342
SECTION I
GENERAL SURGERY
CHAPTER XIV
WOUNDS
OF
THE CHEST
At
the time the United States declared war on Germany, effective methods
for treating
various types of wounds, with some few exceptions, had been established
by surgeons of the
Allied armies. Among these exceptions were wounds of the chest. There
were wide and some
irreconcilable differences of opinion as to the care of intrathoracic
injuries. These differences
were caused by failure to understand the interdependence of the
functions of the circulatory and
respiratory apparatuses and to appreciate the contribution of their
functions to the powers of
resistance, defense, and repair, powers which must be conserved and
developed in order to
facilitate immediate recovery and to minimize the extent and duration
of subsequent disability.
The
possibilities for rendering service to the wounded in this direction,
as well as in
others, through investigations of inherent problems were recognized
early in the history of the
American Expeditionary Forces by the then chief of the research
division of the American Red
Cross in France. He secured early opportunities to begin these studies,
and, in so far as he was
permitted, continued to give assistance; special apparatus was provided
for experiments; also
supplies of oxygen and nitrous oxide gases, and transportation, which
were essential and
otherwise unobtainable, were provided.1
Work
was begun by the writer in 1917 at the Ambulance de l'Ocean, at La
Panne,
Belgium, under Col. A. Depage of the Belgian Medical Department, and
included clinical, post-mortem, and experimental observations. This
work sufficed to disclose the more significant
problems and to indicate means for their solution.
Late
in 1917, the chief consultant, surgical services, of the American
Expeditionary
Forces, recommended continuation of the work, and in 1918, the chief
surgeon, A. E. F., detailed
for this purpose medical officers, nurses and enlisted men for duty at
the Central Medical
Department Laboratory at Dijon.2
Experimental
studies, carried on in the section provided for surgical research, with
the
help and advice of the director and of the chief of the division of
surgical research, were
continued until the Chateau-Thierry operation began.
After
this time, and until the beginning of the armistice, a unit a
composed of medical
officers, nurses and enlisted men appointed by the chief surgeon, .A.
E. F., was detailed to
sundry field hospitals for the care of nontransportable wounded and to
mobile hospitals in zones
where there was active fighting.
The
directions of the chief consultant of the surgical services were (1) to
discover the
physiologic interrelationships between the circulatory and respiratory
mechanisms in order to
determine the functions which need the protection
a The members of the unit detailed to the study
and treatment of thoracic injuries were: Col. J. L. Yates. M. C.. in
charge; Maj. W. F. Verdi, M. C., surgeon; Capt. W. S. Middleton, M. C.,
and Capt. M. A. Blankenhorn. M. C.,
physicians; Capt. Robert Drane, M. C., and Capt. J. M. Steiner, M. C.,
radiologists; Capt. J. T. Gwathmey. M. C.,
and Anna Fitzgerald, A. N. C., anesthetists; Anne Bernard, A. N. C.,
surgical nurse.
343
to assure the largest
opportunities for immediate and remote recoveries; (2) to develop the
simplest effective surgical methods compatible with physiologic
requirements; (3) to apply these
methods to the wounded whenever there was any possibility of saving
life and without regard to
the high mortality rate that would inevitably accompany acceptance of
the gravest risks; (4) to
follow each fatality with necropsy to determine what should not be
done, to trace the results in
those who recovered and thereby discover the dependence of degrees of
functional rehabilitation
upon methods employed in order to get better methods; and (5) to make
eventually a report
indicating how soldiers suffering from intrathoracic injuries could be
the more certainly
protected against death and disability.
What
follows in this chapter is in consequence of compliance with these
directions. No
attempt has been made to preserve chronologic sequence in observations;
facts as they now
appear important are presented. Statistics are avoided as far as
possible since, because of the
many inevitable sources of error, they can not fail to be even more
than usually unreliable.
PHYSIOLOGIC INTERDEPENDENCE OF RESPIRATION
AND CIRCULATION
Two
factors, peculiar to thoracic injuries, are of sufficient importance to
be kept
constantly in mind: First, mere existence, as well as additional
activities, including the capability
of withstanding the extraordinary stresses imposed by wounds and by
surgical treatment,
depends fundamentally upon ability to provide oxygen for tissue
metabolism. Second, chest
injuries impose not only the burdens incidental to other tissue insults
but also definite restrictions
to the supply and delivery of oxygen.
Suitable
methods of treatment will protect the means whereby oxygen is supplied
to the
body and delivered throughout the body and will be determined by
knowledge of the activities
upon which the functions of supply and delivery of oxygen depend. A
summation of all relevant
observations made by the writer during and since the World War was
presented before The
American Association for Thoracic Surgery in 1924.3 It is
given here in full, with a few minor
changes, as it indicates the essential activities and functions, and
how they may be conserved and
rehabilitated.
THE
SIGNIFICANCE OF VITAL CAPACITY IN INTRATHORACIC THERAPY
A
biologic aphorism, no life without breathing, indicates in a general
way the importance
of respiration. Activities sufficient merely to support life or to
realize the utmost physical and
mental powers, including defense and repair, are produced by metabolic
processes which are
dependent primarily on oxidation. This explains why man, although he
may survive for weeks
without food and for days without water, can exist for only a few
minutes deprived of air. It also
explains why any reduction in supplies of oxygen to the body, in
deliveries of oxygen throughout
the body and in utilization of oxygen by the body, imposes a
corresponding degree of disability.
The many
diseases affecting the thorax and its contents, the enormous totals of
transient and permanent disabilities and the large number of deaths
344
they cause constitute a
serious problem. More effective therapy is needed to provide greater
limitations of disability and to reduce mortality.
There
is a direct road to this accomplishment. Reduction in vital capacity is
so constant a
result of thoracic diseases that the extent of this reduction is an
accurate measure of the
disabilities attributable to them.b In order to
obtain better methods of treatment, it is essential
to know the structures and the functions of the structures that
determine vital capacity, how vital
capacity is affected by various lesions and consequent malfunctions of
these structures. and
how therapeutic methods can protect vital capacity against reduction
during aggressive phases
of diseases and facilitate its rehabilitation during regressive phases.
Four
distinct phases are notable in completed respiration: (1) Ventilation
of
intrapulmonary air effected by breathing; (2) external respiration, the
interchange of gases
between the intrapulmonary air and intravascular blood through alveolar
and capillary walls; (3)
transportation of aerated blood to somatic cells and of blood needing
aeration to lungs by a
coordination of the pulmonary and systemic circulations, and (4)
interchange of gases between
blood and tissues through capillary walls and cell surfaces, or
internal respiration. Although most essential, internal respiration is
germane to this subject only as it is influenced by the other
steps in complete respiration.
Clinical
interest centers in the finer workings of the mechanisms of breathing,
of
circulation, and particularly of external respiration, because of its
direct relationships to vital
capacity and to life itself. External respiration not only accomplishes
aeration of blood
throughout life, no matter bow great or how little are the demands for
oxygen, but this
accomplishment has to be relatively complete at any or all intervals.
In order to simplify the
immediate presentation, let it be supposed that the walls of all of the
alveoli are fused into one
sheet of epithelium against which is applied a similar sheet composed
of the pulmonary capillary
endothelium. Suppose further that the intrapulmonary air is in an even
layer on the epithelial
surface and the intrapulmonary blood is flowing in another even layer
on the endothelial surface.
Conditions
being normal, the oxygen in the layer of air suffices to aerate
homogeneously
and completely the layer of blood as it passes over the endothelial
surface. Should the amount of
blood be increased, either the area of the sheet of endothelium. must
be enlarged or the layer of
blood must become thicker. If the layer of blood becomes too thick, it
will be aerated neither
homogeneously nor completely. On the other side, if the intrapulmonary
air be in too thick a
layer, because the area of epithelium is too limited, aeration is
likewise defective. The states of
defective aeration, anoxemia and cyanosis, are abnormal. Therefore, it
is presumable that there is
a natural control which correlates the volume of ventilated air and the
area of alveolar epithelium
b Estimations of vital capacity are not always
the only or even the most dependable sources of information.
Frequently, it is impracticable to make them. Occasionally, they can
lead to erroneous interpretations. As will be
made clear later, vital capacity is influenced by the circulation. An
individual may have an apparently competent
circulation while at rest and show at such times an approximately
normal vital capacity; yet that same individual, if
the reserve cardiac energy were limited, would show a material
reduction in vital capacity after exercise which
would be less of a tax on the myocardium than many types of diseases or
operations. Other examples need not be
cited. This suffices to emphasize the fact that vital capacity
readings, like other single sources of clinical
information, are reliable when intelligently interpreted in
conjunction with all other evidence.
345
(degree of inflation)
with the expanse of endothelium (cross section and length of
capillaries)
and the amount of blood (unit volume). Moreover, since the demand for
oxygen comes from the
tissues and is manifested by increments of carbon dioxide in the blood,
it is likely that the unit
volume of blood in the pulmonary capillaries exerts a telling influence
on the three other
variables.
A
further step in presenting the problem is a supposition that the sheet
of alveolar
epithelium has been turned into a single sac communicating with a
bronchus, and the layer of
blood is confined in loops of contiguous capillaries connected with the
pulmonary artery and
vein. Conditions affecting each of the many alveoli which constitute
the portion of the breathing
unit directly concerned in external respiration would then be
illustrated by a single large alveolus.
Obviously,
the first and great commandment is to discover the means whereby the
amount of blood requiring aeration establishes conditions suited to
this accomplishment.
Knowledge
of the structures constituting the apparatuses of breathing and of
circulation
can alone determine therapeutic priciples. It is necessary to know how
they operate during
periods of rest; what adjustments occur when activities are gradually
or abruptly increased and
diminished; what adaptations are employed to meet handicaps imposed by
disease; what are
nature's methods to increase resistance and to hasten repair; what
forms of treatment cooperating with natural methods of adjustment,
compensation, and adaptation will augment
defense most effectively and facilitate functional recovery.
Breathing,
external respiration, and the deliveries of blood to and from the lungs
are
effected by extrathoracic and intrathoracic structures which are so
intimately associated
physically or physiologically, or both, that they must be considered
together.
The
extrathoracic portions need not be described in detail. It is only
necessary to
recognize that the chief control of the distribution of blood in the
systemic circulation and the
rate of flow in both systemic and pulmonary circuits, as well as the
rate and depth of breathing
efforts, is in the central nervous system.
The
intrathoracic portions not only provide external respiration but they
also are the
structures affected by the diseases here considered, and give
diagnostic, prognostic, and
therapeutic indications.
An
accurate measure of the efficacy of external respiration is vital
capacity, which is
usually defined as the amount of air expelled by the most complete
expiration after fullest
inspiration. This means that when the air cells are (distended to
physiologic limits, inflation, and
therefore the total area of alveolar walls, are greatest for normal
conditions and are thus disposed
to aerate equivalent amounts of blood.
