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MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR II

THORACIC SURGERY

Volume II

Prepared and published under the direction of
Lieutenant General LEONARD D. HEATON
The Surgeon General, United States Army

Editor in Chief
Colonel ARNOLD LORENTZ AHNFELDT, MC, USA

Editor for Thoracic Surgery
FRANK B. BERRY, M.D.

Associate Editor
ELIZABETH M. McFETRIDGE, M.A.

OFFICE OF THE SURGEON GENERAL
DEPARTMENT OF THE ARMY
WASHINGTON, D.C., 1965

Contents

FOREWORD

PREFACE

Part I

SPECIAL TYPES OF WOUNDS OF THE CHEST

Chapter I. Special Types of Thoracic Wounds (Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.)

Wounds of the Chest Wall
Sucking Wounds
Fractures of the Ribs and Adjacent Structures
Wounds of the Lungs
Wounds of the Mediastinal Structures
Wounds of the Trachea and Bronchi
Wounds of the Esophagus
Crushing Injuries
Blast Injuries
Associated Wounds

II. Wounds of the Heart (Including Retained Foreign Bodies), Mediterranean (Formerly North African) Theater of Operations (Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.)

Incidence
Clinical Picture and Diagnosis
Cardiac Tamponade
Pathologic Process
Pericardial Injuries
Contusions
Lacerations
Penetrating and Perforating Wounds
Migratory Foreign Bodies
Stab Wounds
Injuries of the Great Vessels
Management of Cardiac Wounds
Technique of Cardiac Surgery
Analysis of Cases

III. Thoracoabdominal Wounds (Lyman A. Brewer III, M.D.)

General Considerations
Pathologic Process
Diagnosis
Exploration
Resuscitation and Preoperative Preparation
Anesthesia
Surgical Approach
Incision
Technique
Special Surgical Considerations
Postoperative Care
Management in Base Hospitals
Case Histories
Experience of the 2d Auxiliary Surgical Group

Part II

COMPLICATIONS OF WOUNDS OF THE CHEST

IV. Complications and Sequelae (Thomas H. Burford, M.D.)

Tension Pneumothorax
Hemorrhage
Acute Gastric Dilatation
Emphysema
Pulmonary Edema
Atelectasis
Hematoma of the Lung
Bronchopleural Fistula
Wound Disruption
Clostridial Myositis
Chylothorax
Lung Abscess
Mediastinal Abscess
Pneumonitis and Pneumonia
Traumatic Osteomyelitis
Chronic Sinuses of the Chest Wall
Defects of the Chest Wall
Adhesive Pleuritis
Diaphragmatic Hernia
Hernia of the Lung
Residual Symptoms

V. Wet Lung (Thomas H. Burford, M.D.)

Concept and General Considerations
Pathogenesis and Pathophysiology
Etiologic Factures
Clinical Picture
Diagnosis
Prophylaxis
Management
Results of Therapy
Case Histories

VI. Hemothorax and Hemothoracic Empyema (Thomas H. Burford, M.D.)

General Considerations
Incidence of Hemothorax and Its Complications
Pathogenesis of Organizing Hemothorax
Pathologic Changes in Chronic Traumatic Hemothorax
Bacteriology of Organizing Hemothorax
Physiopathology of Hemothorax
Clinical Picture and Diagnosis
Management of Simple Hemothorax
Clinical Picture and Diagnosis of Hemothoracic Empyema
Empyema in the World Wars
Management of Infected Hemothorax and Hemothoracic Empyema
Decortication of the Lung
Technique of Decortication
Postoperative Management After Decortication
Decortication in Empyema of Nontraumatic Origin
Special Studies of Pulmonary Decortication
Case Histories

VII. Management of Retained Intrathoracic Foreign Bodies, Mediterranean (Formerly North African) Theater of Operations (Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.)

Incidence
Indications for Surgery
Surgical Timing
Techniques of Localization
Surgical Technique
Analysis of Cases

VIII. Management of Retained Foreign Bodies in the Heart and Great Vessels, European Theater of Operations (Dwight E. Harken, M.D.)

Anatomic Location of Missiles
Foreign Bodies In and About the Heart
Foreign Bodies In and About the Great Vessels
Migratory Intravascular Foreign Bodies
Experiences at the 155thGeneral Hospital Thoracic Surgery Center

Part III

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

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
Clinical Considerations
Organizing Hemothorax
Hemothoracic Empyema
Retained Foreign Bodies
Chest Wall Defects
Draining Sinuses of the Chest Wall
Associated Wounds

X. Surgical Aspects of Diseases of the Chest (Brian B. Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.)

Bronchiectasis
Pulmonary Tuberculosis
Lung Abscess
Empyema
Actinomycosis
Spontaneous Pneumothorax of Nontuberculous Origin
Malignant Neoplasms
Lesions of the Esophagus

XI. Long-Term (1943-61) Followup Studies in Combat-Incurred Thoracic Wounds (Lyman A. Brewer III, M.D.)

Background of Study
Materials and Methods
Basic Data
Therapeutic Classification
Initial Wound Surgery
Subsequent Surgery
Mortality and Disposition
Wounds of the Chest Wall
Lacerations of the Lung
Mediastinal Injuries
Blast Injuries
Thoracoabdominal Wounds
Hematoma
Wet Lung
Hemothorax
Retained Foreign Bodies
Postdischarge Followup
Summary and Conclusions

APPENDIX

Special Reports and Statistical Data (B. Noland Carter, M.D., and Michael E. DeBakey, M.D.)

