U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Chapter IX

Contents

PART III

OBSERVATIONS ON WOUNDS AND DISEASES OF THE CHEST IN THE ZONE OF INTERIOR


CHAPTER IX

Management of the Sequelae of Combat-Incurred Wounds, Zone of Interior

Brian B. Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.

STATUS OF RETURNING CASUALTIES

The mission of thoracic surgeons in Zone of Interior hospitals as it related to combat-incurred wounds was twofold, (1) reconstructive surgery and (2) rehabilitation of the casualty. From the time the casualty was wounded, the goal of management was the achievement of a completely healed wound and a fully functioning and expanded lung. When these objectives had been accomplished, the casualty was restored to the physical state in which he could perform the duties expected of a soldier returned to duty or could carry on as a civilian discharged from the Army.

Generally speaking, in all theaters, the status of returning casualties depended upon a number of factors, including the character of their wounds and the evacuation policy existing in the particular theater at the particular time, as well as upon the treatment they had received. During the last year of the war, patients received in Zone of Interior hospitals from the Mediterranean and European Theaters of Operations, U.S. Army, had usually been treated definitively at thoracic centers in Italy or the United Kingdom Base. Most of them had also had some form of reconditioning. By January 1945, from 70 to 75 percent were surgically well when they reached the Zone of Interior. They were well nourished and in excellent general condition. This had not been true of thoracic casualties received in the first months of the war from the North African Theater of Operations, U.S. Army, or for the first month or two of the campaign in Western Europe.

With few exceptions, casualties received from the Pacific Ocean areas were never in as good condition as those received from other theaters. Their state of nutrition and their general physical status were usually considerably below the level of similar casualties received from the Mediterranean and European theaters, and until the end of the war they presented a relatively high incidence of hemothoracic empyema and other complications. For this state of affairs, there were three obvious explanations:

1. The environmental differences between the theaters (terrain, heat, disease, insects, fungous infections, and so forth.


400

2. The longer timelag before initial wound surgery, which was frequently inevitable in the Pacific for logistic reasons.

3. The almost complete lack of experienced thoracic surgeons in all Pacific Ocean areas.

Casualties who required further treatment on their arrival in the Zone of Interior included those with chronic hemothorax or hemothoracic empyema; retained foreign bodies; bronchopleural fistulas; and various defects of the chest wall, including chronic draining sinuses. Those who required no further treatment either were ready for duty after evaluation of their general physical and thoracic status or were at the stage of recovery at which disposition would be possible after 2 or 3 months of reconditioning. Some returned casualties had recovered from their chest injuries but had associated injuries, chiefly peripheral nerve or bone injuries, which prevented their return to duty.

Disposition-Many casualties who were returned to the Zone of Interior could have been sent back to duty overseas except for the time limits imposed on their convalescence by theater holding policies. Had the war lasted longer, there is no doubt that many others who were evacuated to the United States would have been kept in combat zones and returned to full duty. An attitude of extreme caution concerning these casualties was adopted early in the war for several reasons: The initial severity of many wounds; the recollection of the poor physical and thoracic status of so many thoracic casualties in World War I; and lack of experience with casualties managed under new policies, which made medical officers uncertain about their ability to resume full military duty.

This attitude was apparent in the Zone of Interior as well as in oversea hospitals. In October 1943, Maj. (later Col.) Brian Blades, MC, head of the thoracic surgery service at Walter Reed General Hospital, Washington, D.C., wrote to Lt. Col. (later Col.) B. Noland Carter, MC, Chief, Surgery Branch, Surgical Consultants Division, Office of The Surgeon General, that the disposition of soldiers who had undergone lobectomy was creating some difficulty. More than 50 such operations had been performed at Walter Reed General Hospital during the past year, and about half of the patients had already been returned to duty. It was anticipated that many of the others would soon be ready for disposition. Yet, in spite of the excellent results secured, disposition boards seemed to have a great deal of hesitancy in returning to duty men who had had any sort of chest wound or disease, and line officers had a corresponding hesitancy in accepting them for service. The attitude grew more liberal as the war progressed, but the original hesitancy concerning these patients never entirely disappeared.