Aeration
is an exchange of oxygen and carbon dioxide through alveolar and
capillary
walls. Natural economy has apparently established a means of control
whereby the total expanse
of alveolar wall as determined by the extent of pulmonary inflation
compels corresponding
variations in the total expanse of capillary wall and the amounts of
intracapillary blood. Grades
of pulmonary
346
inflation are actively
determined by variations in rate, depth, and force of breathing
movements,
and, as will appear later, are influenced passively by the unit volumes
of blood in the pulmonary
capillaries. Length, diameter, and, therefore, the contents of
pulmonary capillaries can be
attributed to three forces, since there is no effective vasomotor
control of the pulmonary
circulation. These forces are the blood pressures in the pulmonary
circulation, fluctuations in intrapleural negative pressures, and
alternating intravascular aspiration and expression caused
by elongation and shortening of blood vessels with the inspiration and
expiration of each
breathing cycle.
In
addition to central control by the nervous system, there is a
peripheral intrathoracic
governor which so coordinates the activities of the breathing and
circulatory units as to keep
volumes of ventilated air present in the alveoli which will aerate at
any and all times those
amounts of blood being driven through the capillaries. The governor
simultaneously correlates
the other two factors, namely, the total area of alveolar epithelium
and the entire expanse of
capillary endothelium.
Knowledge
of the structure and function of the governor or gear which coordinates
the
two sets of variables, volumes of ventilated air and area of alveolar
epithelium, with expanse of
capillary endothelium and amounts of blood to be aerated, is of basic
importance, since it
determines how external respiration is affected by disease and can be
benefited by treatment.
Moreover,
such knowledge answers two other significant questions: Why are
reductions
in vital capacity so accurate a measure of disabilities? What are the
structures and what are their
activities that influence vital capacity?
Investigation
of the various actions and reactions exhibited by the units concerned
in
respiration during health and the changes imposed by diseases should
answer the question. It is
necessary to observe the changes in those units under various
conditions.
Normal
respiration is possible so long as movements of thoracic parietes,
particularly of
the diaphragm, are unrestricted; intrapleural negative pressures are
undisturbed, and pulmonary
elasticity is not impaired, provided the right heart delivers adequate
amounts of good blood in
the absence of obstruction due to incompetence of the left heart.
NORMAL RESPIRATION DURING REST
During
periods of rest, expenditures of energy and hence demands for oxygen
are least.
In consequence, the volume of tidal air, that exchanged with each
complete breathing cycle, is
lowest, as is the tidal blood, the amount driven through the pulmonary
capillaries during the
same breathing cycle. Aeration of tidal blood of rest is accomplished
by the tidal air of rest
which produces the lowest level of pulmonary inflation with minimal
expenditures of energy.
This is the period of greatest physiologic economy in which the storage
of energies exceeds
expenditures by the largest margin.
The
reserve supply of air stored in lungs during periods of rest is five or
six times larger
than the tidal air. Approximately three-fifths of the reserve air is
available for sudden
physiologic requirements, leaving two-fifths to meet
347
urgent pathologic
demands. A comparable amount of reserve blood available for similar
emergencies is stored, less actively circulating, in larger pulmonary
vessels.
Tidal
air, approximately three-eightteenths of all the air concerned in
breathing, serves to
ventilate the intrapulmonary air more than enough to keep its oxygen
content effectively high.
Although one-third of the tidal air is required to fill the trachea and
bronchi, the remaining two-thirds causes a change estimated at
three-twentieths in the sizes of the air cells.
Thus
there is an established relationship between the volume of tidal air
(three-eighteenths) and variation in sizes of air cells
(three-twentieths). Presumably the same
relationship obtains between the amount of tidal blood and the length
and cross section of
capillaries. All combine to afford the means to aeration of the blood
circulating through the
pulmonary capillaries.
NORMAL RESPIRATION-ACTIVITIES GRADUALLY
VARIED
As
activities gradually arc increased after a period of rest, the slowly
progressing
demands for oxygen are met by proportionately higher levels of
inflation produced by larger
volumes of tidal air and by increased amounts of tidal blood driven by
higher pressures. Relationships between tidal air and alveolar size and
between tidal blood and capillary
dimensions occurring during rest are but little distorted though
produced less and less
economically as activities increase.
A
level is reached which may be termed optimum, whereat the tidal air
equals the vital
capacity. This is the upper limit of economic expenditures of energy at
which extraordinary
activities can be prolonged without causing early exhaustion. When this
level is unusually high,
it gives the remarkable endurance exhibited by exceptional athletes, by
superior race horses, and
by certain individuals in meeting the stresses of disease.
Activities
raised above the optimum level initiate compensatory responses and mark
uneconomic expenditures of energies which assure exhaustion. In order
to supply the oxygen
demanded for internal respiration, breathing is more rapid and the
heart beats faster to develop
higher pressures. Finally a still higher level is reached which may be
called maximum, because
at this level the utmost powers are realized for the brief period
before exhaustion forces
reduction in activity.
When
the sequence is reversed, the processes are orderly reductions in
breathing and
cardiac rates and diminutions in volume of tidal air, pulmonary
inflation, the amounts of tidal
blood and capillary expanse. The relationships between the total areas
of alveolar walls and
capillary walls are adapted to the blood that requires aeration and the
intrapulmonary air,
properly ventilated, which supplies the oxygen.
Gradually
increased activities provide opportunities for orderly adjustments in
the actions
of respiratory units and develop the largest total power of which an
individual may be possessed.
Hence the desirability of a suit- able warming-up process before severe
contests.
348
NORMAL RESPIRATION-ACTIVITIES VARIED ABRUPTLY
If
a resting individual should suddenly engage in a critical physical
contest, the demands
for oxygen would jump in a few seconds from lowest to highest. limits.
The reserves of air and
of blood stored in the lungs would be utilized until compensation could
be accomplished. It has
been estimated that the amount of blood delivered by the pulmonary
circulation can be
increased abruptly more than tenfold. Or should the individual while
driving at the maximum
level of action suddenly change to complete rest, the rate of external
respiration measured by
deliveries of aerated blood would decrease with almost the same
rapidity.
The
relationships between volume of air and total area of air-cell wall and
amount of
blood and expanse of capillary wall must be preserved with a fair
degree of accuracy not merely
to effect proper aeration of blood but to continue life. A very few
seconds suffice to cause
dilatation of the right heart or to produce edema of the lungs. These
complications are seen
infrequently because of a peripheral means of control that maintains
the air-cell-capillary
balance.
Abrupt
changes are not alone less economic than are gradual but also are more
dangerous, as they permit less opportunity for orderly adjustments and
are operated almost
entirely by expenditures of reserve energies or margins of safety.
This
also applies to the handicaps imposed by disease. The more gradually
induced are
the less immediately dangerous, and this principle should be recognized
in methods of treatment.
Changes affecting the relationships involved in aeration of blood
should be minimized in extent
and in the rapidity with which they are produced.
ADAPTATIONS TO PATHOLOGIC STATES
Vital
capacity is a suitable term. It does not occur post mortem. When it is
less than the
tidal air of rest, life can not continue. If it is equal to the tidal
air of rest, existence is possible
until the relationships effecting external respiration are disturbed by
increased demands for
oxygen. The excess of vital capacity over the tidal air of rest
measures ability to work and the
margin of safety.
Observations
of natural adaptations to the handicaps of diseased states are as
valuable as
they disclose the compensatory changes that assure the nearest approach
to normal external
respiration of which the measure is vital capacity.
Normally,
a volume of ventilated air on one side of a sheet of alveolar
epithelium of
exactly proportionate dimensions is separated by the interposition of
another wall of vascular
endothelium just as exactly proportionate in area to an equivalent
amount of blood needing
aeration. Normally, these variables fluctuate synchronously and almost
equally. The upper limits
are set by the total areas of epithelium and endothelium which can be
presented, since the
volume of air and blood can be further increased by raising the
respiratory and cardiac rates for
brief periods.
Limitations
in any of the four factors-volume of ventilated air, total expanse of
alveolar
epithelium, total area of vascular endothelium or unit
349
volume of good
blood-reduce the essential function, external respiration, which is
manifested by
corresponding reductions in vital capacity.
Adaptations
strive to maintain the broadest margin of safety or the largest vital
capacity.
When a part of the alveolar epithelium is incapacitated, the remaining
portions are expanded so
that the total area available for external respiration may remain as
nearly normal as possible.
This is compensatory or physiologic emphysema. Likewise, the unit
volume of blood is
correspondingly increased in the capillaries in contact with
hyperfunctioning alveoli. This is
compensatory or physiologic hyperemia. Moreover, the unit volume of
blood is reduced in the
capillaries adjacent to the incapacitated alveoli. Similarly, increase
or decrease in the unit
volume of blood delivered through capillaries is associated with
equivalent inflation or deflation
of corresponding alveoli. Passive congestion is quite different. The
capillaries are engorged, but the unit volume of blood passing through
them is reduced. Pulmonary elasticity is restricted,
and the total area of alveolar epithelial surface is diminished.
Reduced vital capacity here also
indicates the limitations in external respiration.
The
important connection in maintaining the relationships which determine
external
respiration lies between the air cells and the capillaries. The
interdependence of alveolar
inflation and volume of air on one side and of capillary size and
amount of blood on the other
side is obvious.
Air
cells and capillaries are not only intimately associated functionally
but closely related
physically. Capillary loops, arranged in a meshwork, surround,
separate, and yet connect alveoli.
When inflation increases, capillaries are straightened and elongated;
when it decreases, they are
shorter and more tortuous; hence, the aspiration and expulsion of blood
with inspiration and expiration. Contrariwise, if tortuous
capillaries are straightened and elongated by increased unit
volumes of blood, the walls of corresponding air cells are carried with
them and inflation results.
Also, if this action, which corresponds to a positive phase in erectile
tissue, is reversed, capillary
walls are less tense, vessels shorten, and their lumens are decreased,
air cells contract, and some
deflation occurs.
This
is the peripheral control, the intrapulmonary governor, and may be
called the air
cell-capillary gear.
The
existence and functions of an air cell-capillary gear are not generally
recognized and are disputed by clinicians as well as by physiologists.c
The
c Haldane remarked the need of a governor: "We
have no guaranty that even during quite normal breathing the
distribution of air in the individual lung alveoli corresponds exactly
with the distribution of blood to them. Unless
this correspondence is exact some alveoli will receive more air in
proportion to their blood supply than others, and,
as a consequence, the mixed arterial blood will be a mixture of more or
less fully arterialized (aerated) blood with
some of the consequences first discovered (anoxemia). It is probable
indeed that in some way or other the air supply
is proportioned to the blood supply whether by regulation through the
muscular coats of the bronchioles or
regulation of the blood distribution; but it is also certain that this
proportioning is only an approximation" (Haldane
J. S.: Respiration, Yale University Press, New Haven, Conn., 1922,
137).