Illustrations

FIGURE:

Appendix figures:

1. Posteroanterior roentgenogram showing large foreign body in contact with esophagus.
2. Posteroanterior roentgenogram showing Lipiodol visualization of bronchopleural fistula, narrow empyema track, and drainage site at some distance from fistula.
3. Posteroanterior roentgenogram showing pneumonitis and fibrosis associated with retained foreign bodies.
4. Foreign bodies in contact with large blood vessels.
5. Retained foreign bodies giving rise to infection.
6. Retained foreign bodies giving rise to symptoms.
7. Early thoracotomy without drainage in penetrating bullet wound of chest.
8. Early thoracotomy without drainage in penetrating shell-fragment wound of right chest.
9. Early thoracotomy without drainage in perforating wound of right chest.
10. Observations at decortication.
11. Infected organized hemothorax managed by decortication.
12. Infected hemothorax and total empyema.

Color Plates

I.     Appearance of heart at instant of incision into right ventricle
II.    Technique of dislocation of heart from pericardial sac
III.   Marked ventricular dilatation following dislocation of heart

Tables

1.    Blast injuries of nonbattle origin, by numbers of admissions and deaths, and by area, 1942-45
2.    Battle-incurred blast injuries, by numbers of admissions and deaths, and by area, 1942-45
3.    Battle-incurred blast injuries of thorax and thoracoabdominal region, by numbers of admissions and deaths, and by area, 1944
4.    Battle-incurred blast injuries of thorax and thoracoabdominal region, by numbers of admissions and deaths, and by area, 1944
5.    Distribution of injuries and anatomic involvements in 56 combat-incurred cardiac injuries
6.    Distribution of 27 deaths in 56 combat-incurred cardiac injuries
7.    Frequency of wounds and case fatality rates in 903 thoracoabdominal wounds according to combinations of viscera
8.    Case fatality rate according to timelag in 854 thoracoabdominal injuries
9.    Case fatality rate according to surgical procedure in 903 thoracoabdominal wounds
10. Number of admissions and deaths for lung abscess, by area, 1942-45
11. Number of secondary cases of lung abscess, by area, 1944-45
12. Incidence, admissions, secondary diagnoses, and deaths from diaphragmatic hernia, by area, 1944-45
13. Admissions for empyema of the chest, by area, 1942-45
14. Distribution of 20 percent sample of secondary cases of empyema of the chest, by area and type of admission
15. Admissions for bronchiectasis, by area, 1942-45
16. Operations for pulmonary tuberculosis, Fitzsimons General Hospital, 1944-45
17. Incidence of malignant neoplasms of respiratory system and of esophagus, by area,1944-45
18. Morbidity and mortality from malignant neoplasms of respiratory system and of esophagus, 1944-45
19. Deaths due to malignant neoplasms of respiratory system and of esophagus, by area,1944-45
20. Thoracic damage in 167 followed-up thoracic casualties according to surgical procedure in forward hospitals
21. Associated injuries in 167 followed-up thoracic casualties according to surgical procedure
22.  Intra-abdominal damage in 81 followed-up thoracic casualties according to surgical procedure
23.  Complications in forward and fixed hospitals in 167 followed-up thoracic casualties according to surgical procedure in forward hospitals
24.  Surgery required in fixed hospitals according to surgery performed in forward hospitals

MEDICAL DEPARTMENT
UNITED STATES ARMY
IN WORLD WAR II

NOTE

This volume was written and edited under the direction and supervision of Colonel John Boyd Coates, Jr., MC, USA, former Director and Editor in Chief, The Historical Unit, U.S. Army Medical Service.

ARNOLD LORENTZ AHNFELDT,
Colonel, Medical Corps,
Editor in Chief.

