the bone fragments were partly in the parenchyma and partly in the pleural space, a location in which they were likely to produce considerable trauma as the lung reexpanded and came into contact with the chest wall. The result was an air leak in some cases, and provision of an avenue of infection in others. Fortunately, bone spicules partly in the lung and partly in the parenchyma were usually found and removed without difficulty.

Accessibility of objects-If it was necessary to explore the pleura in the course of initial wound surgery in thoracic wounds, the obvious course was to remove any accessible foreign objects, regardless of size. This course, however, was not justified if only debridement was required, nor was it employed in the emergency treatment of sucking wounds.

The majority of foreign bodies were located in the periphery of the lung, where their removal was often-though not always-simple because they were accessible (vol. I). The mere presence of an object in the parenchyma, however, was not in itself an indication for its removal.

Size of objects-The size of the object also played a part in the decision for or against removal. Early in the war, and especially with the establishment of the first thoracic surgery center in the North African theater, the policy was adopted of removing all shell fragments 0.8 cm. in diameter or larger seen on posteroanterior roentgenograms. At this time, it was thought that removal would be simple because the location, by palpation, of objects of this size would furnish no difficulty. Later, when the experience was evaluated, it was found that it furnished a great deal, and the policy was therefore changed, so that only foreign bodies of 1.5 cm. in diameter or larger were removed routinely. This policy, which avoided a great deal of pulmonary trauma, proved increasingly satisfactory, and added experience furnished no reason to alter this limit in the absence of other indications for surgery.

There was never any question that very large objects (over 1.5 cm. in length) should be removed, either in the forward or the base area-that is, during other procedures or electively-as soon as possible. Here, the question was one of timing, not of indication. If the objects were small, not more than 1 or 2 cm. in length, they could be let alone unless they were near the heart, a large vessel, or the esophagus; then they were removed. If foreign bodies near vital structures were let alone until complications had developed, their removal was hazardous.


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Infection-It was recognized that the lung and pleura tolerate foreign bodies well and that many of these retained objects were sterile. Many of them, however, were not, for fragments of ribs, bits of clothing, and other debris were often carried into the chest with the missile and furnished a nidus for infection. Infection was particularly likely when the object was irregular. On the other hand, foreign material was not necessarily a source of infection. In one series studied in the Mediterranean theater, a little over half of the foreign objects removed had bits of clothing about them, but in no instance, aside from 4 cases in which lung abscesses had already developed, could positive cultures be obtained from the missile cavity. Unfortunately, it was not possible to predict, without surgical investigation, in which cases foreign material other than the missiles was present and, if it were, in which cases infection would develop.

Pulmonary infection associated with a retained foreign body was also an indication for surgical intervention. Exploration of the chest and removal of the foreign body before infection developed practically always was followed by a speedy recovery, whereas the delayed treatment of a pulmonary abscess about a foreign body was attended with grave risks.

It was necessary to consider the possible presence of a foreign body in any instance of prolonged pulmonary suppuration after wounding. In an occasional case, a drainage tube which had not been securely anchored and had slipped into the chest might be the cause of the trouble. This possibility made it particularly important that the record state clearly the presence and location of all such tubes.1 2

Clinical considerations-Hemoptysis associated with a retained foreign body was a positive indication for its removal (fig. 71).

Pain was a difficult symptom to evaluate. In most instances, it was connected with the wound in the chest wall and had no connection at all with the presence of the object, though it was not always possible to convince soldiers of this fact.

Psychic manifestations, in fact, played an extremely important part in the decision for or against removal. Many men were seriously disturbed by the knowledge that they had one or more shell fragments in the chest. It was repeatedly observed that a patient who harbored a large foreign body in the thigh, for instance, and a very much smaller one in the pulmonary parenchyma, ignored the former and became lung-conscious because of the presence of the latter. Reassurance by the surgeon that the pulmonary object was unlikely to

1Loss of drainage tubes into the pleural cavity seems to be an important cause of chronic empyema. The exact number of such cases encountered in Veterans' Administration hospitals is not clear, but one of the authors of this chapter has performed several operations for this cause. The experience suggests to him that it is important that the presence of a drainage tube be specifically recorded each time a dressing is changed; failure to find it on subsequent dressings would then be an indication for roentgenologic study and an attempt to retrieve it, which is not a difficult matter if it is searched for immediately. Within 48 hours or longer, the pleura may seal over it and surgery may be required for its removal.-L. A. B. III.
2The obvious solution of this problem is, of course, prophylactic-the attachment of a safety pin or other radiopaque marker to every drainage tube.-F. B. B.


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give him trouble sometimes satisfied him, but in borderline cases, of course, no honest guarantee could be given that he would be immune from late complications. In such cases, the policy was to remove the object.