Certain it is that all the
alveoli are
unequally supplied with air. Fluoroseopic observations of normal
breathing prove this in the increased inflation of the zone of lung
adjacent to the diaphragm during each inspiration.
The control of air and blood, as suggested by Haldane, would scarcely
afford an approximation in the proportioning.
On the other hand, the air cell-capillary gear provides exact
proportioning for each alveolus though not the same
proportioning for all alveoli, else there could be no compensation in
health nor adaption in disease. Inequalities in
alveolar inflation and in the ventilation of intra-alveolar air would
occur even in health, and could explain the
mixtures of more or less perfectly aerated blood noted by Haldane.
350
latter demand properly
controlled crucial animal experiments for proof that would he
acceptable
to them. They are unaware that one animal, even though denied the
distinction of being included
among laboratory species, has been giving conclusive although
spontaneous demonstrations for
centuries. Clinicians have recognized, in those demonstrations, the
signs and symptoms of natural adaptations to intrathoracic diseases
which occur in man.
Animals
are divisible, as Miller4 showed, into those having thin
pleura? and
those having
thick pleurae. Animals with thick pleurae have mediastina which are
impervious to air and to
water. The blood supplied to lung parenchyma and visceral pleura comes
chiefly from the
bronchial artery. Animals with thin pleurae have mediastina which are
pervious to air and to
water. Their lung parenchyma and visceral pleura obtain blood supply
more largely from the
pulmonary artery. Man is of the thick pleura type. Observations made on
the usual laboratory
animals (cat, dog, and rabbit), which are of the thin pleura type, are
not directly applicable to
man. Attempts to use such experimental observations directly in
explanation of human
physiologic and pathologic manifestations have led to confusions which
are the bases of most
misconceptions.
The
evidence for an air cell-capillary gear is direct and indirect.
If
the pulmonary artery is ligated or obstructed in man or in other
animals with a thick
pleura, the portion of the lung supplied is deprived of function. It
atrophies, contracts and
becomes airless. There is no infarction. If a bronchus is ligated or
obstructed and pneumonia is
not occasioned, the portion of lung supplied is deprive(l of function.
It atrophies, contracts and
becomes airless. There is no infarction.
In
man, no portion of lung which has had either its air or pulmonary
arterial supply
destroyed can be functionally rehabilitated. Obviously, if either part
of the air cell-capillary gear
is incapacitated, the other part is simultaneously disabled.
If
the rate and depth of respiration be increased above normal, the carbon
dioxide content
of the blood is reduced and apnea results. The unit volumes of blood in
the pulmonary capillaries
are increased because inflation is increased. Extraordinary aeration
results, not because of tissue
demands expressed through central nervous system control, but because
of the coordinating
action in breathing and circulatory units effected through the
peripheral governor.
If
the rate of cardiac contractions is suddenly increased by emotions,
there is a
correspondingly increased inflation; respirations are deeper and more
rapid. There is a transient
sense of air hunger. This is a common experience. Inspirations are
involuntarily deeper because
a larger unit volume of blood is delivered through pulmonary
capillaries at higher pressures and
inflation of alveoli is inevitable.
Animal
experiments are thus far unsatisfactory. Negative-pressure cabinets are
required
to eliminate complicating factors incidental to disturbed intrapleural
negative pressures and to
the intratracheal positive pressure usually employed. Pneumothorax or
hydrothorax induced in
an animal with a thick pleura causes a contralateral compensatory
emphysema proportionate
tothe amount of air or water introduced. The animal will tolerate
increasing
351
positive pressures so
long as it is able to develop and to maintain the higher pulmonary
arterial
pressures required to develop the degree of contralateral compensatory
emphysema required for
external respiration. If the animal be fatigued previous to the
experiment, the limit of tolerance is
lowered because cardiac energies are less. If the same experiments are
made on animals with a
thin pleura, pneumothorax and hydrothorax are soon bilateral;
compensation is less possible
because intrapleural pressures of both chest cavities vary together and
toleration is limited.
Further confirmation lies in the fact that as animals with a thick
pleura are progressively
exhausted, the tolerance of intrapleural positive pressures falls until
it equals the intolerance of
animals with a thin pleura.
Observations
have been made often enough during operations on human beings to
furnish
sufficiently reliable controls to satisfy all requirements for
accuracy. The following examples are
pertinent. When chronic pleuritic adhesions are divided before
pulmonary elasticity has been
permanently destroyed, the underlying lung, relieved of restraint,
bulges outward if the patient is in fairly good shape even when no
differential pressures are employed. If, during an
open thoracotomy performed on a strong patient under positive pressure
anesthesia, the positive
pressures are reduced or stopped, the mediastinum bulges toward the
open side. A focal
parenchymatous hemorrhage is surrounded by a halo of emphysema. The
focal pressure of a
finger on visceral pleura will produce emphysema in the adjacent lung.
Other
observations, after lobectomies, are notable. Each lobectomy causes
greater
compensatory emphysema in the remaining lung. The limit of lung capable
of supporting life is
that which will provide a vital capacity slightly in excess of the
tidal air of rest.
Attempts
to observe actions of the air cell-capillary gear in excised lungs are
quite futile.
Post-miortem changes occur rapidly. Blood pressures in the bronchial
artery are absent. It is
impossible to wash out all the blood from the capillaries. The effects
of negative pressures are
lost. The amount of force which must be applied to drive water through
the pulmonary arteries
exceeds the strength of the capillary endothelium and alveolar
epithelium. Leakage through the
air passage results. Inflation of lung bv forcing air into bronchi will
not cause the pulmonary
artery to aspirate fluid because the capillaries are plugged or
collapsed. Injecting awater into the
pulmonary veins causes no inflation just as might be expected because
passive congestion is
known to reduce vital capacity.
On
the other hand, sufficient air pressure in the pulmonary artery will
cause inflation of
the lung and aspiration of fluid by the bronchus before the capillary
walls are ruptured.
The
simplest experimental demonstration is to ligate with suitable
precautions in a strong
living animal the pulmonary artery of one lung and to observe by
Röntgen-ray examination
the increased compensatory emphysema produced in the contralateral
lung.
All
the manifestations noted can be explained by the interactions of
pulmonary inflation
and deflation and of the amounts and pressures of blood in
352
pulmonary capillaries
effected through the air cell-capillary gear. They are supplemented by
the
forces of blood in the bronchial arteries which fluctuate with
physiologic activities of the lung,
since they are under control of the systemic vasomotor mechanism.
Dunham
had recognized the air cell-capillary governor and constructed a model
to
illustrate its actions as shown in Figure 180. The jar represents a
pleural cavity. It contains a
rubber bag, an air cell instead of a lung, connected with the middle
glass tube instead of a
bronchus. The glass tube at the left is connected with a coil of guinea
pig's intestine glued to the air cell to imitate a pulmonary capillary.
The tube at the right makes it possible to establish
negative or positive (intrapleural) pressures. Suitable variations of
air pressures exerted through
the three tubes demonstrate the effects of breathing, fluctuations in
unit volumes of blood
delivered to the pulmonary capillaries, and chances in intrapleural
pressures. The model has been criticized because the pulmonary
capillaries have been represented as end vessels. A
moment's consideration will explain how difficult or impossible it
would have been to reproduce
a complete circulation and how unnecessary. Whether or not some blood
passes through the capillaries, a sufficient unit volume of blood would
cause them to straighten and to elongate.
FIG.
180.- Dunham's original
model of the air cell-capillary
gear.
The adaptations
are few in number. Their effectiveness
varies directly with grades of competence or
incompetence of the
circulatory unit. Hence, there are many variations in extent though
none in character of
responses.
COLLAPSE
Collapse
results when intrapleural negative pressures are neutralized byan open
thorax or
intrapleural exudates of appropriate amounts. One or both lungs may be
affected. The extent of
collapse is determined by elastic recoil of the lung opposed by the
expansive forces exerted
through the pulmonary and bronchial arteries. The lower the blood
pressures, the greater the
collapse. The greater the collapse, the less reserve air and blood in
the lung, the less the residual
air is ventilated, the less blood is in circulation and the more urgent
the
353
need for contralateral
compensation to protect external respiration. Unfortunately, the
greater the
need, the less the capacity to develop compensation.
Another
important influence is the rapidity of reductions in negative
pressures. As
already noted, adjustments are most effective when they are induced
gradually and thus occasion
less unfavorable expenditures of energies.
Observations
on the effect of war injuries and surgical wounds of the thorax have
proved
that ai competent individual can survive a wide parietal opening even
when suddenly produced,
whereas a comparable individual, made incompetent by exhaustion,
exposure, starvation,
hemorrhage, dehydration, and infection can barely tolerate a small
opening. Likewise, it has long
been known that a gradually increasing pleuritic exudate is of far less
moment
FIG. 181.- Sheep's
lung five weeks after
ligation of the artery
supplying the left upper lobe
than one produced
rapidly, and that life is possible when the former exceeds in bulk
amounts
which are fatal in the latter. The extraordinary dangers of abrupt
production of bilateral
pneumothorax or the rapid formations of bilateral pleural effusions are
well known, even to
laymen. Graham and Bell,5 working with animals of the thin
pleura type, in which, unlike man,
a unilateral pneumothorax can not be maintained, found that the evil
effects of the rapid bilateral reductions in intrapleural negative
pressures could be measured by the size of parietal
defects. Other experimental evidence has been presented to indicate
that if negative pressures are
reduced sufficiently gradually, almost normal inflation of the lung can
be maintained when
parietal defects are created subsequently.
354
All
of these manifestations can be explained physiologically. Nature
attempts to maintain
suitable areas of alveolar air and blood requiring aeration in order to
protect external respiration
on which life depends. Should intrapleural negative pressures be
reduced sufficiently gradually
in a competent individual. there is reason to believe that
redistributions of blood in both circuits
and increased blood pressures can by action through the air
cell-capillary gear maintain full
normal inflation after the negative pressures are neutralized. When
negative pressures are so
rapidly reduced in the competent that compensator adjustment can not be
made, or gradually
reduced in the incompetent, who are unable to make adjustments,
corresponding grades of
deflation are caused.