SURGERY IN WORLD WAR II

Advisory Editorial Board

                                                        MICHAEL E. DEBAKEY, M.D., Chairman
                                    FRANK B. BERRY, M.D.                     JOHN B. FLICK, M.D.
                                    BRIAN B. BLADES, M.D.                    FRANK GLENN, M.D.
                                    J. BARRETT BROWN, M.D.                M. ELLIOTT RANDOLPH, M.D.
                                    STERLING BUNNELL, M.D. (dec.)     ISIDOR S. RAVDIN, M.D.
                                    NORTON CANFIELD, M.D.               JOSEPH R. SHAEFFER, M.D.
                                    B. NOLAND CARTER, M.D.              ALFRED R. SHANDS, Jr., M.D.
                                    EDWARD D. CHURCHILL, M.D.       HOWARD E. SNYDER, M.D.
                                    MATHER CLEVELAND, M.D.            R. GLEN SPURLING, M.D.
                                    DANIEL C. ELKIN, M.D. (dec.)          BARNES WOODHALL, M.D.
                                                                    ROBERT M. ZOLLINGER, M.D.
                                                Brigadier General DOUGLAS B. KENDRICK, Jr. (ex officio)
                                                        Brigadier General JAMES E. GRAHAM (ex officio)
                                                    Colonel JOHN BOYD COATES, Jr., MC, USA (ex officio)

The Historical Unit, United States Army Medical Service

Colonel ARNOLD LORENTZ AHNFELDT, MC, USA, Director
CHARLES J. SIMPSON, Executive Officer
Lieutenant Colonel GILBERT A. BISHOP, MSC, USA, Chief, Special Projects Branch
CHARLES M. WILTSE, Ph. D., Litt. D., Chief, Historians Branch
ERNEST ELLIOTT, Jr., Chief, Editorial Branch
Lieutenant Colonel JEROME RUDBERG, MSC, USA, Chief, Information Activities Branch
RODERICK M. ENGERT, Chief, General Reference and Research Branch
HAZEL G. HINE, Chief, Administrative Branch

Library of Congress Catalog Card Number: 63-6000

For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C., 20402



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	ACCESS TO CARE HISTORY OF THE OFFICE OF MEDICAL HISTORY ANC HISTORY AMEDD BIOGRAPHIES AMEDD CORPS HISTORY BOOKS AND DOCUMENTS HISTORICAL ART WORK & IMAGES MEDICAL MEMOIRS AMEDD MEDAL OF HONOR RECIPIENTS ORGANIZATIONAL HISTORIES THE SURGEONS GENERAL ANNUAL REPORTS OF THE SURGEON GENERAL RECENT MEDICAL INNOVATIONS AMEDD UNIT PATCHES AND LINEAGE		Contents