CLINICAL CONSIDERATIONS

The management of the sequelae and residua of chest injuries observed in Zone of Interior hospitals was conducted on the same general principles and practices as in oversea hospitals. For that reason, and to maintain con-


401

tinuity, most complications have been discussed in detail under special headings, including:

Hemothorax (p. 237).
Hemothoracic empyema (p. 272).
Retained foreign bodies (pp. 325 and 353).
Bronchopleural fistulas (p. 169).
Chest wall defects (p. 181).
Draining sinuses of the chest wall (p. 180).
Lung abscess (p. 175).
Hernia of the lung (p. 197).
Diaphragmatic hernia (p. 186).
Traumatic osteomyelitis (p. 179).

Only a few of these conditions need any further discussion from the standpoint of their management in Zone of Interior hospitals.

ORGANIZING HEMOTHORAX

As a rule, more than 8 weeks had elapsed between their wounding and the reception of thoracic casualties in Zone of Interior hospitals. Most hemothoraces that had been correctly treated originally therefore needed little or no attention on their arrival. Figures from the chest center at the Walter Reed General Hospital are typical: Of the first 107 casualties with hemothorax received, 77 were in satisfactory condition, and in 24 of the remaining 30 patients, the lung reexpanded satisfactorily after continued aspiration. This is an unusually high percentage of good results from conservative treatment after such a timelag.

In the six remaining cases, however, an extensive organizing process had occurred, and four of them furnish interesting lessons concerning the proper management of hemothorax. All four wounds had been caused by rifle or machinegun bullets. All wounds were relatively minor as compared with most of the wounds in the other 103 cases in the series, in all of which recovery was without complications. None of the four wounds had originally been of the sucking type. In no instance was the lung damage extensive. No patient had a history of hemoptysis. In every instance, however, aspiration of the chest had been delayed, apparently because the primary wound was not severe and because respirations were not immediately embarrassed. A single case history will serve as an illustration for them all:

Case 1-This patient, who had sustained a machinegun wound, had his first aspiration 10 days after injury. The procedure was repeated several times, but the largest amount of blood obtained at any aspiration was 180 centimeters. About 30 cc. of air was injected into the chest each time blood was removed.

When this patient was received at Walter Reed General Hospital several weeks after wounding, he was having daily low-grade temperature elevations. He was extremely emaciated. The left chest was flattened, and the expiratory excursion on this side was


402

greatly limited. Thoracentesis yielded only a few cubic centimeters of dark, bloody fluid. It was necessary to open the chest, evacuate the organized clot, and decorticate the lung.

Comment-If this man had been treated originally by simple aspiration of the chest soon after wounding, he would probably have been saved weeks of invalidism and a second operation.

Policies of Management

Organizing hemothorax encountered in Zone of Interior hospitals was treated by exploratory thoracotomy. An overlying rib was resected, the cavity was widely opened by means of a rib spreader, and fluid and organized clots were evacuated. If careful inspection showed no need for further surgery, the chest was closed at once. If it showed that the lung could not reexpand because of the pathologic process present, decortication was performed.

Case 21-A commander of a tank company, wounded in action on 12 July 1944, sustained a penetrating shell-fragment wound of the left chest with a fracture of the eighth rib. Treatment overseas consisted of debridement and closure of the wound on the day of injury, supplemented by two later thoracenteses. When the patient arrived at Halloran General Hospital, Staten Island, N.Y., on 1 September 1944, roentgenograms of the chest (fig. 184A) showed an encapsulated hemothorax on the left side and a shell fragment overlying the seventh intercostal space near the vertebral column. Thoracotomy, performed on 30 October, revealed a cavity containing 150 cc. of old blood clot and a rigid fibrous membrane covering the adjacent portion of the lung. The blood clot was evacuated and the limiting membrane removed, after which the lung was reexpanded. Closure was effected without drainage. Removal of the shell fragment was not attempted. The lung was completely reexpanded on the 15th postoperative day (fig. 184B), and the thoracotomy wound was completely healed at this time (fig. 184C).

Comment-This case history illustrates the successful management of a small chronic hemothorax by decortication. The rigid limiting membrane revealed at thoracotomy contraindicated any other procedure.

Case 3-This soldier sustained a perforating wound of the chest on 29 March 1945; the shell fragment lodged in the soft tissues of the back, at the level of the second lumbar vertebra. No immediate effort was made to aspirate the complicating hemothorax. When the patient reached Halloran General Hospital almost 3 months later, examination showed contraction and marked limitation of motion on the right side of the chest. Roentgenograms showed an encapsulated hemopneumothorax in the right axilla.