It was also the policy to remove the object when the patient with an intrathoracic foreign body complained of vague pains in the chest, shortness of breath, and other subjective symptoms. If these manifestations persisted, his emotional attitude, quite aside from any physical considerations, would obviously interfere with his return to duty, and the proper course was to remove the retained missile.

Conclusions-The final decision concerning removal was based on a number of factors, including the size and shape of the foreign body; whether there were multiple or single objects; the location of the object or objects; the presence or absence of symptoms which could be attributed to the presence of the object; and the patient's ability to withstand surgery. Objects which had been retained from 10 to 14 days were unlikely to cause immediate trouble, and individualization of each case was therefore possible. As a matter of fact, a theater policy regarding the removal of foreign bodies was necessarily tentative; whether retained objects would give future trouble was a question which could be answered only by followup in the future.

SURGICAL TIMING

Although there was eventually a fair amount of agreement concerning the size of foreign bodies for which removal was indicated, the proper time for operation remained the subject of considerable discussion until the end of the war.

The removal of foreign bodies could seldom be justified as an indication for thoracotomy in forward areas, especially when immediate evacuation to the rear was contemplated. Removal of the objects within 24 to 48 hours, unless they were encountered in the course of initial wound surgery, was generally frowned upon. The surgical risk, the rate of infection, and the morbidity from other causes were all increased when this practice was followed. Experience proved that only a very few objects gave rise to any difficulty if they were left in situ until the patient was evacuated to a fixed hospital (vol. I). It was therefore the policy to leave them undisturbed when thoracotomy was done on some valid indication in a field or evacuation hospital unless they were readily accessible. When the missile could be seen under the fluoroscope to be pointing against a large vessel and moving with each pulsation, prompt removal was obviously indicated.

Very few experienced thoracic surgeons removed retained foreign bodies until at least 14 days after wounding. By this time, pulmonary equilibrium had been reestablished. Traumatic wet lung had been controlled, with reaeration of alveoli, absorption of interstitial fluid, removal of extravasated intrapulmonary blood, and reestablishment of normal tracheobronchial patency.


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Technically, it was far easier to locate metallic fragments in crepitant, aerated pulmonary tissue than in the boggy, indurated tissue present soon after injury. The lung was better able to withstand lobotomy after it had recovered to some extent from the original injury. Finally, secondary closure of debrided wounds had usually been accomplished within the period specified, and the absence of granulating wounds in the chest wall greatly reduced the hazard of infection. The general policy was to close open wounds in the chest wall by delayed primary wound closure at least 24 hours before thoracotomy for removal of retained foreign bodies. The incision for the thoracotomy was then so planned that these wounds were avoided. It was even better if the operation could be deferred until the chest wound was solidly healed, especially if it had to be traversed in performance of the thoracotomy for removal of the foreign body.

The status of the wound in the chest wall played a part in the end results of removal of foreign bodies. In 102 operations in one series (p. 349), 3 of the 4 empyemas which developed after operation were directly attributable to the presence of an unhealed wound in the thoracic wall at the time of operation.

By the policy of delayed surgery, the patient was in a hospital toward the rear, where more detailed study could be made and the decision for or against removal of the foreign body arrived at deliberately, and not under the stress of combat conditions in a forward hospital. Better preoperative and postoperative care was also available in a fixed hospital, in which the patient could be kept as long as was necessary. All the circumstances, therefore, were more favorable for success than they were after a hasty operation performed as an emergency before cardiorespiratory equilibrium was reestablished.

While foreign bodies were frequently removed without difficulty weeks and even months after wounding, long delays were not desirable if it was clear that the objects must be removed. When more than 2 weeks had elapsed, the increased fibrosis present around them sometimes made repair and closure of the parenchymal incision more difficult. Extensive intrapleural adhesions, composed of fibrous tissue, sometimes made it difficult to palpate the object within the lung, and separation of the adhesions was likely to be time consuming and associated with considerable oozing. In addition, the fibrous tissue reaction which had usually developed around the object by this time itself resulted in the creation of a space in the lung that was often difficult to obliterate.

Delay in the removal of the foreign body when its excision was clearly indicated was sometimes necessary because of other wounds. One patient, for instance, with a spinal injury, also harbored a large intrapleural foreign body 6 by 3 by 2 centimeters. The size of the object furnished a clear indication for its removal, but the condition of the patient because of his spinal injury made it impossible to operate on him until 20 days after wounding. By this time, the missile had produced so much erosion of lung tissue that a bronchopleural fistula had formed; empyema had then developed; and a severe intrapleural hemorrhage occurred and was a contributing cause of death. In retrospect, an


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FIGURE 124 (case 1).-Retained foreign body in lung. A. Posteroanterior roentgenogram showing metallic foreign body in upper lobe of right lung immediately after wounding. B. Same, 2 weeks after thoracotomy and removal of foreign body.

earlier attempt to remove the foreign body, in spite of the surgical risk presented by the patient, might have been lifesaving.