			Books and Documents MEDICAL DEPARTMENT, UNITED STATES ARMY SURGERY IN WORLD WAR II THORACIC SURGERY Volume II Prepared and published under the direction of Lieutenant General LEONARD D. HEATON The Surgeon General, United States Army Editor in Chief Colonel ARNOLD LORENTZ AHNFELDT, MC, USA Editor for Thoracic Surgery FRANK B. BERRY, M.D. Associate Editor ELIZABETH M. McFETRIDGE, M.A. OFFICE OF THE SURGEON GENERAL DEPARTMENT OF THE ARMY WASHINGTON, D.C., 1965 Contents FOREWORD PREFACE Part I SPECIAL TYPES OF WOUNDS OF THE CHEST Chapter I. Special Types of Thoracic Wounds (Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.) Wounds of the Chest Wall Sucking Wounds Fractures of the Ribs and Adjacent Structures Wounds of the Lungs Wounds of the Mediastinal Structures Wounds of the Trachea and Bronchi Wounds of the Esophagus Crushing Injuries Blast Injuries Associated Wounds II. Wounds of the Heart (Including Retained Foreign Bodies), Mediterranean (Formerly North African) Theater of Operations (Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.) Incidence Clinical Picture and Diagnosis Cardiac Tamponade Pathologic Process Pericardial Injuries Contusions Lacerations Penetrating and Perforating Wounds Migratory Foreign Bodies Stab Wounds Injuries of the Great Vessels Management of Cardiac Wounds Technique of Cardiac Surgery Analysis of Cases III. Thoracoabdominal Wounds (Lyman A. Brewer III, M.D.) General Considerations Pathologic Process Diagnosis Exploration Resuscitation and Preoperative Preparation Anesthesia Surgical Approach Incision Technique Special Surgical Considerations Postoperative Care Management in Base Hospitals Case Histories Experience of the 2d Auxiliary Surgical Group *Part II* COMPLICATIONS OF WOUNDS OF THE CHEST IV. Complications and Sequelae (Thomas H. Burford, M.D.) Tension Pneumothorax Hemorrhage Acute Gastric Dilatation Emphysema Pulmonary Edema Atelectasis Hematoma of the Lung Bronchopleural Fistula Wound Disruption Clostridial Myositis Chylothorax Lung Abscess Mediastinal Abscess Pneumonitis and Pneumonia Traumatic Osteomyelitis Chronic Sinuses of the Chest Wall Defects of the Chest Wall Adhesive Pleuritis Diaphragmatic Hernia Hernia of the Lung Residual Symptoms V. Wet Lung (Thomas H. Burford, M.D.) Concept and General Considerations Pathogenesis and Pathophysiology Etiologic Factures Clinical Picture Diagnosis Prophylaxis Management Results of Therapy Case Histories VI. Hemothorax and Hemothoracic Empyema (Thomas H. Burford, M.D.) General Considerations Incidence of Hemothorax and Its Complications Pathogenesis of Organizing Hemothorax Pathologic Changes in Chronic Traumatic Hemothorax Bacteriology of Organizing Hemothorax Physiopathology of Hemothorax Clinical Picture and Diagnosis Management of Simple Hemothorax Clinical Picture and Diagnosis of Hemothoracic Empyema Empyema in the World Wars Management of Infected Hemothorax and Hemothoracic Empyema Decortication of the Lung Technique of Decortication Postoperative Management After Decortication Decortication in Empyema of Nontraumatic Origin Special Studies of Pulmonary Decortication Case Histories VII. Management of Retained Intrathoracic Foreign Bodies, Mediterranean (Formerly North African) Theater of Operations (Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.) Incidence Indications for Surgery Surgical Timing Techniques of Localization Surgical Technique Analysis of Cases VIII. Management of Retained Foreign Bodies in the Heart and Great Vessels, European Theater of Operations (Dwight E. Harken, M.D.) Anatomic Location of Missiles Foreign Bodies In and About the Heart Foreign Bodies In and About the Great Vessels Migratory Intravascular Foreign Bodies Experiences at the 155thGeneral Hospital Thoracic Surgery Center *Part III* OBSERVATIONS ON WOUNDS AND DISEASES OF THE CHEST IN THE ZONE OF INTERIOR 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 Clinical Considerations Organizing Hemothorax Hemothoracic Empyema Retained Foreign Bodies Chest Wall Defects Draining Sinuses of the Chest Wall Associated Wounds X. Surgical Aspects of Diseases of the Chest (Brian B. Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.) Bronchiectasis Pulmonary Tuberculosis Lung Abscess Empyema Actinomycosis Spontaneous Pneumothorax of Nontuberculous Origin Malignant Neoplasms Lesions of the Esophagus XI. Long-Term (1943-61) Followup Studies in Combat-Incurred Thoracic Wounds (Lyman A. Brewer III, M.D.) Background of Study Materials and Methods Basic Data Therapeutic Classification Initial Wound Surgery Subsequent Surgery Mortality and Disposition Wounds of the Chest Wall Lacerations of the Lung Mediastinal Injuries Blast Injuries Thoracoabdominal Wounds Hematoma Wet Lung Hemothorax Retained Foreign Bodies Postdischarge Followup Summary and Conclusions APPENDIX Special Reports and Statistical Data (B. Noland Carter, M.D., and Michael E. DeBakey, M.D.) Illustrations FIGURE: 1. Superficial bullet wounds of chest wall not involving bony structures 2. Schematic showing of pathologic physiology of sucking chest wound 2b. Schematic showing of pathologic physiology of sucking chest wound (cont.) 3. Schematic showing of pathologic physiology of flail chest 4. Management of flail chest 4b. Management of flail chest (cont.) 5. Schematic showing of results of laceration of main bronchus 6. Thoracic laceration of esophagus 7. Cervical laceration of esophagus 8. Acute suppurative mediastinitis secondary to