FIG.182.--
Sheep’s
lungs five months after ligation of the artery supplying the inferior
margin of the left lower lobe, showing adhesions produced by simple
thoracotomy
Pulmonary
deflation inevitably measures an equivalent reduction in the
corresponding
pulmonary blood supply. It should be recalled that the pulmonary
circulation is not provided
with an effective vasomotor control. The blood normally destined to
reach an area of deflated
lung is delivered to the nearest areal in whlich the ilitracapillary
pressures will permit circulation
to occur. Wherever an increased amount of blood is driven through
pulmonary cappilaries there
is produced a corresponding degree of inflations, a compensatory
emphysema. Thus, if the area
of deflationl is small, the compensatory emphysema will appear in the
same lobe; if larger, in the
same lung; if larger still, in thee opposite lung. Compensation is
produced by the amounts and
pressures of blood delivered and is, therefore, most effective in the
virile. Limitations of
compensatory pressures can be estimated in the weak by determining
reductions in circulatory
competence as well as by measuring the deficit. in vital capacity.
355
These
are nature's methods of maintaining the air alveolar capillary blood
relationships
that underlie external respiration. The effectiveness of the
relationships is measured by vital
capacity. If it is less than the tidal air of rest, life is impossible;
if equal, bare existence is
possible; and as it exceeds the tidal air of rest, it measures the
margin of safety, the limits of
possible physical and mental activities, including defense and repair.
EXTERNAL COMPRESSION
Collapse
is the deflation caused by the elastic recoil of lung when intrapleural
negative
pressures are neutralized. The amount of deflation is controlled by the
opposing forces, the blood
pressures in the pulmonary and bronchial arteries. External compression
is produced when a
force exceeding the pressure of an atmosphere acts on a lung from
without and produces a grade
of deflation corresponding to the preponderance of compressive force
from without the lung over
the expansive resistance of the blood pressures within the lung. On the
release of external
compression the lung reexpands to the grade of deflation due to
collapse. This is often noted
when chronic pleural exudates are divided or removed or when pleural
effusions are removed.
Deformity
of chest walls, intrathoracic tumors, aneurysms, intrapleural
transudates,
exudates, spontaneous and artificial pneumothorax, thoracoplasty and
intrathoracic operations
are causes of compression. An outline of changes produced by the common
cause, pleuritic
exudates, suffices for all.
Exudates
formed in a pleural cavity free from adhesions eventually gravitate.
Should they
increase, the lung is floated upward so far as its hilum attachments
permit. As the level of the
fluid rises out of the costophrenic sinuses, the lung is elevated and
negative pressures are
reduced to zero after which external compression begins. It is exerted
first on the supra-adjacent
lung. This is exactly contrary to the effects of diaphragmatic
contractions, which diminish
pressures on supra-adjacent lung, and are readily seen fluoroscopically
in the zone of increased
inflation just above a contracting diaphragm.
Pulmonary
vessels carrying low pressures are easily compressed: air cells are
smaller;
and this zone of lung becomes proportionately inactive physiologically
so that the bronchial
arterial blood supply is also correspondingly reduced by the usual
vasomotor responses. The
same series of changes, becoming more and more accentuated, develop as
the exudate increases. With increasing exudation, the significant
adaptive changes become more noticeable.
At
first, compression of the pulmonary circulation diverts blood to the
nearest margin of
lung under less compression and creates there a zone of physiologic
emphysema in the same
lobe. Gradually, this extends to higher lobes and finally to the
contralateral lung. Thus are
produced zones of skodaic resonance and the contralateral emphysema
long noted with pleuritic
effusions.
Should
the exudate form rapidly, as it often does in streptococcus infections,
patients
may succumb in a few hours because of their inability to deliver the
requisite blood pressures to
continue the adaptive emphysema. Physiologic emphysema, be it recalled,
is merely a natural
method of developing a sufficiently large area of functioning alveolar
epithelium in one part of a
lung to compensate
356
for reductions
elsewhere, and thus to provide enough external respiration to support
life. Again,
the exudate may be produced more gradually, and, though it cause
complete external
compression of the entire lung on the affected side, the patient is
able to survive. Moreover, the
more gradual productions of exudates are favorable to the formation of
adhesions between
visceral and parietal pleurae and thus to localization of the process.
Another
point is noteworthy. Intense irritation of visceral pleura tends to
produce a
subserositis or cortical pncumonitis that may be effective in reducing
pulmonary elasticity,
which interferes with vital capacity.
There
is a parallelism between the adaptive processes in the cerebral and
pulmonary
circulations neither of which is under direct vasomotor control. Both
can compensate for
gradually increasing antagonistic pressures remarkably well. Both are
lethally incapacitated if
the counter pressures rise more rapidly than the patient can develop
compensatory rises in blood
pressures to offset their effects which are respectively cerebral
anemia and impaired external
respiration.
INTERNAL COMPRESSION
Internal
compression differs from external in that the force is exerted within
the lung
instead of on it. The common causes are chronic passive congestion,
pneumonias, tumors,
foreign bodies and parenchymatous hemorrhages.
The
effects of internal compression are the same as those arising from
external
compression. They differ in extent and in distribution. Compensatory
emphysema develops
about a focus of internal compression by the same air cell-capillary
gear. The blood being
diverted from a focus of greater to surrounding zones of lesser
pressures produces an enveloping
layer of hyperemia and consequent emphysema. If the foci of internal
compression are
sufficiently large and numerous, they can produce a manner of skodaic
resonance and even lead
to contralateral emphysema.
Should
the force exerted by foci of internal compression be sufficient, large
branches of
pulmonary arteries, bronchial arteries or bronchi can be occluded. The
effectsof such occlusions
will be noted later.
PULMONARY CIRCULATION
Abnormalities
in the arterial circulation are gradual occlusions of pulmonary
arteries
producing equally gradual increments in peripheral resistance, sudden
occlusions of larger
branches by injuries, ligations and emboli causing abrupt increments in
peripheral resistance.
Gradual
occlusions or obstructions to arterial circulation occur in chronic
external and
internal compressions of the lung in pleural effusions, tuberculosis,
bronchiectasis and
pathologic emphysema. High peripheral resistance leads to hypertension
in the pulmonary
circulation by extraordinary exertion of the right heart which results
in hypertrophy and
diminished reserve power. This explains why individuals so affected are
especially sensitive to
sudden changes in intrathoracic pressures and why all grades of
pulmonary compression should
be minimized.
357
Sudden
occlusions or obstructions to main branches of the pulmonary artery are
produced
by ligation and by emboli. They cause a sudden shunting of considerable
volumes of blood into
other vessels and an abrupt rise in peripheral resistance. A strong
individual tolerates such a
change without notable variations in pulse rate or systemic blood
pressures. A weakened heart
may be incapacitated almost immediately. Permanent occlusion of a
pulmonary artery causes
atrophy, shrinkage and atelectasis in the lung affected. Ligation has
been practiced and is still
advocated in treating tuberculosis and bronchiectasis. It is in effect
a physiologic lobectomy
when the principal artery to a lobe is tied. But it does not cause
gangrene or infarction because the parenchyma and visceral pleura are
supplied by the bronchial arterial circulation.
Experiments
indicate that life is possible after four-fifths of the pulmonary
arterial
circulation has been destroyed in successive stages, as in repeated
lobectomies. Sudden
occlusions of much more than three-fifths are incompatible with life.
Two
erroneous notions about the effects of pulmonary embolism are
prevalent. One is
that embolism is the cause of gangrene and infarction of the lung; the
other, that deaths from
emboli can always be attributed to their size.
Embolism
can be an indirect cause of gangrene or infarction if it produces
secondarily
enough internal compression to occlude a bronchial artery. Usually,
gangrene and infarction are
occasioned by thrombosis in pneumonia or occur in lungs with
circulatory impairments
incidental to cardiac lesions or consequent on pleural effusions.
The
victims of pulmonary embolism expire or they recover, perhaps to die
later of
pneumonia. Survivors suffer only from such ill effects as may be
attributed to a physiologic
lobectomy. Deaths from pulmonary embolism in debilitated patients are
often due to emboli
sufficiently large to raise peripheral resistance abruptly above the
limits of their restricted
powers of cardiac compensation. There are, however, many deaths of
relatively healthy individuals, as, for example, a few weeks after a
simple herniotomy, which fail to be thus
explained. Barcroft 6 has suggested that an embolus can be
caught close to one of the nerve
endings present in the pulmonary arterial wall and may, by irritation,
interfere reflexly with
normal cardiac impulses.
Operative
removal of pulmonary emboli has been recommended and, in one instance,
has
been accomplished without killing the patient. Removal of emboli could
not be sufficiently
prompt to obviate the sudden deaths. It could therefore only be
employed to rehabilitate a
fraction of the pulmonary circulation or prevent embolic pneumonia. The
very patients needing
to have a portion of their pulmonary circulation restored are those so
debilitated that
thoracotomy would be a fatal burden. None could say that any given
embolus was going to cause
metastatic pneumonia, or that its removal would prevent the pneumonia
or would help to reduce
the dangers of septicemia. Hence, the removal or attempted removal of a
pulmonary embolus is
almost without exception a highly dramatic example of surgical
malpractice.
358
Interference
with the circulation in the pulmonary veins is due to obstructions
caused by
incompetence of the left heart or resulting from pulmonary compression.
Both add to peripheral
resistance in the pulmonary circulation.
If
the obstruction develops abruptly and the use of positive pressure with
too great
anesthesia is a nice example, acute cardiac dilatation is constant and
often fatal. Acute venous
obstruction can become so critical that systematic venesection is
indicated. Gradually increased
obstruction leads to chronic passive congestion with its series of
handicaps. Abrupt increments
in chronic obstruction can cause edema of the lungs.
BRONCHIAL ARTERIAL CIRCULATION
Bronchial
arteries carry six times the pressure of the pulmonary artery, and, as
stated,
supply the major part of nutrition to lung parenchyma and visceral
pleura. Hemorrhage from
rupture of the bronchial artery into a bronchus causes exceptional
deaths with hemoptysis; into a
lung, the diffuse parenchymatous hemorrhagic infiltration called
splenization. Obstruction of this blood supply can produce infarction
and gangrene. The principal significance is surgical.
Splenization is commonly a positive indication to excise the portion of
lung affected. Incisions
and resections of lung require accurate ligation of severed branches of
the bronchial artery
which are easily recognized by the spurting of red blood. Usually, it
is safest to remove all lung
bereft of its bronchial arterial blood supply.
BRONCHIAL AIR CIRCULATION
Obstruction
of bronchi deprives the corresponding lung of its supply of air and
assures
atelectasis because the air present at the time obstruction occurs is
rapidly absorbed. Commonly,
an obstruction of larger bronchi leads to pneumonia through infection
added to the pressure
exerted by retained secretions.
The
surgical significance is clear. Bronchial defects must be repaired
accurately, and,
when such repair is impossible, the corresponding lung should be
removed.