The following case reports are not exceptional. They are typical of the favorable results consistently obtained when retained intrathoracic foreign bodies were correctly handled, according to the principles of management standardized in the Mediterranean theater.

Case 1-A U.S. Army nurse, when struck by a bomb fragment on 29 March 1944, sustained a penetrating, sucking wound of the right chest and a right-sided hemopneumothorax. The bomb fragment lodged in the right upper lobe.

The wound of entry was debrided and the sucking wound closed, after which thoracentesis was instituted. Closure was completed by delayed primary wound closure 5 days later.

Fluoroscopic and roentgenologic localization revealed a fragment 1.5 cm. in its greatest diameter lying in the upper lobe of the right lung (fig. 124A). Thoracotomy, without costal section or resection, was done 4 weeks after injury, and the fragment was removed.

The patient made an uneventful recovery (fig. 124B). Her transfer to the Zone of Interior for reassignment was for psychic rather than physical factors.

Case 2-This patient, who was wounded by a high-velocity missile, underwent thorough debridement at an evacuation hospital, after adequate resuscitation, and was evacuated to a thoracic center 4 days after injury. The wound was closed on the fifth day and healing per primam occurred. Aspiration of a hemothorax of moderate size, which had been begun in the evacuation hospital, was continued daily until the pleural space was empty.

Accurate localization of the missile to the posterior portion of the apex of the left lower lobe was accomplished by roentgenologic examination in two planes (fig. 125A and B). Thoracotomy, without costal section or resection, was performed on the 12th day after wounding. The object was removed without difficulty.

Convalescence was entirely uneventful. One week after thoracotomy, the lung was clear and well expanded (fig. 125C), and the pleural space contained neither air nor fluid. Ten days after operation, the wound was solidly healed; the patient was progressively


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FIGURE 125 (case 2).-Retained foreign body in lung. A. Posteroanterior roentgenogram showing missile in left lung field. The obscuration is the result of an organizing peel on the pleural surfaces. B. Lateral roentgenogram. C. Posteroanterior roentgenogram 7 days after thoracotomy and removal of foreign body. Lung is now completely expanded. D. Photograph of patient 10 days after operation. Note well-healed scar and full range of arm motion at this time.


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ambulant; and he had a full range of arm and shoulder motion (fig. 125D). Within 22 days after injury, the reparative phase of management was completed and, after a brief period of rehabilitation, return to full duty was anticipated.

TECHNIQUES OF LOCALIZATION

Thoracotomy for the removal of foreign bodies retained in the pleural cavity and the lungs was a safe and rational procedure only when the preoperative localization of these objects had been sufficiently accurate for their removal without extensive manipulations and an extended search for them. Only by the possession of reliable information concerning their location could there be a logical surgical approach.

General considerations-While all phases of localization were important, the first problem that concerned the thoracic surgeon was whether the foreign body lay within the confines of the pleura or in the extrapleural tissues. Many objects in the chest wall could be removed under local analgesia, and no specialized training was required for their proper management. The object which lay within the pleural cavity necessitated a very different intellectual and technical approach from that which would be used for an entirely extrapleural foreign body in the chest wall. Once the pleural boundary had been crossed, the surgeon was confronted with a host of problems, such as the management of open pneumothorax and the necessity for positive pressure anesthesia, which required specialized training for their solution.

In a war zone, there was frequently not at hand the equipment commonly employed in peacetime for the accurate localization of intrathoracic foreign bodies, such as stereoscopy, the parallax method, and electric locators. That did not mean, however, that accurate localization could not be accomplished in almost every case if cognizance was taken of basic principles and if a systematized plan of study was followed. The plan to be described proved its efficiency in the localization of several hundred foreign bodies in the chest observed in the Mediterranean theater.

Physical examination-Careful palpation, if successful, was the most accurate possible method of determining the location of a foreign body. Palpation soon after wounding might be futile because of tenderness and spasm. When they had disappeared, palpation was frequently very useful.

Case 3-This patient received a chest wound from an enemy machine pistol, the bullet coming to lie in the soft tissues of the posterior thoracic cage. It was easily visualized (fig. 126) by posteroanterior and lateral films. When the patient was admitted to the chest center, the bullet could not be palpated. As spasm and tenderness subsided, it was readily palpable. At operation, it was found lying in the erector spinae muscles and was recovered without difficulty under local anesthesia.