perforation of esophagus 9. Large esophagopleural fistula with total right pyopneumothorax 10. Schematic showing of pathologic physiology of blast injury 11. Fatal cardiac contusion 12. Survivor of cardiac wound shortly after machinegun slug had been removed from his heart 13. Foreign body in left ventricle of heart 13b.Foreign body in left ventricle of heart (cont.) 14. Foreign body in wall of left ventricle near cardiac apex 15. Serial electrocardiograms taken after penetrating wound of heart 16. Machinegun bullet in right side of heart near junction of right auricle and right ventricle 17. Shell fragment in anterior wall of heart in region of right ventricle 18. Schematic showing of pathologic physiology of acute pericardial tamponade 19. Pneumopericardium with retained foreign body just behind heart 20. Management of cardiac tamponade by aspiration 21. Scattered petechial and confluent hemorrhages of right ventricle caused by penetrating bullet wound of sternum 22. Electrocardiogram of patient with cardiac contusion 23. Technique of cardiac surgery 24. Technique of cardiac surgery 25. Repair of through-and-through wound of heart 25b.Repair of through-and-through wound of heart 25c.Repair of through-and-through wound of heart 26. Repair of through-and-through wound of heart 27. Migratory intravascular foreign body 28. Migratory intravascular foreign body 29. Migratory intravascular foreign body 29b.Migratory intravascular foreign body (cont.) 30. Retained shell fragment in close apposition to ascending aorta 31. Retained .38-caliber bullet lying directly against ascending aorta for 20 years 32. Technique of cardiac surgery 33. Technique of cardiac surgery 34. Suppurative pericarditis 35. Types of wounds of diaphragm possible from penetrating or perforating missiles 36. Schematic showing of maximum expiratory excursion of diaphragm 37. Technique of transdiaphragmatic operation for left-sided thoracoabdominal wound 38. Thoracoabdominal wound requiring later drainage of anterior subphrenic abscess following laceration of liver 39. Thoracoabdominal wound requiring later drainage of large intrahepatic abscess 40. Management of subphrenic abscess secondary to laceration of liver 40b. Management of subphrenic abscess secondary to laceration of liver (cont.) 41. Coexistent bile empyema and subphrenic abscess 42. Pathologic physiology of tension pneumothorax 43. Tension pneumothorax of various origins 43b. Tension pneumothorax of various origins (cont.) 44. Pressure (tension) pneumothorax 45. Lateral roentgenogram showing extreme degree of pressure pneumothorax with mediastinal shift 46. Management of tension pneumothorax 47. Schematic showing of pathologic physiology of mediastinal emphysema 47b. Schematic showing of pathologic physiology of mediastinal emphysema (cont.) 48. Management of mediastinal emphysema 49. Management of mediastinal emphysema 50. Technique of intermittent positive pressure oxygen administration in field and evacuation hospitals 51. Postoperative atelectasis with complete collapse of lung 52. Posteroanterior roentgenogram showing hematoma and clearly defined missile track in left lung 53. Posteroanterior roentgenogram showing typical intrapulmonary hematoma 54. Posteroanterior roentgenogram showing sharply defined intrapleural hematoma 55. Hematoma of lung 55b.Hematoma of lung (cont.) 56. Bronchopleural fistula 57. Sinus of chest wall resulting from traumatic osteomyelitis of clavicle 58. Defect of anterior chest wall 59. Diagrammatic representation of infolded lung (adhesive pleuritis) 60. Traumatic diaphragmatic hernia 60b. Traumatic diaphragmatic hernia (cont.) 61. Diaphragmatic hernia 62. Diaphragmatic hernia 63. Anatomic distribution of 28 diaphragmatic hernias 64. Diaphragmatic hernia 65. True hernia of lung 66. Technique of repair of pulmonary hernia 66b.Technique of repair of pulmonary hernia (cont.) 66c.Technique of repair of pulmonary hernia (cont.) 67. Management of patient with wet lung 68. Intercostal nerve block in management of painful wounds of chest wall 69. Technique of tracheobronchial catheter aspiration 69b.Technique of tracheobronchial catheter aspiration (cont.) 69c.Technique of tracheobronchial catheter aspiration (cont.) 70. Administration of oxygen under intermittent positive pressure in management of wet lung 70b.Administration of oxygen under intermittent positive pressure in management of wet lung (cont.) 71. Hemothorax with recurrent pulmonary hemorrhage 71b.Hemothorax with recurrent pulmonary hemorrhage 72. Posteroanterior roentgenogram showing clotted right hemothorax 73. Massive liquid hemothorax without infection 74. Photomicrograph showing organizing hemothorax with replacement of acute fibrinopurulent deposit 75. Photomicrograph showing fibroblastic membrane from clotted hemothorax 11 days after wounding 76. Photomicrograph showing section of peel of clotted hemothorax 4 weeks after wounding 77. Photomicrograph showing section from clotting hemothorax 78. Photomicrograph of section through membrane, pleura, and lung in posttraumatic empyema 12 weeks after wounding 79. Cross-sectional diagram showing pathologic process in clotting, organizing hemothorax 80. Photomicrograph showing layer of fibrin 3 mm. thick, removed from visceral pleura in uninfected clotted hemothorax 11 days after wounding 81. Fibrotic process in organizing hemothorax 82. Photomicrograph showing calcium deposition in collagenous tissue layer of exudate on