Because of an attack of malaria, the patient could not be operated on until 21 July 1945. At this time, exploration revealed a cavity of approximately 300-cc. volume, and a rigid fibrous membrane overlying the lung. The membrane was excised and the wound closed without drainage after the lung had been inflated. The postoperative course was complicated by a second hemothorax, which could not be controlled by aspiration because the blood clotted so rapidly. A second decortication was therefore performed on 13 August, after the blood clot had been evacuated. The wound was closed temporarily with a silk and gauze tampon, which was left in place for 7 days. The cavity finally closed on 1 December 1945.

Comment-The first operation on this casualty was unsuccessful because the blood that had accumulated in the pleura had clotted and could not be removed by aspiration. This is a complication that is always a risk after pulmonary decortication. When post-

1This history and the subsequent case histories in this chapter concern patients observed by Maj. Richmond L. Moore, MC, at Halloran General Hospital.


403

FIGURE 184 (case 2).-Encapsulated hemothorax managed by decortication. A. Posteroanterior roentgenogram of chest showing encapsulated hemothorax on left and metallic fragment in seventh left intercostal space near vertebral column. B. Same, 15 days after evacuation of clot and decortication of lung. Note that lung is completely reexpanded. C. Photograph of patient on 15th postoperative day, showing primary healing of wound.

operative oozing was profuse and difficult to control, as it was in this case, it was safer to establish and maintain some form of closed drainage until the lung had reexpanded and the pleural space was closed.

Case 4-A large encapsulated hemothorax on the right, with areas of calcification in the thickened membrane on the surface of the lung (fig. 185), was an unexpected finding in a soldier who was evacuated from the Aleutian Islands in the spring of 1944. He had no history of a combat injury to his chest, but he stated that in August 1941 he had been knocked down by an automobile. No roentgenograms of the chest were taken at that time. Operation was recommended and refused.


404

FIGURE 185 (case 4).-Traumatic hemothorax. A. Posteroanterior roentgenogram of chest showing large encapsulated hemothorax on right side. Note areas of calcification in thickened membrane on pulmonary surface. B. Lateral roentgenogram showing same findings.

HEMOTHORACIC EMPYEMA

Empyema, most often originating in an earlier hemothorax, was the most frequent complication of wounds of the chest observed in Zone of Interior chest centers. It decreased in frequency as the war progressed, and it also decreased in seriousness, at least in casualties received from the Mediterranean theater and the European theater. The circumstances of the Pacific Ocean areas, as already pointed out, were different and much more difficult. No matter from what theater they were received, however, few patients reflected the effects of the chronic sepsis and general debilitation so typical of similar patients in World War I.

Early in the war, there were many errors in the management of patients with empyema, including the basic error, failure to treat hemothorax by frequent and vigorous aspiration. In a few instances, initial surgery had been ultraconservative, and revision of the thoracotomy was necessary to provide adequate drainage. In most instances, simple revision, combined with intensive physiotherapy, was sufficient, and complete obliteration of the cavity resulted. If additional surgery was necessary, the patient's general condition was invariably greatly benefited by the preliminary revision.

Also early in the war, an occasional patient was received with closed intercostal drainage in effect. This technique created serious problems during transportation, and drainage was never satisfactory. Later, practically all surgeons overseas abandoned this method and treated empyema by dependent open drainage.


 405

Still another error observed early in the war was the placement of the drainage incision. In October 1943, Maj. (later Lt. Col.) William F. Hoyt, MC, reported from the chest center at Hammond General Hospital, Modesto, Calif., that almost all the patients with empyema received there from overseas had been drained anteriorly and their empyemas had become chronic. Major Blades, transmitting this information to Colonel Carter, stated that the same error was being observed in casualties received at the Walter Reed General Hospital chest center. Reoperation was necessary in all such cases to establish adequate drainage.

The following case history illustrates initial errors of management that led to chronic empyema:

Case 5.-This 24-year-old soldier was struck by a machinegun bullet on 22 September 1944. The bullet entered the left chest posteriorly, between the scapula and spine, and emerged anteriorly in the midclavicular line, about 2 inches below the clavicle. The lung was lacerated and the posterior portion of the fourth rib and the anterior portions of the second and third ribs were shattered. Both wounds were sutured about 30 minutes after injury. The next day, both wounds were reopened and debrided, and the lung was sutured. Both wounds were then closed. After this procedure, the anterior wound became badly infected and a left empyema developed.