Roentgenologic examination.-The study of a patient with a foreign body in the chest began with routine posteroanterior and lateral roentgenograms. Although in numerous instances, these two views apparently sufficed


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FIGURE 126 (case 3).-Retained foreign body in posterior chest wall. A. Posteroanterior roentgenogram showing missile probably in thoracic wall. B. Lateral roentgenogram. At operation, the missile was found in the erector spinae muscles.

for accurate localization, in general, they were usually considered as little more than scout films, to indicate the direction that subsequent investigation should take. To rely solely upon them could easily lead to grief. That one view was worthless for localizing purposes seems almost too obvious to mention, but occasionally, a patient was encountered whose chest had been explored-fruitlessly-on the basis of a single film.

In the examination of the initial films, the chest was divided into sectors (fig. 127), which made it possible to determine certain facts at once. If the object lay outside of these sectors, it was clear that it was extrapleural. To illustrate:

Let it be assumed that a missile lies on the right side of the chest, in sector B-B (fig. 127). If only the posteroanterior film were examined, the object could lie anywhere in the sagittal plane of the right mid hemithorax. Further examination of the lateral film clarified the matter. If the object lay in the anterior chest wall, it would appear in sector A. If it were in the tissues of the posterior chest wall, it would lie in sector C. Since, in the lateral view, it lay in sector B, it was assumed to lie in the midcoronal plane, and to be intrapulmonary, as it proved to be:

Case 4.-This patient was struck in the right side of the chest by a German rifle bullet. Examination of posteroanterior and lateral films (fig. 127) showed that it lay in sector B-B. At operation, the missile, which was the brass jacket of a rifle bullet, was removed from the right middle lobe.


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FIGURE 127 (case 4).-Localization of intrathoracic foreign bodies by division of chest into arbitrary sectors. A. Posteroanterior roentgenogram showing object in lung. B. Lateral roentgenogram.

Both suspected and unsuspected foreign bodies frequently came to light after withdrawal of fluid or air or both from the chest, with resulting reexpansion of the lung and coincidental changes in position of the object (fig. 128). Such evidence was always looked for on serial films. Foreign bodies observed in serial films to have dropped from apex to base were intrapleural and extrapulmonary. A characteristic positional change related to movement of the shoulder girdle or of large muscle group of the chest wall furnished prima facie evidence that the foreign body was extrapleural.

The following case history illustrates this situation:

Case 5-In this case, the foreign body was found in sector B in the left side of the chest (fig. 129A). It seemed suspended high in the center of a pneumothorax pocket, with no visible means of support. Since it did not drop to the bottom of the pleural cavity, it could not possibly lie free within it. When the lung was completely reexpanded (fig. 129B), there was no significant positional change; the slight change in the axis of the metallic fragment was caused by elevation of the shoulders. This phenomenon was frequently helpful in localizing foreign bodies in and about the scapula and clavicle.

At operation, this shell fragment was removed from a location deep to the pectoralis major muscle, just inferior to the left clavicle.

The closer the foreign body lay to the pleural surface, the more difficult it was to be certain that it lay within the lung tissue. In fact, if it lay in sectors other than B-B, posterolateral and anterior films were inadequate, and recourse to supplemental procedures was necessary.


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FIGURE 128.-Localization of intrathoracic foreign body. A. Posteroanterior roentgenogram showing foreign body in undetermined location. B. Same, after expansion of lung. The change of position of the object with the movement of the lung shows that it is intrapulmonary.

FIGURE 129 (case 5).-Localization of foreign body in chest wall. A. Posteroanterior roentgenogram. B. Reexpansion of lung. Missile has not moved. The change in its axis is explained by the difference in the position of the shoulder girdle in the two views. At operation, it was removed from the chest wall just inferior to the left clavicle.


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FIGURE 130 (case 6).-Localization of intrapulmonary foreign body. A. Posteroanterior roentgenogram. B. Lateral roentgenogram. At operation, the missile was removed from the left lower lobe.

Fluoroscopy-If, during the examination under the fluoroscope, the retained missile was observed to move the distance of an interspace with the respiratory act, it was assumed to be intrapulmonary. If it moved synchronously with the cardiac pulsations, then it might be in the lung or in the mediastinum.

Case 6-This patient, an Italian prisoner of war, was struck in the left chest by a high explosive fragment. On fluoroscopic examination, the object was seen to move synchronously with the respiratory excursions. Posteroanterior and lateral films (fig. 130) showed it lying in sector C-C.

At thoracotomy, it was removed without difficulty from deep in the left lower lobe.

Case 7-This patient was struck in the left chest by a high explosive fragment. Examination of the posteroanterior and lateral films placed the object in sector A-C (fig. 131). It was not possible to determine, from the films alone, that the fragment did not lie outside the bony cage. Fluoroscopy projected the missile within the arc of the ribs and thus in lung tissue.