visceral pleura in organizing hemothorax 83. Photomicrograph showing biopsied section of lung and pleura after removal of overlying exudate 84. Photomicrograph showing replacement of fibrinous exudate, pleura, and adjacent lung 85. Photomicrograph showing infected organizing hemothorax 86. Spontaneous resolution of clotted hemothorax 87. Posteroanterior roentgenogram showing right clotted hemothorax 88. Lateral roentgenogram showing clotted hemothorax over right lower and middle lobes 89. Clotted hemothorax with spontaneous clearing 90. Clotted hemothorax with spontaneous clearing 91. Management of hemothorax by thoracentesis 92. Schematic showing of recurrent hemothorax after thoracentesis 93. Schematic showing of massive clotted hemothorax 94. Decortication in hemothoracic empyema 95. Management of hemothoracic empyema by rib-resection drainage 96. Posteroanterior roentgenogram showing massive liquid empyema on right side 4 weeks after rib-resection drainage 97. Management of clotted hemothorax with retained foreign body 97b. Management of clotted hemothorax with retained foreign body (cont.) 98. Management of clotted hemothorax with retained foreign body 99. Technique of decortication 100. Techniques of decortication showing alternate methods of entering pleural cavity 101. Technique of decortication 102. Technique of decortication 103. Technique of decortication 104. Technique of decortication 105. Management of clotted hemothorax by decortication 106. Management of massive liquid hemothoracic empyema 107. Technique of decortication 108. Typical temperature charts of patients with hemothoracic empyema treated by primary decortication with penicillin coverage 109. Comparative results of management of empyema in World Wars I and II 109b. Comparative results of management of empyema in World Wars I and II (cont.) 110. Management of hemothorax by secondary decortication 111. Management of hemothoracic empyema by primary decortication 112. Management of hemothoracic empyema by decortication 113. Management of clotted hemothorax by primary decortication 114. Spontaneous clearing of clotted hemothorax 115. Management of clotted hemothorax by decortication 116. Management of hemothoracic empyema by primary decortication 117. Management of clotted hemothorax by primary decortication 118. Posteroanterior roentgenogram showing organizing clotted hemothorax on left side 119. Management of organizing clotted hemothorax by decortication 120. Management of clotted hemothorax with retained foreign body and bronchopleural fistula by primary decortication 121. Management of tension hemopneumothorax and total hemothoracic empyema by secondary decortication 121b.Management of tension hemopneumothorax and total hemothoracic empyema by secondary decortication (cont.) 122. Management of infected clotted hemothorax by early primary decortication 123. Management of infected clotted hemothorax with complications by early primary decortication 124. Retained foreign body in lung 125. Retained foreign body in lung 126. Retained foreign body in posterior chest wall 127. Localization of intrathoracic foreign bodies by division of chest into arbitrary sectors 128. Localization of intrathoracic foreign body 129. Localization of foreign body in chest wall 130. Localization of intrapulmonary foreign body 131. Localization of foreign body in lung 132. Localization of foreign body in chest wall 133. Localization of foreign body in chest wall 134. Localization of foreign bodies in chest wall 135. Localization of foreign body in lung 136. Localization of foreign body in diaphragm 137. Localization of foreign body in diaphragm 138. Localization of foreign bodies in right chest 139. Localization of foreign body in mediastinum 140. Localization of foreign bodies in lung and mediastinum 141. Localization of foreign body in intrapleural space 142. Intrapleural foreign body associated with massive empyema 143. Specimens of metallic foreign bodies removed from lungs and pleural cavity 144. Gross location of foreign bodies removed from cardiac and vascular structures at 160th General Hospital 145. Missiles removed from chambers of heart, with their location 146. Roentgenograms showing original position of fragment in right ventricle 147. Electrocardiograms taken before first cardiotomy 148. Positioning of patient at successive cardiotomies 149. Roentgenograms showing position of fragment in right auricle after first operation 150. Electrocardiograms taken after first cardiotomy 151. Roentgenograms showing fragment again in right ventricle after second cardiotomy 152. Electrocardiogram taken after second cardiotomy 153. Electrocardiograms taken during third and successful cardiotomy 154. Migration of foreign body at successive cardiotomies 155. Electrocardiograms taken after third and successful cardiotomy with removal of fragment from right ventricle 156. Patient just before evacuation to Zone of Interior, after three cardiotomies 157. Electrocardiograms taken before cardiotomy showing left ventricular damage 158. Preoperative roentgenograms showing retained missile in left ventricle 159. Preoperative roentgenograms showing retained fragment in left auricle 160. Electrocardiogram taken before operation showing possible damage to anterior myocardial wall 161. Technique of removal of retained shell fragment from left auricle 162. Electrocardiogram after left auricular cardiotomy and removal of intra-auricular shell