When the patient was admitted to Halloran General Hospital on 27 December 1944, he had lost 38 pounds (fig. 186). The left chest was contracted and fixed. The anterior wound was still draining, and the opening in the chest wall was large enough to show a large defect in the lung with multiple fistulas. A drainage tube entered a residual empyema at the site of a previous rib resection.

This casualty was transferred to another hospital for definitive treatment, and his subsequent course is not known.

Decortication

Generally speaking, if a well-drained empyema cavity showed no reduction in volume after a period of 6 weeks, the patient was regarded as a candidate for surgical intervention. The only reliable way of determining the volume of the cavity was by its accurate measurement with injected fluid. This test was omitted only if the patient also had a bronchial fistula.

In the Mediterranean theater, where the operation was introduced in World War II, the optimum time for decortication for empyema was considered to be within a range of 3 to 6 weeks after wounding (p. 286). When patients with empyema were received in Zone of Interior hospitals, their infections had practically always become chronic, and the optimum time for decortication had long since passed. As a matter of necessity, the time was extended, and the results were remarkably good.

In 1945, for instance, 67 delayed decortications were performed for organizing hemothorax or chronic empyema at the chest center at Fitzsimons General Hospital, Denver, Colo., with complete restoration of a functioning lung in every instance; in some cases, the preoperative pulmonary function on the affected side had been as little as 10 percent of the normal. This operation, however, when it was delayed, was not the universal answer to the problem,


406

FIGURE 186 (case 5).-Hemothoracic empyema managed by anterior drainage. A. Lateral view of casualty with wound of left chest 4 months after wounding, showing extreme degree of malnutrition, with contraction of left chest. The anterior wound below the left clavicle is the point of exit of the bullet. The wound in the axilla is the site of the rib resection performed 3 months earlier; it leads into the dependent portion of the empyema cavity. B. Posterior view showing wound in left scapular region which is point of entrance of bullet. This wound was completely healed 3 months after wounding. Note the scoliosis secondary to the contraction and fixation of the left chest.

as is shown by the fact that at this center, over the same period, 51 patients with chronic empyema required some type of thoracoplasty.

When decortication was performed weeks and months after wounding, it was frequently difficult to separate the greatly thickened fibrous membrane from the visceral parietes. Some modifications of the standard technique were therefore introduced. At Brooke General Hospital, San Antonio, Tex., the practice was to separate the membrane from the parietal surface as the first step of the operation. The thickened endothoracic fascia was dissected down to the line of reflection from the parietal to the visceral surface. Once this line was crossed, the adhesions were filmy and readily separated. The peel was then freed from the apex to the diaphragm and anteriorly. After this part of the operation had been completed, the lung was reexpanded under positive pressure, and separation from the visceral pleura was accomplished by sharp dissection.

Patients who had undergone decortication overseas were usually in good condition when they reached the Zone of Interior. If there was any residual, it was usually no more than a small basal empyema, readily corrected by open drainage.


407

Other Procedures

If delayed decortication could not be carried out without too great risk of damage to pulmonary tissue, other procedures had to be employed. Internal pneumonolysis was frequently used at the chest center at the Walter Reed General Hospital. The operation began with resection of a rib, followed by wide exposure of the entire empyema cavity, as in decortication. If inspection showed that decortication was not practical, the fibroblastic membrane was incised around the periphery of the empyema cavity. Then the incision was carried through the membrane at the juncture of the parietal and visceral portions. The visceral portion was left adherent to the underlying lung, which was cautiously freed from the involved portion of the chest, preferably by blunt dissection with the gloved fingertip or with a dissecting sponge. After the lung had been freed, it was reexpanded by positive pressure (not more than 10 cm. H2O). As a rule, the empyema cavity was promptly obliterated by this maneuver. Closure was accomplished as in decortication. This operation, which is not a deforming procedure, frequently obviated the necessity for thoracoplasty, which is a deforming procedure.

Physical Therapy

A competent physiotherapist, with special training in the problems of chest conditions, was of great help in the accomplishment of maximum reexpansion of the lung and in overcoming the chest wall deformities commonly seen in chronic empyema and other chest conditions (vol. I).