PNEUMONIAS
The
more acute and diffuse the inflammation, the greater and more abrupt is
the internal
compression and increase in peripheral resistance in the pulmonary
circulation. Processes of this
type are more apt to be accompanied by restricted movements of the
diaphragm on the affected
side, which are almost certainly inhibited if pleurisy develops. The
danger lies chiefly in the
extra load thrown on the right heart in addition to the burdens of
myocardial injuries from
toxemia. It is particularly desirable to reduce the expenditures of
energy by the heart. Benefits of
early and repeated aspirations of pleural exudates introduced years ago
by Bowditch 7 are too
important to be neglected. Occasionally, the diaphragm is but little
affected. Paralysis obtained
by injecting the phrenic nerve can be helpful. The main obligation is
to reduce cardiac labor in
order to aid compensation and to increase pulmonary blood supply.
Chronic
pneumonia reduces pulmonary elasticity and increases peripheral
resistance in
the pulmonary circuit.
359
EMPHYSEMA
Pathologic
emphysema means reduced pulmonary elasticity, increased peripheral
resistance in the pulmonary circulation and a limited capacity for
compensation. It commonly
indicates a narrower margin of safety than would be suspected. The
right heart has been working
for a considerable period against abnormally high peripheral
resistance, and its store of reserve
energy is subnormal. The bronchial arterial supply is reduced, and the
powers of resistance and
repair in both parenchyma and visceral pleura are accordingly
restricted.
Intrathoracic
operations on patients suffering from emphysema are extraordinarily
hazardous. Such patients are likewise less able to tolerate pleural
effusions and should be
protected by early and repeated aspirations, preferably bv continuous
one-way drainage.
ATELECTASIS
Lung
becomes atelectatic when its supplies of air or of blood from the
pulmonary artery
are stopped. It is physiologically inactive and receives the least
blood through the bronchial
arteries. Such lung atrophies and is cicatrized, both leading to
contraction. Contraction
is powerful enough to carry with it adjacent lung so that an area of
atrophy,
which is but a part of a lobe, may reduce the whole lobe to a small
mass puckered about the
hilum.
In
the performance of intrathoracic operations, this must be considered.
Lung that has
become permanently atelectatic or is likely to become so is more safely
excised as a rule.
Observations
of the actions and reactions in the breathing and circulatory units
occurring
under physiologic and pathologic conditions show that nature attempts
to maintain such
interrelationships as will assure preservation of the basic function of
external respiration with the
largest margin of safety therein.
Control
of the basic relationships, namely volume of ventilated air, area of
alveolar
epithelium, expanse of capillary endothelium and unit volume of blood,
is in part in the central
nervous system, but to a larger extent is vested peripherally in the
air cell-capillary gear.
Vital
capacity measures the efficacy of the relationships so that, in effect,
nature strives
to maintain a high normal vital capacity, a lead that therapy must
follow.
Vital
capacity is determined in the last analysis by the integrity of the
pulmonary
circulation affected by and affecting the state of the breathing unit.
Preservation and
rehabilitation of the pulmonary circulation, the quality, quantity and
pressures of the blood
delivered by it, are the most important part of intrathoracic
therapeutics.
NATURAL DEFENSE
REACTIONS
Nature's
methods of meeting irritations from injury or disease by increasing
resistance
and hastening repair through reduced but not inhibited function are
more evident and perhaps
more significant in the chest than elsewhere.
Irritations
affecting thoracic parietes or viscera almost constantly restrict
parietal
movements. Costal excursions may be more affected than diaphragmatic
360
or vice versa.
Both are influenced because there is a common control. This is well
illustrated if one side of the diaphragm is paralyzed by blocking the
cervical portion of the
phrenic nerve when there is an immediate, if transient, limitation in
the costal excursions on that
side.
The
effects of restricted motion are to encourage somatic rest, to conserve
energy, to
limit dissemination of irritants and to prevent atrophy and hyphemia
inevitable with nonuse.
They may be noted in parietes, in lung and in pleurae.
Restricted
motion in extrapleural parietes subject to irritation is of no especial
moment
other than assuring the richest blood supply compatible with minimal
expenditures of energy.
Restricted
motion in the parietes has very definite influence on the lungs. When
restricted motion is considerable, as in more intense types of
irritations, the diaphragm is more
or less relaxed and is prone to be forced by intraabdominal positive
pressures into an unusually
high position. Pulmonary excursions are thereby reduced, and more
important still, the total
volume of lung or the grade of inflation is less. It has been found
experimentally that a lung in approximately a mean position between
extremes of inflation and deflation produced by
inspiration and expiration receives the largest unit volume of blood
with the least cardiac effort.
Under such conditions the vessels are neither elongated nor tortuous
and peripheralresistance is
lowest. It has also been found that under these most favorable
conditions pleuropulmonary
resistance to infection is highest, and the rate of repair and
functional rehabilitation is well-nigh
doubled.
The
effects of restricted parietal motion on the visceral and parietal
pleura are significant
since pleurisy is commonly the cause and frequently the danger of
treatment. The parietal pleura
receives its blood from the same vessels that supply the adjacent
parietes so it is helped by
restricted parietal motion. The visceral pleura is more effective in
defense against pleural irritations than the parietal because it has a
richer blood supply and a
larger expanse. The gravity of
serositis in general is determined by the excess rate of production of
effusions over the rate of
their absorption. Resistance of serous cavities is commensurate with
their ability to maintain
visceral and parietal reflections of serosve in apposition by
absorption of exudates. Absorption
from the pleural cavity is notoriously slow and slower still if
visceral pleura is incapacitated by
compression of exudates. Lung in the mean position between inflation
and deflation provides its
pleural surface with its richest blood supply. Hence, through
diminished parietal motion, Nature
protects the welfare of parietes, viscera, and pleurae.
Besides
the foregoing adaptations in the breathing apparatus, there are
responses in the
circulatory unit. Satisfactory determinations of rates of flow and
pressure of blood within the
pulmonary circulation are yet to be made. Blood is forced through the
lesser circuit in one-fifth
the time under one-sixth the pressure required to drive it through the
systemic. Fluctuations in
blood pressure occur, perhaps synchronously with variations in systemic
pressure, but are less in
extent. Presumably, the margin of safety in the right heart
361
is as wide as in the
left. However, nothing definite is known of the persistence and effects
of
pulmonary arterial hypertension.
Shunting
of blood from one part of a lung to another or to the contralateral
lung is
attributable in the main to hydrodynamic influences. Anatomists have
found nerve cells
indicating possible vasomotor controls, but physiologists have not
demonstrated corresponding
functions. However, two peculiar reactions occur that may be caused by
such influences.
Massive collapse of an entire lung has followed injury to the opposite
side of the chest. Such
lung must be deflated, and deflation can result only from failure of
air to enter the bronchi or
from interference with delivery of blood through the pulmonary
arteries. Massive collapse
might be explained by a unilateral temporary occlusion near the
bifurcation of the trachea were it
not for the second reaction. Surgeons who have performed open
thoracotomy without the
protections from differential pressures have noted a sudden lateral
shifting of the mediastinum
which has been called fluttering or epilepsy of the mediastinum. This
has been found
experimentally to be associated with equally sudden variations in
intrapleural negative pressures,
and, in the absence of tracheal obstruction, was attributed to shunting
of blood from one
pulmonary artery to the other. Conceivably, such shunting might be
explained by alternating
kinking and unkinking of the pulmonary arteries, but alternating
vasometer spasms seem more
plausible.
TREATMENT
The
object of treatment is to protect and to restore the function of
external respiration,
which is estimated by the vital capacity. The means are to assure the
integrity of both the
circulatory and the breathing units. Available methods are few.
CIRCULATORY UNIT
Abnormalities
occur in the amount and distribution of blood in an organism. If the
amount of blood has been reduced by hemorrhage or as the result of
increased blood destruction
or decreased hematopoiesis, prompt relief is attainable with
transfusions. If the amount of blood
in circulation is reduced because of exemia or the escape of plasma
into the tissues, benefits
follow intravenous administration of hypertonic glucose which may be
given with and without
insulin or with and without gum acacia. Each has its indications.
The
importance of overcoming shock or states bordering on shock can be
illustrated
experimentally. If a robust dog is bled from a femoral artery until the
heart stops, and an open
thorax is then created promptly, the heart beats again for a
considerable interval and more blood
escapes from the artery. If, however, a dog in a state of prolonged and
profound shock is
similarly treated. the heart is not reactivated. In other words, little
or no reserve blood is stored in
pulmonary vessels during shock. Immediate compensatory or adaptive
responses are impossible.
Additional demands for oxygen can not be met because an important cog
in the mechanism of
external respiration is not working; hence, the need for providing an
ample blood supply before
attempting an operation and avoiding pulmonary compression, so far as
possible, if that
operation is intrathoracic.
362
BREATHING UNIT
Means to counteract lesions in the breathing
apparatus are
extrapleural and intrapleural.
Extrapleural
procedures can restrict parietal movements, increase pulmonary
deflation or
produce compression.
Lesser
degrees of restricted movements of the parietes can be obtained by
bandages,
swathes, and adhesive plaster, particularly if it is remembered that
adhesive plaster splints are
fully effective only when snugly applied, corsetlike, around the entire
chest. Frequently,
desirable benefits can be secured by further increasing the spontaneous
restrictions to motion,
particularly if the lung is placed simultaneously in that stage of
deflation wherein the blood
supply is most favorable. Then, benefits may be provided readily by
section of the cervical
portion of the phrenic nerve, if permanence is required, or by
injecting it with cocain or with
appropriate dilutions of alcohol should subsequent regeneration be
desirable.
Extrapleural
thoracoplastic operations are effective in producing permanent
compression
to aid in obliteration of cavities, particularly in tuberculosis and
some forms of bronchiectasis.
Failures of these operations, if patients are properly selected, can be
attributed to insufficient
costal resections or to having attempted too much at one stage.
The
operations are dangerous because the patients are usually weakened by a
losing
struggle against an affection that is mainly unilateral, and during
operation they must lie on the
sounder side. A more serious handicap is cardiac incompetence.
Increased peripheral resistance
in the pulmonary circuit has resulted from the internal compression
caused by the lesions. It is
usually of long duration and has sufficed to reduce the margin of
safety especially in the right
heart. Fever, intoxication and anemia add burdens by causing myocardial
degeneration. It is
obvious why excisions of parts of only a few ribs can so alter
distribution of blood in the
pulmonary circulation that the greater labor required to effect
compensation can lead through
progressively increasing tachyeardia to lethal myocardial exhaustion.
Rest,
digitalis, transfusions and intravenous administrations of glucose can
be extremely
valuable in surgical preparation. The greatest assurance of safety lies
in performing these
operations in stages with sufficient intervals to permit orderly
readjustments in the circulatory
apparatus. One stage too many is preferable to one stage too few. An
incompleted operation can
provide the dangers and distresses of a finished procedure without
affording the benefits.