fragment 163. Incisions used to obtain exposure of foreign bodies in heart 164. Roentgenograms showing foreign body in chamber of right ventricle 165. Technique of removal of foreign body 166. Technique of combined intercostal-transsternal approach to right aspect of right ventricle 167. Roentgenograms showing missile in right auricle 168. Technique of removal of foreign body 169. Technique of posterior approach to pericardium and heart on right 170. Roentgenograms showing foreign body in interauricular septum and right auricle 171. Technique of removal of foreign body in right auricle by incision in superior vena cava 172. Roentgenograms showing foreign body in pericardial abscess well back on diaphragmatic surface of heart 173. Electrocardiograms taken during operation for removal of pericardial foreign body 174. Roentgenograms showing .30-caliber bullet in hilar region of left lung 175. Roentgenograms taken immediately after left thoracotomy 176. Technique of removal from right pulmonary artery of foreign body 177. Roentgenograms showing retained shell fragment posterior to right sternoclavicular joint in region of innominate artery 178. Technique of removal of retained missile from innominate artery 179. Roentgenograms 3 days after wounding showing clear lung fields 180. Roentgenograms 1 month later, 2 days after sudden onset of pain in left lower hemithorax 181. Migration of bullet from left pulmonary artery into main pulmonary artery and into right pulmonary artery 182. Probable course of migratory missile from left auricle through left ventricle and aorta into innominate artery 183. Course of migratory bullet from entry into inferior vena cava through right auricle and ventricle 184. Encapsulated hemothorax managed by decortication 185. Traumatic hemothorax 186. Hemothoracic empyema managed by anterior drainage 187. Retained foreign body with delayed manifestations due to infection 188. Retained foreign body without symptoms 189. Retained foreign body without clinical manifestations 190. Bronchospirometric tracing 1 month after left lower lobe lobectomy for bronchiectasis 191. Bronchospirometric tracing 7 weeks after left lower lobe lobectomy for bronchiectasis 192. Bronchospirometric tracing 8 weeks after right middle and lower lobe lobectomy for bronchiectasis 193. Bronchospirometric tracing 7 weeks after resection of left lower lobe and lingula of the upper lobe for bronchiectasis 194. Patient after final closure of tuberculous sinus complicating thoracoabdominal wound 16 months earlier 195. Punchcard designed to secure data in long-term followup of veterans with combat-incurred wounds of chest 196. Schematic showing of large defects of chest wall 196b. Schematic showing of large defects of chest wall (cont.) 197. Serial roentgenograms in large defect of chest wall 197b. Serial roentgenograms in large defect of chest wall (cont.) 198. Schematic showing of sucking wound with defect of chest wall 198b. Schematic showing of sucking wound with defect of chest wall (cont.) 198c. Schematic showing of sucking wound with defect of chest wall (cont.) 199. Serial roentgenograms in sucking wound with defect of chest wall complicated by severe infection 200. Sucking wound of left posterior chest with early infection 200b.Sucking wound of left posterior chest with early infection (cont.) 200c. Sucking wound of left posterior chest with early infection (cont.) 201. Serial roentgenograms of sucking wound with early infection 202. Anterolateral sucking wound of left chest 202b.Anterolateral sucking wound of left chest (cont.) 203. Serial roentgenograms in mediastinal injury with intrapericardial foreign bodies and hematoma 204. Serial roentgenograms in blast injury 205. Schematic showing of thoracoabdominal wound 205b.Schematic showing of thoracoabdominal wound (cont.) 206. Serial roentgenograms in thoracoabdominal wound 206b.Serial roentgenograms in thoracoabdominal wound (cont.) 207. Schematic showing of thoracoabdominal wound 207b.Schematic showing of thoracoabdominal wound (cont.) 207c.Schematic showing of thoracoabdominal wound (cont.) 208. Serial roentgenograms in thoracoabdominal wound 209. Schematic showing of thoracoabdominal wound 210. Serial roentgenograms in thoracoabdominal wound 210b. Serial roentgenograms in thoracoabdominal wound (cont.) 211. Schematic showing of thoracoabdominal wound 212. Serial roentgenograms in thoracoabdominal wound 212b. Serial roentgenograms in thoracoabdominal wound (cont.) 213. Schematic showing of thoracic wound with massive hematoma of the right lung 213b. Schematic showing of thoracic wound with massive hematoma of the right lung (cont.) 214. Serial roentgenograms of hematoma of right lower lobe of lung 214b.Serial roentgenograms of hematoma of right lower lobe of lung (cont.) 215. Schematic showing of large sucking wound of chest 215b. Schematic showing of large sucking wound of chest (cont.) 216. Serial roentgenograms of sucking wound of chest with wet lung syndrome 217. Schematic showing of chest wound with massive chest wall and intrapleural trauma 217b.Schematic showing of chest wound with massive chest wall and intrapleural trauma (cont.) 217c.Schematic showing of chest wound with massive chest wall and intrapleural trauma (cont.) 218. Serial roentgenograms in thoracic wound complicated by massive hemothorax 219. Schematic showing of chest wound with retained foreign body 219b. Schematic showing of chest wound with retained foreign body (cont.) 220. Serial roentgenograms in wound with intrapulmonary foreign body 221. Schematic showing of chest wound with retained foreign bodies in lung 221b. Schematic showing of chest wound with retained foreign bodies in lung (cont.) 221c. Schematic showing of chest wound with retained foreign bodies in lung (cont.) 222. Serial roentgenograms of thoracic wound with retained bodies in lung Appendix figures: 1. Posteroanterior roentgenogram showing large foreign body in contact with esophagus. 