RETAINED FOREIGN BODIES

It is unfortunate that the Foreign Body Registry, proposed in the 1944-45 report of the Surgical Consultants Division, Office of The Surgeon General, was not instituted, so that permanent records could have been kept on casualties with foreign bodies left in situ. The presumed innocuousness of these objects could then have been established or disproved. The extremely valuable followup information secured by the Peripheral Nerve Registry illustrates what a similar project might have accomplished in thoracic injuries.

Indications for Removal

The indications for removal of foreign bodies in Zone of Interior hospitals were essentially the same as in oversea hospitals. They included their size, their shape (irregularity), the symptoms and signs referable to them, and psychosomatic indications.

Hemoptysis was infrequent. It was observed only twice at the Walter Reed General Hospital chest center and was equally uncommon at other chest centers. Pain, which was the most frequent symptom, was often difficult to evaluate. If the object was peripheral and lay on either the pleural or the


408

diaphragmatic surface, there was little doubt that it was responsible for the complaint, and its removal was advised. Retained missiles were removed in a considerable number of instances, however, in which there was genuine doubt as to the relation between their presence and the patient's complaint of pain, though there was no doubt at all that until psychosomatic difficulties were thus ended, these men would not again be useful soldiers.

The attitude in Zone of Interior hospitals toward retained foreign bodies was, in general, extremely conservative. Of the first 30 casualties in this category received at the Walter Reed General Hospital chest center, 16 were operated on, 12 because of the size of the objects or because of clear-cut evidence of their responsibility for signs and symptoms, and 4 for psychosomatic reasons. The proportion at other centers was about the same. At Fitzsimons General Hospital, for instance, only 68 foreign bodies were removed from the lung during the entire period of its operation; these were chiefly high explosive shell fragments. In 19 other cases, foreign bodies were removed from the chest wall.

Localization Techniques

In addition to routine techniques of localization (p. 332), certain adjunct techniques were used at the various chest centers. All of the centers found the Berman locator of much supplemental value when foreign bodies were deeply embedded in the parenchyma of the lung or in the mediastinum. It could be used to explore any cavity that could be entered surgically. A constant vibratory sound was heard when the tip of the probe approached, or came into contact with, a retained magnetic object, the volume varying directly with the distance between the object and the probe.

Some surgeons employed a visual-radiopaque technique. A few cubic centimeters of methylene blue or gentian violet were mixed with Lipiodol and injected into the chest wall at the point at which the object was nearest to the surface. Routine roentgenograms were then taken.

The angiocardiographic technique employed at the Walter Reed General Hospital chest center was devised by Lt. Col. George P. Robb, MC, chief of the cardiovascular section. This technique, which was used for the accurate localization of foreign bodies in intimate contact with vessels in the mediastinum, was carried out in three steps:

1. The circulation time from the arm to the tongue was determined by the injection of a solution of Decholin (dehydrocholic acid) and the accurate measurement, by a stopwatch, of the lapsed time between the injection and the patient's report of a bitter taste.

2. The lapsed time was determined between the injection of a solution of ether into the arm and its detection on the patient's breath.

3. After these time factors had been determined, the patient was positioned between a stereoscopic cassette, and angiocardiograms were obtained after the intravenous injection of a concentrated solution of Diodrast (iodopyracet). This radiopaque agent, instead of disseminating immediately in the vascular


409

FIGURE 187 (case 6).-Retained foreign body with delayed manifestations due to infection. A. Patient on admission to Halloran General Hospital 14 months after wounding. Scar shows point of entrance of bullet. B. Left anterior oblique roentgenogram showing bullet in right chest opposite tenth intercostal space. C. Lateral roentgenogram showing bullet situated posteriorly just above dome of diaphragm.

system, forms a bolus which can be followed from the point of injection through the cardiovascular system until it is broken up in the peripheral vessels. By evaluation of the previously determined circulation time, the approximate time of opacification of the intrathoracic cardiovascular system could be determined. Separate roentgenograms were made showing contrast filling of the right ventricle and pulmonary arterial tree, the left ventricle and aorta, the right auricle and superior vena cava, and the left auricle and pulmonary veins. With this information, which was usually remarkably precise, it was often possible to determine almost exactly the location of mediastinal foreign bodies in relation to the cardiovascular system in the mediastinum.