At thoracotomy, the missile was removed from the left lower lobe.

Fluoroscopic examination was supplemented by spot films made by a special technique whenever the missile was in a peripheral sector and had not been located by other means. Under fluoroscopic visualization, the patient was rotated so that the foreign body was brought to the position apparently nearest to the external thoracic surface. In this profile position, as the following case shows, it was usually possible to determine whether the object was extrapleural, intrapleural, or intrapulmonary. Spot films were made for more deliberate study:


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FIGURE 131 (case 7).-Localization of foreign body in lung. A. Posteroanterior roentgenogram showing missile on left in indeterminate position. B. Lateral roentgenogram, which is equally inconclusive. Fluoroscopy was necessary in this case to localize the object in the left lower lobe.

Case 8.-This patient was wounded by a high explosive fragment. The foreign body lay in sector A-B (figs. 132A and B). When objects were in this location, it was impossible, without supplemental studies, to be certain that they lay intrapleurally or extrapleurally. Utilizing fluoroscopy, with rotation of the patient, an additional roentgenogram (fig. 132C) showed that the object lay outside the lung surface. Since, furthermore, it was projected external to the inner margin of the rib, it necessarily lay in the thoracic wall and not within the pleural cavity. The straight line of increased density shown in the roentgenogram in this position was due, as in similar cases, to an extrapleural hematoma associated with the metallic object deep in the thoracic wall.

Diagnostic pneumothorax-If the issue was still in doubt, the matter could usually be promptly settled by diagnostic pneumothorax (fig. 133). When air was injected into the chest and the foreign body underwent positional changes coincidental with those observed in the lung, it was obviously intrapulmonary. If it remained in its original position, as in the following case, it was obviously extrapulmonary.

Case 9.-This patient sustained multiple penetrating chest wounds from high explosive fragments. Two objects lay in the soft tissues of the lower lateral chest wall (fig. 134). The third object lay in sector B-C, in which supplemental studies are practically always required. Diagnostic pneumothorax did not alter the position of the fragment.

The extrapulmonary location of the object, as indicated by fluoroscopy, was confirmed by operation, at which it was removed through a simple incision over the ninth interspace.

A combination of fluoroscopic examination and pneumothorax also settled the location of foreign bodies lying partly in the extrapleural tissue and partly intrapleurally. This was a particularly important variety of retained object


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FIGURE 132 (case 8).-Localization of foreign body in chest wall. A. Posteroanterior roentgenogram showing missile in undetermined position. B. Lateral roentgenogram, which is also indeterminate. C. Roentgenogram taken after rotation of patient to bring foreign body to profile position. It is now seen to lie in the thoracic wall.

(p. 326). In the following case, the development of a hemopneumothorax served the purpose of an artificial pneumothorax and clarified the position of the fragment:

Case 10-This patient was wounded by a penetrating high explosive fragment. Posteroanterior and lateral roentgenograms showed it lying in sector B-B. Since it was quite large, it was thought that accurate localization might be difficult. Later, when the patient developed a hemopneumothorax, the definite rotation of the object (fig. 135) showed that it must be within lung tissue.

The diagnosis was confirmed at operation.

Pneumothorax was never instituted until a competent thoracic surgeon or other medical officer had stated that it could safely be used. Lung puncture and hemorrhage were always possibilities. The use of this method was limited.


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FIGURE 133.-Localization of foreign body in chest wall. Posteroanterior roentgenogram after small artificial pneumothorax. In this case, both plain roentgenography and fluoroscopy had failed to localize the object.

FIGURE 134 (case 9).-Localization of foreign bodies in chest wall. A. Posteroanterior roentgenogram showing two objects in soft tissues of lower lateral chest wall and a third possibly within the lung parenchyma. B. Lateral roentgenogram showing the position of the third fragment was not altered by diagnostic pneumothorax. It was removed at operation by a simple incision over the ninth interspace.


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FIGURE 135 (case 10).-Localization of foreign body in lung. A. Posteroanterior roentgenogram showing foreign body in indeterminate position. B. Lateral roentgenogram. C. Posteroanterior roentgenogram showing change in position of foreign body with development of hemopneumothorax.


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FIGURE 136.-Localization of foreign body in diaphragm. A. Posteroanterior roentgenogram of chest and upper abdomen. B. Left lateral roentgenogram. C. Oblique view after induction of artificial pneumoperitoneum. The diaphragm is shown in profile in this film, and the foreign body is clearly seen embedded in it. The localization was found correct at operation.

A special technique was required, in which relatively few medical officers were trained, because of the decreasing use of pneumothorax in the treatment of tuberculosis.