Intrapleural
procedures are called closed when free pleural surfaces are not exposed
to
the air and open when they are so exposed.
Closed
methods are drainage afforded by single or repeated aspirations or by
the
continuous removal of exudates accomplished by air-tight, intercostal
tube drains, artificial
pneumothorax and thoracotomies performed through preformed adhesions.
The same sources of
danger are present in all. One is the sudden entrance of air into free
pleural space. The other is
caused by rapid and forceful operating. Both have the same effect,
abrupt changes in
363
intrathoracic pressures
which require immediate readjustments in the pulmonary circulation.
Likewise, the same precautions are to be observed. Aspirations and
drainage through tubes
should be gradual. Artificial pneumothorax should be induced slowly and
at repeated sittings
so/that intrapleural pressures are progressively reduced before
positive pressures are created.
Accuratehemostasis and gentleness are essential in closed
thoracotomies.
Empyema
will continue to be an important part of intrathoracic therapy. The
best
treatment is prevention, which means early diagnosis and immediate
aspiration as first advised
by Bowditch. 7 Fluoroscopy, essential to both, has *
been insufficiently practiced and is more
generally available since bedside roentgenray units have been made
easily portable.
Early
aspiration, perhaps closed drainage, even if it fail to abort empyema,
can minimize
its severity, extent and the necessity for rib resection. More
important still, it reduces the
persistence of diaphragmatic paralysis, which Pryor 8
showed to be so common and Middleton 9 found to be commensurate with reduced vital capacity and degrees of
disability. Moreover,
pulmonary deflation with its added burdens on the pulmonary circulation
are minimized during
aggressive phases of pneumonias when a slight shift in the patient's
favor can obviate a fatality.
Rib
resections impair parietal mobility and are to be avoided whenever
possible. On the
other hand, it is usually unwise to delay performing this operation
after the application of
ordinary surgical principles indicates open drainage. Much may be
accomplished by the use of
surgical solution of chlorinated soda (Dakin's solution) to dissolve
fibrin and by employing
gentian violet as advocated by Keller,10 to disintegrate
fibrous tissue.
After-care
has been too often neglected. As soon as the acute process permits,
breathing
exercises are needed to stretch adhesions, to reactivate the diaphragm
and to develop
compensatory physiologic emphysema in order to maintain a high vital
capacity.
Discussion
of open methods for treating intrathoracic lesions is limited to
consideration
of ways of performing thoracotomy in the absence of pleural adhesions.
Incisions should be
designed to assure permanent air-tight healing, else open pyothorax is
inevitable. It is the
principal cause of postoperative disabilities and deaths. Differential
pressure is required for
safetv. Analgesia suffices. Both can be obtained by the proper use of
gas-oxygen as developed by Gwathmey.11 It is wise to inject
the phrenic nerve with 1 per cent cocaine. The immediate
paralysis of the diaphragm makes operation easier and hastens recovery.
There is less
postoperative discomfort as the effects of cocaine last for four or
more days. Effusions are more
rapidly absorbed because the pulmonary blood supply is richest under
these conditions and
healing of lung tissue is favored. Operators differ in respect to
drainage. Postoperative pleuritic
effusions are constant, commonly of considerable volume, are slowly
absorbed and offer a
favorable medium for bacterial growth. They cause pulmonary compression
and its train of evil
influences. Air-tight drainage is possible, is effective, and is seldom
to be regretted. Omission of
drainage can be disastrous. While suturing the wound at the end of a
thoracotomy,
364
it is important to
obtain air-tight closure with lungs in full inflation and to obtain it
in such a
manner that the stitches mav not cause tension necroses.
After-care,
if otherwise it can be called such, includes breathing and body
exercises to
restore parietal movements, pulmonary elasticity, and intrapleural
negative pressures as steps in
the rehabilitation of external respiration which can be measured by
frequent estimations of vital
capacity.
SUMMARY
Life
and activities are made possible by external respiration which is
provided through
coordinated actions of the breathing and circulatory units.
Coordinated
actions of breathing and circulatory units maintain sufficient volumes
of
ventilated air in contact with a suitable area of alveolar epithelium
to assure such interchange of
gases through a similar expanse of capillary endothelium as will aerate
equivalent amounts of
blood. The interrelationships between the volumes of ventilated air,
the area of alveolar
epithelium, the expanse of capillary endothelium and the amounts of
blood needing aeration
must remain constant although they are constantly fluctuating with each
breathing cycle and with
variations in activities of the individual.
This
constancy is assured under normal conditions by an arrangement of an
air cell-capillary structure and function whereby fluctuations in
degrees of inflation produce equivalent
fluctuations in amounts of blood, and vice versa.
Under
abnormal conditions, the relationship is modified through the air
cell-capillary
gear, so that additional areas of alveolar epithelium and of capillary
endothelium are provided to
compensate for such as may be temporarily or permanently inactivated.
External
respiration in a normal individual is undisturbed whether lie is at
rest or
exercising full mental and physical powers. Disability is nil, and the
limits of activities,
including defense and repair, are measured by normal vital capacity.
External
respiration in persons affected with incompetent breathing or
circulatory units is
impaired. This impairment restricts the development of mental and
physical powers to the level
at which the relationships between ventilated air, areas of alveolar
epithelium, expanse of
capillary endothelium and amounts of blood can no longer be kept
constant. There is disability
corresponding to the level. Activities including defense and repair are
proportionately restricted,
and the restriction is measured by the reduction in vital capacity.
Preservation of vital capacity
during the acute phases of diseases affecting the thorax and its
contents and restoration of vital
capacity thereafter are the therapeutic objectives.
Vital
capacity measures external respiration which is largely under control
of the air cell-capillary gear. Treatment seeks to renew parietal
mobility. to reestablish normal intrapleural
negative pressures and to restore pulmonary elasticity, at the same
time providing for deliveries
of suitable amounts of good blood by the right heart and preventing
obstruction to the pulmonary
circulation through incompetence of the left heart. The specific aim is
to rehabilitate the air cell-capillary gear in order to secure the
largest measure of external respiration. Achievement is
measured by vital capacity.
365
CONCLUSION
The
principal effects of intrathoracic diseases are the malfunctions due to
lesions of heart
and lungs. Both heart and lungs are possessed of remarkable powers of
compensation and repair
but, when seriously affected, cause enormous totals of distress,
disability and death. Many
lesions of heart and lungs from which spontaneous recovery is
impossible can be remedied
surgically by procedures already devised.
A
wider application of known methods and the introduction of new
procedures can be
hastened by more exact knowledge of intrathoracic structures and
functions.
At
present, vital capacity is significant in estimating latent powers
including defense and
repair, in determining therapeutic procedures and in measuring results
of treatment.
Vital
capacity is regulated by the air cell-capillary gear, the weaker part
of which is the
circulatory segment. Progress in intrathoracic surgery depends largely
on the realization of more
effective measures to promote and to conserve the integrity of the
pulmonary circulation.
APPLICATION
OF BIOLOGIC PRINCIPLES TO THORACIC INJURIES
The
actions, reactions, and adaptation of the breathing and circulatory
units above
described will be discussed in reference to thoracic injuries in
particular. Repetition, even though
fatiguing, will emphasize the biologic principles underlying treatment,
which, if correct, will be
permanent however much methods may be improved.
Thoracic
injuries affect the parietes alone, the viscera alone, or, most
frequently, both
parietal and visceral lesions are produced. Hemorrhage and the exposure
of lacerated tissue to air
and to infection, which occurs with all wounds, are of special
significance because of the
untoward effects of hemopneumopyothorax.
Chest
injuries, severe enough to need treatment and not causing prompt death,
produce
an immediate defense reaction, restricted motion, particularly of the
injured side or the side of
greater injury.
The virtues of restricted motion in respect
to defense and
repair are two-fold. The blood
supply exceeds deliveries made when there is immobilization. Continued
limited motion, an
incomplete interference with function, assures opportunities for the
earliest and most complete
restitution of function.
Thoracic
parietes are benefited by a narrowing of intercostal spaces. Tension
upon soft
tissues is reduced, a richer blood supply is favored and the size of
tissue defects is minimized.
Simultaneously, diaphragmatic excursions are curtailed, first, through
spasm; later, through
relaxation due to fatigue, which, in the presence of intra-abdominal
pressure, carries the affected
side to an unusually high position. Some motion, even when there is
paralysis of one side of the
diaphragm, is provided by a contralateral tug with each inspiration so
that here, too, conditions
favorable to healing are provided.
Diminished
motion of the parietes, and particularly of the relaxed diaphragm, not
only
decreases pulmonary excursions but also lowers the mean
366
pulmonary inflation.
Hence there is a diminished volume of lung subjected to less motion.
Observations made by Steiner12 upon patients suffering
from irritations to lung and to the
visceral or parietal pleurae, even before pneumonitis or pleuritis is
demonstrable and though they
may never develop, prove this reduction in size and motion of lung to
be a natural defense
reaction. Experimental evidence (Cloetta)13 Shows that
these conditions provide for delivery of
the richest blood supply to a unit volume of lung, and, quite as
important, with the least
expenditure of cardiac energy.
Pleural
defense and repair is obviously affected by the same conditions since
the blood
supply to the parietal reflection is derived from the vessels supplying
the chest wall and the
diaphragm and the visceral layer is nourished (in man) chiefly by the
bronchial arteries. Pulmonary inflation is also affected through
injuries to the circulatory mechanism by
hemothorax, by intrapulmonary hemorrhage and by variations in the
volume and force of the
blood delivered to the lung.
Hemothorax,
usually accompanied by some pneumothorax, is the commonest
complication. Blood, escaping from either visceral or parietal
lacerations into a pleural cavity
free from adhesions, tends to settle in the costophrenic angles so that
intrapleural negative
pressures are reduced and progressive degrees of collapse occur before
the lung volume is
affected by direct pressure. As the level of the extravasated fluids
rises, pressure is exerted
chiefly upon the contiguous lung which is also elevated. When the
extrapulmonary pressure
exceeds the tension within the pulmonary arteries, that portion of the
lung is deflated. At the
same time the blood which should have been delivered to the zone of
lung under compression is
shunted to the superadjacent lung, wherein, because of the air
cell-capillary gear, a margin of
compensator emphysema is produced. This emphysema produces the Skodaic
resonance
constantly recognizable above the level of pleural effusions. Should
the hemorrhagic
extravasation continue to increase, the same compensatory changes are
augmented so long as the
circulation remains competent. However, a point will be reached at
which the excess blood
diverted from the compressed lung can no longer be distributed only to
homolateral lung, but
will in part be shunted to the lung in the opposite side of the chest.