Case Reports

Case 6.-A 21-year-old soldier, struck in the right chest by a machinegun bullet on 28 July 1943, made an uneventful recovery. The wound healed satisfactorily, and a complicating hemothorax cleared without aspiration. He had no symptoms referable to his chest until June 1944, when he coughed up a small amount of bright red blood. Another hemoptysis occurred in September. When the patient was admitted to Halloran General Hospital shortly after the second hemoptysis, he was in good general condition (fig. 187A). 


410

FIGURE 188 (case 7).-Retained foreign body without symptoms. A. Posteroanterior roentgenogram of chest 10 weeks after wounding, showing large metallic fragment in left chest at level of tenth dorsal vertebra. Another smaller fragment is seen outside the chest cavity in the axillary tissues. B. Lateral roentgenogram taken at the same time, showing the posterior location of the larger fragment.

Roentgenograms (fig. 187B and C) showed a .25-caliber bullet situated posteriorly on the right side, at the level of the tenth intercostal space. Roentgenograms made after the instillation of Lipiodol showed no evidence of bronchiectasis.

The bullet was removed on 13 October 1944. The space which it occupied, which communicated freely with the bronchial tree, contained a small amount of necrotic material, culture of which revealed hemolytic Staphylococcus aureus. Convalescence was satisfactory except for a small empyema, which healed rapidly after resection and drainage.

Comment.-As this case demonstrates, a foreign body may be embedded in the lung for many months before it causes symptoms. The patient's history suggests that the hemoptyses which finally occurred were secondary to the staphylococcic infection.

Case 7.-This soldier received multiple penetrating wounds of the left chest on 28 July 1944. On 30 July, all wounds were debrided and several readily accessible foreign bodies were removed. When he arrived at Halloran General Hospital on 9 October, he was pale and weak and showed evidence of considerable weight loss. The temperature was 103F., the pulse 120, and the respirations 30. The red blood cell count was 2,270,000 per cu. mm. and the white blood cell count 3,900 per cubic millimeters. The hemoglobin (Sahli) was 7.5 gm. percent. Roentgenograms of the chest (fig. 188) showed a metallic fragment, about 2 by 3 cm., in the posterior portion of the left lung at the level of the tenth dorsal vertebra.

Treatment consisted of penicillin, repeated blood transfusions, and vitamin therapy. A subcutaneous abscess in the left scapular region was drained on 19 October 1944, and 3 pieces of woolen shirt were evacuated with 25 cc. of purulent fluid. Culture of the exudate showed Bacillus coli and nonhemolytic Staph. aureus. After drainage of the abscess, the temperature quickly fell to normal, and convalescence was satisfactory except for an attack of malaria, which responded well to Atabrine (quinacrine hydrochloride). By the middle of November, the patient had gained 19 pounds, and his red blood cells had risen to 4,870,000 per cubic millimeters. The time was considered optimum for removal of the fragment from the left lung, but since he had now become transportable, he had to be reported to the hospital registrar for transfer to another institution for definitive care.


411

FIGURE 189 (case 8).-Retained foreign body without clinical manifestations. A. Posteroanterior roentgenogram about 6 months after wounding, showing metallic shell fragment in right upper lung field. B. Photograph taken at operation 4 months later. The shell fragment can be seen deeply embedded in the lung. C. Photograph of patient 10 days after operation, showing surgical wound over second right interspace.

Comment.-This case is an example of the retention of a metallic foreign body in the lung for many months without symptoms. It also shows the ineffectiveness of penicillin in controlling a suppurative process associated with tissue damage and retained foreign material when the causative organism is not susceptible to it. In this case, it was the fragments of cloth, and not the metallic foreign body, that were responsible for the infection. 

Case 8.-This patient, when struck by a shell fragment on 7 November 1944, sustained a penetrating wound in the right supraclavicular region. Recovery was rapid, and there were no complaints referable to the chest. When he reached Halloran General Hospital, in May 1945, he was in excellent condition and had no complaints. Roentgenograms of the chest (fig. 189A) showed a shell fragment in the right upper lobe of the lung and a healed fracture of the right second rib. The fragment was removed in September 1945 (fig. 189B). Cultures taken from the cavity which it occupied revealed nonhemolytic Streptococcus and nonhemolytic Staph. aureus. Penicillin was given postoperatively. Healing was uneventful (fig. 189C) except for a small pleural effusion that cleared without aspiration.