2. Posteroanterior roentgenogram showing Lipiodol visualization of bronchopleural fistula, narrow empyema track, and drainage site at some distance from fistula. 3. Posteroanterior roentgenogram showing pneumonitis and fibrosis associated with retained foreign bodies. 4. Foreign bodies in contact with large blood vessels. 5. Retained foreign bodies giving rise to infection. 6. Retained foreign bodies giving rise to symptoms. 7. Early thoracotomy without drainage in penetrating bullet wound of chest. 8. Early thoracotomy without drainage in penetrating shell-fragment wound of right chest. 9. Early thoracotomy without drainage in perforating wound of right chest. 10. Observations at decortication. 11. Infected organized hemothorax managed by decortication. 12. Infected hemothorax and total empyema. Color Plates I. Appearance of heart at instant of incision into right ventricle II. Technique of dislocation of heart from pericardial sac III. Marked ventricular dilatation following dislocation of heart Tables 1. Blast injuries of nonbattle origin, by numbers of admissions and deaths, and by area, 1942-45 2. Battle-incurred blast injuries, by numbers of admissions and deaths, and by area, 1942-45 3. Battle-incurred blast injuries of thorax and thoracoabdominal region, by numbers of admissions and deaths, and by area, 1944 4. Battle-incurred blast injuries of thorax and thoracoabdominal region, by numbers of admissions and deaths, and by area, 1944 5. Distribution of injuries and anatomic involvements in 56 combat-incurred cardiac injuries 6. Distribution of 27 deaths in 56 combat-incurred cardiac injuries 7. Frequency of wounds and case fatality rates in 903 thoracoabdominal wounds according to combinations of viscera 8. Case fatality rate according to timelag in 854 thoracoabdominal injuries 9. Case fatality rate according to surgical procedure in 903 thoracoabdominal wounds 10. Number of admissions and deaths for lung abscess, by area, 1942-45 11. Number of secondary cases of lung abscess, by area, 1944-45 12. Incidence, admissions, secondary diagnoses, and deaths from diaphragmatic hernia, by area, 1944-45 13. Admissions for empyema of the chest, by area, 1942-45 14. Distribution of 20 percent sample of secondary cases of empyema of the chest, by area and type of admission 15. Admissions for bronchiectasis, by area, 1942-45 16. Operations for pulmonary tuberculosis, Fitzsimons General Hospital, 1944-45 17. Incidence of malignant neoplasms of respiratory system and of esophagus, by area,1944-45 18. Morbidity and mortality from malignant neoplasms of respiratory system and of esophagus, 1944-45 19. Deaths due to malignant neoplasms of respiratory system and of esophagus, by area,1944-45 20. Thoracic damage in 167 followed-up thoracic casualties according to surgical procedure in forward hospitals 21. Associated injuries in 167 followed-up thoracic casualties according to surgical procedure 22. Intra-abdominal damage in 81 followed-up thoracic casualties according to surgical procedure 23. Complications in forward and fixed hospitals in 167 followed-up thoracic casualties according to surgical procedure in forward hospitals 24. Surgery required in fixed hospitals according to surgery performed in forward hospitals MEDICAL DEPARTMENT UNITED STATES ARMY IN WORLD WAR II NOTE This volume was written and edited under the direction and supervision of Colonel John Boyd Coates, Jr., MC, USA, former Director and Editor in Chief, The Historical Unit, U.S. Army Medical Service. ARNOLD LORENTZ AHNFELDT, Colonel, Medical Corps, Editor in Chief. SURGERY IN WORLD WAR II Advisory Editorial Board MICHAEL E. DEBAKEY, M.D., Chairman FRANK B. BERRY, M.D. JOHN B. FLICK, M.D. BRIAN B. BLADES, M.D. FRANK GLENN, M.D. J. BARRETT BROWN, M.D. M. ELLIOTT RANDOLPH, M.D. STERLING BUNNELL, M.D. (dec.) ISIDOR S. RAVDIN, M.D. NORTON CANFIELD, M.D. JOSEPH R. SHAEFFER, M.D. B. NOLAND CARTER, M.D. ALFRED R. SHANDS, Jr., M.D. EDWARD D. CHURCHILL, M.D. HOWARD E. SNYDER, M.D. MATHER CLEVELAND, M.D. R. GLEN SPURLING, M.D. DANIEL C. ELKIN, M.D. (dec.) BARNES WOODHALL, M.D. ROBERT M. ZOLLINGER, M.D. Brigadier General DOUGLAS B. KENDRICK, Jr. (ex officio) Brigadier General JAMES E. GRAHAM (ex officio) Colonel JOHN BOYD COATES, Jr., MC, USA (ex officio) The Historical Unit, United States Army Medical Service Colonel ARNOLD LORENTZ AHNFELDT, MC, USA, Director CHARLES J. SIMPSON, Executive Officer Lieutenant Colonel GILBERT A. BISHOP, MSC, USA, Chief, Special Projects Branch CHARLES M. WILTSE, Ph. D., Litt. D., Chief, Historians Branch ERNEST ELLIOTT, Jr., Chief, Editorial Branch Lieutenant Colonel JEROME RUDBERG, MSC, USA, Chief, Information Activities Branch RODERICK M. ENGERT, Chief, General Reference and Research Branch HAZEL G. HINE, Chief, Administrative Branch Library of Congress Catalog Card Number: 63-6000 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C., 20402

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