Here will be produced by the
same air cell-capillary action the contralateral emphysema so commonly
noted with large pleural
effusions and massive pulmonary consolidations.
When
unilateral negative intrapleural pressures are nullified--i. e., equal
to the
atmospheric pressure--the lung is in a position of collapse or as it
would be with an open thorax.
Intrapleural pressures in excess of the atmospheric produce degrees of
pulmonary compression
which vary directly with the amount of positive pressure exerted upon
the lung and indirectly
with intrapulmonary intravascular tensions. The final state, complete,
rapidly produced unilateral
compression, is seldom compatible with life and therefore rarely
encountered.
From
a practical standpoint it is wise to examine these adaptations more
closely.
However they may be produced, by variable proportions of hemothorax,
pneumothorax and
pleuritic effusions, as unilateral intrapleural pressures grow
progressively more positive, they are
met, as has been shown experimentally,3 by increments in
systemic blood pressures within the
lesser circulation.
367
So long as intravascular
tension within a lung exceeds the extrapulmonary pressure the unit
volumes of blood delivered will remain approximately normal, but such
deliveries are secured
by a greater expenditure of cardiac energy. When the extrapulmonary
pressure exceeds the
intrapulmonary vascular tension, there occurs the inevitable shunting
of blood from zones of
greater to the nearest zones of lesser compression. The compensatory
emphysema inevitable
with increased blood deliveries assures proper aeration of excess
blood, but it is obtained at the
cost of increased cardiac labor which is proportionate to the
adaptations demanded and is
effective so long as circulatory competence persists.
Possibilities
for compensation vary within wide limits. Our observations have shown
that
a competent circulation in man will adjust itself to an abrupt
interruption to the blood supply of
an entire lung without recognized embarrassment. A healthy monkey will
tolerate an increase in
unilateral intrathoracic pressure exceeding twice the atmospheric
pressure without giving
indications of immediate distress. On the other hand, dogs, in which
neither unilateral
pneumothorax nor unilateral hydrothorax can be maintained, have not
such powers of
adjustment. They can barely tolerate atmospheric intrapleural pressure
and then the better when
slowly induced so as to provide opportunity and time for a compensatory
rise in blood pressures.
When their heart muscle is fatigued by meeting repeated demands for
compensation, dogs can
tolerate progressively less reduction in negative pressure. Similarly,
a fatigued monkey or a man
handicapped by myocardial deficiency, hemorrhage or shock, may be
unable to withstand even
atmospheric pressure, although gradually induced.
Another
complication due to lesions in the circulatory apparatus is
intrapulmonary
hemorrhage, which may arise from lacerated pulmonary arteries or veins
or from severed
bronchial arteries. Resultant interstitial extravasations reduce
pulmonary elasticity and affect
pulmonary inflation. The results vary from localized hematomas to a
diffuse brawny infiltration
or splenization that may involve an entire lobe and is in effect an
infarction.
Intrapulmonary
hemorrhages cause intrapulmonarv compression, and, like
extrapulmonary compression, compel a shunting of blood from foci
wherein intravascular
tension is exceeded to surrounding lung wherein it is not exceeded, so
that the same factors are
active in causing compensatory emphysema.
Incompetence
is the most significant of all injuries to the circulatory unit whether
produced by myocardial deficiency, anemia or exemia alone or in
combination, because of the
limitations to compensations that make external respiration possible.
So important is this phase
of the problem that it is fair by way of emphasis to anticipate
therapeutic discussion and state
that those procedures offering the greatest immediate protection to the
lesser circulation and the
largest possibilities for its rehabilitation, both measurable by vital
capacity, are most effective in
intrathoracic therapy.
SURGICAL METHODS
The
aims of civil and of military surgery are identical, to provide the
largest
opportunities for functional recovery with the least danger, delay, and
distress. Handicaps
imposed by warfare too frequently restrict what
368
should be done to what
can be done. Makeshift methods need not be discussed as they are born
of unfavorable conditions and individual ingenuity. Interest centers in
means to a satisfactory
performance of thoracotomy under field conditions, for thereby alone
can many of the severely
wounded be saved from death and a very large proportion of all the
wounded be returned
promptly to duty.
Surgeons
have been enabled to invade body cavities effectively by first learning
to
control subsequent inflammation of the lining membranes of those
cavities. This is particularly
true of the thorax. Appreciation of the need to control pleuritis by
restricting pleural irritation
and by conserving the defensive and reparative powers of the pleura is
simultaneous with the
realization that the great majority of deaths not immediately due to
injury and much of the late
disability are attributable to acute and chronic pleural inflammation.
The
explanation is simple. Chest wounds provide all of the conditions
favorable to the
development of pleuritis, tissue laceration, unyielding costal
parietes, hypertension due to
hemothorax, exudation more rapid than absorption, foreign bodies, and
the presence of bacteria.
Acute pyothorax added to burdens of recent wounds and exposure is an
extremely serious
complication, particularly when, as often occurs, circumstances prevent
adequate personal
attention to the sick. Chronic pyothorax, even though treated as
superbly as has been done by
Keller,10 inevitably causes material disability.
Methods
for controlling pleural irritation should cooperate with natural
defense reactions.
Mesothelium lining serous cavities, compared to other tissues, is
exceptionally resistant to
irritants and possessed of correspondingly high powers of regeneration,
provided its blood
supply is adequate.
The
extent and character of serositis is determined by the intensity of
irritations, their
dissemination through motion, capillarity. and gravity, by the
hypertension produced within the
cavity and the subserous reactions which curtail the supply of blood.
In other words, resistance
of serous activities is commensurate with their ability to maintain
their mesothelial surfaces in
approximation. This depends upon a greater rate of absorption than of
exudation and upon
flexible parietes.
Pleural
resistance is relatively lower than peritoneal because the rate of
absorption of
pleural effusions is less rapid than the rate of exudation and because
parietal adaptability is
virtually limited to the various positions which may be taken by the
diaphragm.
A major portion of pleural resistance is borne by the
visceral reflection
and this is subject
to material reductions by the interferences with the circulations in
the lung consequent upon
injury. As already stated, the total volume of blood delivered to a
normal lung is commensurate
with activity of respiration and with circulatory competence. If, as
the result of extrapulmonarv
pressures (air, blood, exudate) or intrapulmonary pressures
(interstitial hemorrhage), the
pulmonary arterial pressure is surpassed, deflation occurs which
amounts eventually to
atelectasis when blood flow is inhibited. By the same token, if a large
branch of the pulmonary
artery is occluded, permanent atrophy of the lung supplied thereby is
the result (figs. 181, 182).
Presumably, in areas
369
of partial or complete
deflation and in atrophy the bronchial arterial blood supply is
proportionately reduced. If the bronchial supply is withheld, necrosis
follows. Although Karsner
and Ghoreyeb14 have shown that when the pressure in either
the pulmonary or bronchial
circulation is reduced to zero, blood may pass over from one to the
other, it was not evident in
wounded human lungs that this interchange was free enough to be
effective. Therefore, in man,
because the visceral pleura is supplied by the broncial arteries, the
basic need is to maintain a
degree of pulmonary inflation compatible with function because the
bronchial arterial blood
supply varies directly with functional activity.
Natural
defense reactions indicate that the limited degree of inflation
determined by
reduced costal excursions and the high position of a relaxed diaphragm
is the most propitious.
According to Cloetta,13 the pulmonary vessels in at lung
thus inflated are neither tortuous, as in
greater deflation, nor elongated, as ill great inflation. In
consequence, lungs thus inflated contain
the maximum unit volume of blood delivered with the least cardiac
effort.
Rapidity
and extent of dissemination of intrapleural irritants are well
illustrated by a
simple hemothorax. As first demonstrated experimentally by Denny and
Minot,15 and confirmed
by the observations of Elliott and Henry16 upon the
wounded, intrathoracic movements are
sufficiently active to defibrinate the blood in the pleural cavity
which does not coagulate
promptly and to spread the exudate over the entire pleura free from
previous adhesions. Delrez17
and Middleton18 showed that blood is so irritating to
joint and chest serosa as to produce a
serofibrinous serositis. Middleton18 found the chief
irritants to be fibrin and fibrinoplastic
substances. Not all of the latter are removed when coagulation occurs
so that serum remains an
active irritant.
These
facts explain the diffused pleural reactions, varying from a
serofibrinous to an
organized exudate, noted when a thoracotomy is performed hours, days,
or weeks after hemothorax has resulted from injury. They also help to
explain why pleuritis must be combatted
otherwise than peritonitis. Generalized pleuritis is the rule;
generalized peritonitis, the exception.
Thoracic parietal adaptability is restricted to the diaphragm;
abdominal parietal adaptability is
only restricted beneath the costal angles and in the pelvis. In both
healing occurs by adhesions
between irritated surfaces which must be in apposition. Hence routine
drainage of the general
pleural cavity, which is possible if properly done, is indicated, and
attempted drainage of the
general peritoneal cavity. which is physically and physiologically
impossible, is contraindicated. Irritation of serosa provokes a very
rapid serous effusion which occurs promptly with
hemothorax and soon exceeds the amount of blood originally present.
High position of the
diaphragm is a constant accompaniment of hemothorax (Bradford,19
Elliott,'s Soltau20 ) and is
due at first to inhibition of contractions and later to paresis.
Steiner's12 observations upon the
early effects and Pryor's 8 studies of the late effects of
pleuritis show that the early upward (displacement of the diaphragm is
almost constant and tends to persist rather than to recover
unless specially treated.
The
effects of pleuritis above mentioned are intensified by the presence of
bacteria and
their toxins. When the pleuritis is intense it provokes a cortical
370
subserous pneumonitis
unless the lung be so devoid of circulation that reaction is
impossible,
and then, like a foreign body, it is an added burden to defense.
Moreover, even when a lung is
but partially compressed its circulation is inadequate for defense
because it is only under such
conditions, according to Karsner and Ash,21 that pulmonary
embolism causes infarction.
The
effects of collapse and compression of the lung upon the circulation,
particularly the
burdens thereby adcled to the heart, have been described. It is only
necessary to add here that
heart muscle, recently compelled to overexertion, is particularly
susceptible to intoxication.
Hearts, already fatigued and still compelled to work disadvantageously,
tolerate so poorly even
the limited absorption from pleuritic effusion that the margin of
safety is widened if their
physical load is reduced by pulmonary reinflation which decreases
peripheral resistance
notwithstanding greater absorption of toxins from the pleura through
the improved circulation.
Moreover, the improved circulation also raises local resistance and
favors repair.
BASIC PRINCIPLES IN THE TREATMENT OF
THIORACIC INJURIES
The
capability of maintaining its lining membranes in apposition is a gauge
of its powers
of absorption and roughly measures resistance of a serous cavity.