412

Comment.-This case history is another illustration of the retention of a metallic foreign body in the substance of the lung for many months without symptoms. The fact that this man did not develop a postoperative empyema, in view of the organisms present, is probably to be explained by the use of penicillin.

CHEST WALL DEFECTS

The incidence of serious defects of the chest wall in casualties received in Zone of Interior hospitals was remarkably low, especially in comparison with the much larger proportion of such defects observed in the fewer thoracic casualties of World War I. There were several explanations for the low incidence:

1. The excellent emergency care these casualties received.

2. The low incidence of wound infections, due to the adequacy of debridement at initial wound surgery. The extensive infections and massive sloughing wounds so frequent in World War I were scarcely ever observed in World War II, in spite of the greater destructiveness of World War II weapons.

3. The practice of delayed primary wound closure in fixed hospitals overseas.

4. The supplemental use of the sulfonamides and later of penicillin.

It was usually possible to effect satisfactory repair of chest wall defects by the use of regional tissues; that is, the bones, muscles, fascia, subcutaneous tissue, and skin of the chest. Split-thickness skin grafts were frequently used, and pedicle grafts were used as necessary. In the few instances in which tantalum plates were employed to bridge the defect, the results were disastrous. The plate acted as a foreign body, and if it did not slough out of itself, it had to be removed at a secondary operation.

DRAINING SINUSES OF THE CHEST WALL

The draining sinuses of the chest wall encountered in Zone of Interior hospitals were due to the same causes as those observed overseas; that is, injuries to the costal cartilages (with subsequent infection), retained foreign bodies and other foreign material, unwisely selected suture material, and unwise suture techniques. Infections of the cartilages and unwisely selected suture material were the chief causes; they accounted for most of the 62 draining sinuses treated at the Fitzsimons General Hospital chest center. Associated empyema was surprisingly infrequent, probably as the result of the generally excellent initial treatment of the chest wound.

The principle of management of draining sinuses was removal of the offending material, whether it was necrotic bone and cartilage, foreign material, or suture material. Since all of these wounds were infected, primary closure was seldom successful. On the other hand, there were two objections to leaving the wounds open to heal by granulation. The first was the long convalescence inevitable under this plan. The second was the tendency of


413

granulation tissue to contract, with resultant exposure of the cut edges of previously healthy rib or cartilage.

The most satisfactory technique of repair was as follows: The sinus tracts were fully exposed, with due care to preserve as much healthy skin as possible. The affected cartilages were excised down to healthy tissue, and all foreign material, including sutures, was removed. The wound was then dressed with petrolatum-impregnated gauze and left open. As a rule, clean granulations were observed in 4 to 7 days. As soon as they were evident, the wound surface was covered with a split-thickness skin graft. This simple technique usually resulted in prompt healing and greatly reduced the period of hospitalization required when more complicated techniques were used.

ASSOCIATED WOUNDS

Associated wounds in patients with thoracic injuries referred to chest centers were most often regional fractures and regional nerve injuries. Many ribs were splintered and many scapulas shattered by missiles, and some surgeons thought that such injuries accounted for more residual pain than ordinary fractures. Major Hoyt, at Halloran General Hospital, had the impression that casualties with such fractures took a considerable time to regain their mental equilibrium. Many of them referred repeatedly to the difficulty in breathing they had experienced soon after injury. When hemoptysis was added to the respiratory embarrassment, the experience seemed particularly frightening. These patients required a great deal of individual attention, and their physical recovery progressed more rapidly as their mental status improved.

A number of chest wounds were complicated by nerve injuries, particularly injuries of the brachial plexus. The position at wounding accounted for these injuries. If the soldier was crawling forward on his hands and knees, or was advancing in a bent over position, the supraclavicular area was presented as a target. The entering missile fractured the clavicle and emerged between the scapula and spine or the scapula and ribs. The location of the wound was such that the brachial plexus was implicated in it, and partial paralysis of the arm and hand resulted. Many of these patients had to be transferred to neurosurgical centers for treatment after their thoracic injuries were completely healed.

RETURN TO TABLE OF CONTENTS