Diagnostic pneumoperitoneum-Foreign bodies about the diaphragm were notoriously difficult to localize. It was frequently necessary to induce a diagnostic pneumoperitoneum to establish their exact location (figs. 136, 137, and 138). Once it had been induced, posteroanterior and lateral films were made in the upright position, sometimes supplemented by oblique films and films in the lateral decubitus. If these studies produced even a single view showing


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FIGURE 137 (case 11).-Localization of foreign body in diaphragm. A. Posteroanterior roentgenogram showing foreign body in vicinity of diaphragm. B. Posteroanterior roentgenogram after pneumoperitoneum showing object possibly in abdomen. C. Lateral roentgenogram showing foreign body in diaphragm.

the foreign body above the diaphragm, it was evident that the location was intrathoracic and not subdiaphragmatic, as the following cases show:

Case 11-This patient sustained a wound of the left chest from a high explosive fragment. Posteroanterior and lateral views (fig. 137) showed it lying in sectors A-B, in the vicinity of the diaphragm, a location in which accurate localization was always more difficult. After pneumoperitoneum had been induced, additional films left the location still undecided. A third film (fig. 137C) definitely located the object in the superior substance of the diaphragm.


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FIGURE 138 (case 12).-Localization of foreign bodies. A. Posteroanterior roentgenogram showing three foreign bodies in right chest (No. 1 extrapleural, No. 2 undetermined location, No. 3 in abdomen). B. Lateral roentgenogram showing same positions. C. Profile roentgenogram after pneumoperitoneum. Object No. 2 in this film is seen projected in the lung tissue; at operation, it was found in the middle lobe of the lung. D. Oblique roentgenogram showing right costal margin. In this view, object No. 3 lies outside the substance of the liver.


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FIGURE 139.-Localization of foreign body in mediastinum. A. Lateral roentgenogram showing foreign body in mediastinum. At operation, it was found to be associated with abscess formation. B. Posteroanterior roentgenogram 2 weeks after thoracotomy, removal of object, and evacuation of abscess. Recovery was uncomplicated, without mediastinal or pleural complications.

In this case, as in a number of similar cases, the oblique view was decisive.

Case 12-In this case, as in the preceding case, it was necessary to induce pneumoperitoneum to secure exact localization of three foreign bodies (fig. 138). Posteroanterior and lateral films showed one object to be extrapleural, lying in the soft tissues of the chest wall. The second object lay in the anterior costophrenic region above the diaphragm, though whether it was intrapulmonary or intrapleural was not clear. A profile view (fig. 138C) projected the missile in lung tissue, thus proving that it did not lie in the intercostal soft tissues. A third object lay outside the substance of the liver (fig. 138D).

At thoracotomy, the second object was found lying in the substance of the middle lobe of the lung.

Pneumoperitoneum, like pneumothorax, had to be used with care and judgment. It was never employed in the presence of intra-abdominal infection. If abdominal surgery had been performed recently, satisfactory air caps, because of adhesions, were not usually seen over and around the liver. If the object was on the left side, a 2-gm. dose of sodium bicarbonate given orally 15 minutes before the films were made frequently produced enough gaseous distention for a satisfactory outline of the left diaphragm. In an occasional case, both pneumothorax and pneumoperitoneum had to be employed diagnostically to achieve definitive localization of the object.


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FIGURE 140 (case 13).-Localization of foreign bodies in lung and mediastinum. A. Posteroanterior roentgenogram showing one foreign body in lung and other either in lung or mediastinal tissue. B. Lateral roentgenogram showing same indeterminate location of second object. At operation, it was found just under the mediastinal pleura.

Localization of mediastinal foreign bodies.-Mediastinal foreign bodies sometimes offered difficulties of localization (figs. 139 and 140). They were most often found in sector C-B and in this location were frequently observed to move synchronously with the cardiac pulsations. On the left side, in this location, they might be either cardiac or pericardial problems. Differential diagnosis required careful study and consideration:

Case 13-This patient received multiple wounds of the extremities and the right side of the chest when a shell exploded close to him. Examination of the posteroanterior film (fig. 140A) showed two foreign bodies. The first lay in sector B-B and was clearly in the intrapulmonary substance. The second lay in sector C-B, which made it necessary again to differentiate between an intrapulmonary and a mediastinal location.

At operation, the second object was found in the mediastinum, just under the mediastinal pleura.

The evaluation of mediastinal foreign bodies was also important from another standpoint, the possibility of injury of the esophagus. If this suspicion existed, operation was a matter of extreme urgency. Overlooked esophageal perforations were attended with a very high mortality. Moreover, the surgical approach was different from that employed in the removal of intrapleural, intrapulmonary, and other mediastinal foreign bodies. Patients were questioned explicitly concerning any symptoms which might point to esophageal injury, particularly dysphagia.

It was difficult to differentiate some intrapulmonary missiles from missiles located in the mediastinum, but, since the surgical approach was the same in both instances, the differentiation was academic rather than practical.


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FIGURE 141.-Localization of foreign body in intrapleural space. A. Posteroanterior roentgenogram showing object in either intrapleural or intrapulmonary location. B. Lateral roentgenogram, which also does not differentiate the position. At operation, the object was found free in the intrapleural space. In this case, clotted hemothorax prevented the use of diagnostic pneumothorax.

SURGICAL TECHNIQUE

The fundamental surgical principle of adequate exposure was particularly important in the removal of foreign bodies from the lungs. Skin and muscle incisions had to be wide enough to permit access to at least two interspaces when the bony thoracic cage was exposed. If precise localization had been accomplished and if the lung was adherent to the chest wall, it was sometimes possible to remove the object without entering the free pleural space.

When the object was deeply embedded in the lung, an opening into the pleura was necessary and had to be large enough to permit palpation and adequate exposure.

A posterior incision was usually employed, without division or resection of the ribs. A short incision was made into the lung, at the point at which localization procedures, confirmed by palpation, had indicated that the foreign body was nearest the surface. When operation was performed soon after wounding (within 14 days), there was, as a rule, little or no reaction about it.

Localization was sometimes less accurate than desirable because the presence of a clotted pneumothorax prevented the use of diagnostic pneumothorax (fig. 141). Hemothorax or hemothoracic empyema sometimes complicated the situation at operation also. Decortication, in some cases, had to be carried out before a search for the object was undertaken, as it was not possible to palpate a


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FIGURE 142 (case 14).-Intrapleural foreign body associated with massive empyema. A. Posteroanterior roentgenogram showing intrapleural metallic object (arrow) with associated clotted hemothorax, which went on to massive hemothoracic empyema. B. Same, 10 days after removal of foreign body and decortication of lung. Recovery was complete.

fragment through the inelastic rind. If the hemothorax involved only a single lobe, decortication was also preferable to an extended and difficult search for the foreign body. Associated abscesses were either curetted out or, if the lesion was peripheral, were managed by wedge resection.

Closure was by the silk technique throughout. The lung was closed in two layers, the pleura being inverted with the second layer. Sutures were placed in the intercostal muscles and tied after the ribs had been approximated. Pericostal sutures were avoided.

The chest was ordinarily drained with both anterior and posterior intercostal water-seal tubes. The use of the anterior tube, which was usually removed within 48 hours, insured prompt expansion of the upper lung. The posterior tube was kept in place for 3 or 4 days.

In the early experience, penicillin was used intrapleurally, but this practice was subsequently discarded, and the antibiotic was used systemically before and after operation.

The following case history illustrates the successful management of foreign bodies associated with massive empyema:

Case 14-This patient was struck in the right chest by a bomb fragment on 26 March 1944, sustaining a severe penetrating wound, with hemothorax. A metallic foreign body was retained in the affected area.

The wound was debrided, and repeated aspiration was employed. This procedure, at first effective, later ceased to be useful, and the patient developed fever and other symptoms and signs of sepsis. Roentgenograms revealed a right clotted hemothorax in addition to the retained foreign body (fig. 142A). Material aspirated from the right chest became


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progressively more purulent and more offensive in odor. Cultures grew proteolytic clostridia.

Under penicillin protection, a thoracotomy was done 21 days after injury, with removal of the foreign object and decortication of the lung.

Recovery was prompt and uneventful (fig. 142B). The patient was discharged to full duty on 5 June 1944, about 10 weeks after injury.

ANALYSIS OF CASES

In a series of 1,058 penetrating wounds of the chest observed by surgeons of the 2d Auxiliary Surgical Group in the Mediterranean theater, an experience which may be assumed to be typical, there were 291 retained intrathoracic foreign bodies, exclusive of foreign bodies in the heart and pericardium. Of these, 39 were intrapleural and 252 intrapulmonary and mediastinal. Since the great majority of these patients were under observation in thoracic surgery centers for periods ranging from a week to 2 months after injury, this series offered an excellent opportunity to determine what happens to retained intrathoracic missiles within this period after wounding.

Preoperative Complications

The following complications, which developed during the periods of observation, represent the ill effects of retained foreign bodies:

In the 252 intrapulmonary and mediastinal foreign bodies, there were 4 delayed or recurrent hemoptyses; 2 secondary intrapleural hemorrhages from the lung; 18 late or recurrent bronchopleural fistulas; 4 lung abscesses; 2 mediastinal abscesses associated with the retained objects; and 30 empyemas.

In the 39 intrapleural foreign bodies, there were 15 empyemas.

The total complications in these 291 cases were thus 75 in number, 25.8 percent; 60 were associated with the 252 intrapulmonary and mediastinal objects and 15 with the 39 intrapleural objects.

There was no correlation in this study between the incidence of complications and the size and configuration of the missiles. There was also no correlation as to location except in one regard, that missiles located in the periphery of the lung gave rise to a higher incidence of complications than those in the hilus. This observation was at variance with the popular concept that a missile lying in close proximity to vascular or bronchial structures in the hilus was more likely to give rise to complications than a missile in the periphery. The explanation may be that missiles that lodged at or near the hilus were missiles that had lost their momentum. Those that tore through it usually lacerated the major divisions of the pulmonary artery or vein, with rapid death by exsanguination. Surgeons who worked in field hospitals almost never saw a casualty with damage to a major pulmonary vessel. These casualties did not live long enough to be hospitalized.


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These figures are significant in view of the numerous discussions concerning the relative incidence of empyema in intrapleural versus intrapulmonary retained foreign bodies. In the 39 intrapleural cases, empyema occurred 15 times, an incidence of 38.5 percent. In the intrapulmonary group of 252 objects it occurred 30 times, an incidence of 11.9 percent, which is strikingly close to the overall incidence of empyema in chest wounds in the Mediterranean theater. This observation corroborated the opinion generally held by thoracic surgeons that intrapleural foreign bodies were far more likely to give rise to trouble than intrapulmonary missiles.

The majority of the complications, almost 75 percent, developed during the second and third weeks after injury. Aside from the empyemas, the earliest complication observed was a lung abscess which appeared a week after injury. Only 4 complications, none in the intrapleural group, developed earlier than 10 days after wounding. The earliest complications were usually hemorrhage, atelectasis, pneumonitis, and pulmonary embolus. Lung abscess was extremely uncommon (at all times), though in this series it was the first complication to be observed, 7 days after wounding.

Results of Surgery

Surgery was carried out in 102 of these 291 retained foreign bodies, in 15 instances for intrapleural objects and in 87 for objects in the intrapulmonary or mediastinal tissues (fig. 143). In five instances, the object was not removed, for various reasons, and in four instances, it was not found at the site expected from the preoperative localization.

There were no deaths in the 102 operations and no instances of permanent disability or deformity. The 13 postoperative complications were distributed as follows: 3 wound infections; 4 empyemas (3 small, resulting from subjacent extension of the wound infection to the pleural cavity and 1 basal, unrelated to wound infection); 1 clotted hemothorax; 1 atelectasis; 1 secondary hemorrhage; 2 bronchopleural fistulas; and 1 thrombophlebitis. None of these complications resulted in prolonged disability.

About half of the retained objects, as previously mentioned, were found with associated cloth fragments at the site of lodgment, but, except in the four lung abscesses, no positive cultures were obtained from the missile cavities.

Conclusions

Although the series is small, these figures are important, since they overturn many misconceptions as to the innocuousness of retained intrathoracic missiles. An incidence of 15 percent of significant complications within the first 60 days after wounding points to the fact that the retained missile is, on the contrary, a real source of danger to the host and must be considered seriously in the reparative management of every case. On the other hand, the fact that so few complications developed earlier than 10 days after wounding justified


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FIGURE 143.-Specimens of metallic foreign bodies removed from lungs and pleural cavity.

the policy of waiting until the patient had arrived in a fixed hospital to remove the missile.

This comparison definitely favors the removal of retained foreign bodies, though not statistically. The incidence of postoperative complications, when surgery was done at the thoracic surgery center in this series was approximately 13.4 percent, while the incidence of complications encountered when the foreign bodies were not removed was 15 percent. Statistically, this is a totally insignificant difference, almost an argument, in fact, for leaving these objects in situ. Clinically, however, the balance is all in favor of their removal at the proper time and on the proper indications. The complications of retained foreign bodies are all debilitating, and many of them are potentially fatal. The properly staged removal of these objects, however, is attended with a minimal mortality-there were no deaths in this series-and with a low morbidity.

Much remains to be learned concerning the question of retained foreign bodies in penetrating thoracic wounds. This analysis of a small series of cases


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is not conclusive, and final statistics are not yet available. The analysis, however, does show the fallacy of the opinion that it can be confidently anticipated that such objects will do no harm, and it also vindicates the Mediterranean theater policy of removing all objects larger than 1.5 cm. in their greatest diameter, preferably within the first 14 days after injury, after the patient has been evacuated to the base.

Final appraisal must await long-term followup studies on both the group in which the object was retained and the group in which it was removed.3

3The reader is referred to chapter XI (p. 441) for long-term followup studies on casualties with retained foreign bodies in the chest.

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