Accumulation of fluid or air
means dead space, hypertension within the cavity, diminished blood
supply and decreased
resistance, and in the chest, added cardiac labor. Methods of
treatment, which prevent
separation of serous surfaces, or, after separation has occurred,
reestablish and maintain sur- face contact, provide the best
opportunities for immediate recovery, of course assuming that
circulatory incompetence is given proper attention.
The
degree of ultimate recovery is determined by the promptness and
completeness of
restoration of function. Since the identical factors controlling
respiration affect the circulation,
measures must be adapted to restore mobility of the parietes,
especially the diaphragm, to
reestablish normal intrapleural negative pressures and pulmonary
elasticity.
The
most important part of treatment is restriction of pleuritis; the next
most important is
overcoming the effects of pleuritis. If these demands are given due
consideration, non essential
detail will be omitted. The specific objectives are four:
(1)
Parietal healing.- Permanent air-tight parietal closure is
imperative, because the worst
complication is open pyothorax, particularly if it occurs early and
before the formation of
limiting adhesions. Smooth healing of parietal pleura is especially
advantageous. It limits pleural
effusions and offers the most effective barrier to the extension of
inflammation, the usual
antecedent to open pyothorax, either from within the chest to the
parietes, or vice versa. Also it
is the best protection against persistent or recurrent empyema.
(2)
Restriction of pleural effusions.- Pleuritic effusions interfere
with all of the factors
which together make normal respiration possible and they likewise
decrease pleural resistance.
They can be restricted by reducing pleural irritation but not enough to
be absorbed as rapidly as
they form. Their removal is
371
always desirable and
often iniperative and may be accomplished without ill effects by closed
(air-tight) drainage.
(3)
Pulmonary inflation.- Underinflated or overinflated lung adds to
cardiac labor and
narrows the margin of safety. Lung tissue that can not be inflated, or,
if inflated, can not remain
inflated, is without function and therefore without the blood supply
essential to defense and
repair. In general, such tissue is a direct menace and shorld be
removed.
(4)
Pleural adhesions.- Early fibrinous adhesions are inevitable and
desirable. They limit
the progress and extensions of pleuritis. Experience in com-bating
peritoneal adhesions and the
work of Delrez17 and of Willems 22 in
overcoming adhesions following arthritis have proved
that the principle of inducing active motion as early as the infectious
process permits and of
continuing it to the limit of pain inhibition gives the best functional
results. The same principle
applied in the treatment of pleurisy is equally efficacious. The
anatomic explanation for the
return of function is the persistence of some more or less isolated
mesothelial cells of the serosa
beneath exudates, even after organization has occurred. If motion
disrupts adhesions gradually
and without causing hemorrhage, the mesothelial cells which have been
exposed by the
disruption can, because of their extraordinary regenerative powers,
overgrow the adjacent tissue
defects. Thus is made possible restoration of a pleural cavity after
pleuritis which can be so
perfect as to permit of normal function.
If
these four points are kept constantly in mind, the details of treatment
to be described
will appear less petty. Attention to details secured the tissue repair
upon which recovery of
function depends, and when neglected, as was at times imperative during
periods of stress, the
average of results obtained was less satisfactory.
TYPES OF CHEST INJURIES
Injuries
to the thorax affect the parietes alone, both the parietes and viscera,
or, more
infreqentlv, the viscera alone. The last are due to indirect violence,
or to sudden and
considerable changes in atmospheric pressure result- ing from near-by
explosions. Wounds,
perforating, penetrating, or tangential, are similar to those involving
other structures, but are
distinguishled by one peculiarity-their liability to produce an open
thorax. They are also coin- plicated by wounds of the abdomen and spine
more commonly than are wounds elsewhere.
In
general, shell fragments cause greater tissue injury than bullets, and
more commonly
carry other foreign bodies and bacteria with them into the tissues. The
physical injuries of the
thorax are of the same type as injuries elsewhere; they include a
central zone of tissue
destruction, an intermediate zone of tissue injury, and a
surrounding
zone of hemorrhagic
infiltration, which merges into an outer margin of active hyperemia in
the tissues still capable of defensive reaction. They are subject to
the same bacterial contamination, the same implantation
of foreign bodies, as are other wounds.
INJURIES OF THE THORACIC PARIETES ALONE
These
comprise about 10 percent of chest wounds, and consist of contusions,
lacerations,
and punctures, with or without simple or compound fractures
372
of the ribs,
scapula, clavicle, or sternum. They are caused by crushing injuries, by
the
direct impact of spent missiles, and most commonly by tangential
injuries from various types of
projectiles.
In
general such injuries require the same treatment as similar wounds
elsewhere-thorough cleansing and at resection of the necrotic and
dangerously devitalized tissues. The
most important details are to avoid opening the pleural cavity and to
protect the parietal pleura
from infection. Contused skin and subcutaneous fat do not heal well,
particularly if suture is
necessary. As a rule wide cutaneous resections are avoidable, but when
indicated some plastic
flap closure can be made.
Except
in the muscles of the erector spina, group and the muscles attached to
the scapula,
there is relatively little danger of gas gangrene, because chest
muscles are not surrounded by
unyielding structures, and are less liable to the pressure anemia
caused by swelling after injury
or by the constriction of bandages. As a consequence less radical
excisions of injured portions of
the chest musculature are required than in similar injuries elsewhere.
Fractures
are treated upon general principles although in compound fractures of
the ribs
particular care is necessary to resect damaged tissues widely and to
avoid additional injury to
intercostal structures. Injuries to nerves and blood vessels about the
clavicle are repaired as
accurately as possible.
Perforating
wounds of the parietes occurring so low in the lateral aspects of the
chest as
to affect only the costophrenic sinuses may occasion negligibly slight
intrathoracic disturbances,
and yet they may require thoracotomy to effect deep transpleural
repair.
Injuries
of the spine without cord lesions require particularly careful excision
because of
the liability to infection due to muscle injury and the presence of
bone fragments. Lesions of the
cord may demand laminectomy. When paralysis is complete, efforts to
obtain primary healing
are particularly desirable in order to reduce subsequent distress.
INJURIES INVOLVING BOTH PARIETES AND VISCERA
In
10 percent the visceral injuries are due to force transmitted from the
parietal injury
without penetration of the parietal pleura. In the remaining 80 percent
the visceral lesion is
caused by projectiles or indriven rib fragments. In these it is
important that an air-tight closure of
the pleura be secured whether it has been opened by the primary injury
or at operation.
Variations
in methods of operating upon wounds of the chest wall, from those
outlined
above, are determined by the extent of intrathoracic injury, the
necessity for performing
thoracotomy, and the general condition of the patient. Whether the
parietal pleura is opened by
the primary injury or at subsequent operation, a permanent air-tight
closure is essential.
Ideal
repair of defects in serous membranes is obtained by an accurate
approximation of
serous surfaces without undue tension, because anything foreign to
serous surfaces, including
other living tissues, is an irritant. When the defects in the parietal
pleura can not be closed by
approximation, as frequently occurs with multiple rib injuries,
makeshifts must be provided. The
best substitute for parietal pleura is visceral pleura. Distended lung
is easily
373
stitched to the margins
of the defect in the parietal pleura. Injuries low in the flanks quite
often
require this type of closure; frequently the diaphragm must be
utilized, either alone or in
conjunction with the visceral pleura. Adhesions about an injured area
of serosa are unavoidable
and their immediate establishment by suture is sometimes desirable to
reeduce subsequent intra-pleural effusion. The next best substitute for
parietal pleura is accurate apposition of the
smoothest obtainable muscle surfaces. Failing these a covering can be
obtained by using a
pedicled skin flap.
Wounds
of the diaphragin are always serious because of added intraabdominal
complications and occasional pericardial involvement. Those on the
right side are commonly
associated with a flow of bile from the injured liver into the thorax,
which is generally followed
by a severe empyema. On the left side there is liability to
diaphragmatic hernia. On both sides
there may occur a back flow of urine from injured kidneys.
Diaphragmatic
defects are best closed so as to effect a smooth approximation of
intrathoracic serous surfaces. On the right side the edges of diaphragm
everted against the
lacerated liver aid in hemostasis; on the left, the irritation from
exposed muscle is better tolerated
by the peritoneum than by the pleura. Excision of lacerated edges of
wounds in the diaphragm
need not as a rule be extensive and should be as limited as conditions
permit. Lockwood and
Nixon23 believe that repair of these wounds is more
important than that of any hollow or solid
abdominal organ. Transpleural repair of the diaphragm is usually simple
and accurate;
transperitoneal repair may be impossible.
Considerations
of injuries to thoracic contents may be almost restricted to wounds of
the
lung. Cardiac, intramediastinal and vascular injuries seldom come to
operation. The effects of
traumatism, direct and indirect, upon the lung are intrinsic and
extrinsic, as they occasion
pressure upon and irritation to the surface bv hemothorax and
inflammatory exudates, or
pressure within the parenchyma through interstitial infiltration with
blood or transudate and by
pneumonia. Tissue destruction, injury, and infection of the lung are of
relatively little importance
because of the natural resistance of lung tissue and its remarkable
powers of repair, provided it
has an adequate blood supply-a factor letermined principally by the
degree of compression.
Operations upon the lung are required to protect the pleural cavity and
to make possible an
immediate resumption of respiration, rather than to prevent
complications in the lung itself.
Injury
to the lung, whether caused directly by a projectile or an in driven
rib fragment, or
indirectly by the impact of a high-velocity projectile, or by sudden
variations in atmospheric
pressure, is evidenced by parenchymatous bleeding. If the
parenchymatous injury is superficial
and extends through the pleura a hemothorax results. Bradford I showed
that the injured lung is the principal source of hemothorax.
Though
some hemoptysis is constant, intrapulmonary hemorrhage due to
laceration of
the pulmonary artery is mainly interstitial and usually is limited,
since lung tissue is capable of a
high degree of spontaneous hemostasis for bleeding from pulmonary
vessels. Hemorrhage from
a freely opened bronchial artery, carrying six times the pressure of
the pulmonary circulation,
produces
374
a very much more
extensive infiltration before the extravascular tension suffices to
check the
bleeding.
Interstitial
hemorrhage may vary from a slight, limited, plum-colored effusion,
which
barely interferes with normal aeration, to a true, bright red,
traumatic infarction or splenization.
The danger from splenization arises from its interference with aeration
and with pleural blood
supply. Experimental evidence in this respect (Plate IV) confirms
clinical observations. If this
brawny hemorrhagic infiltration extends to the pleura, an intense
reaction results. If such an area
can not be aerated with the aid of increased intratracheal pressure,
the affected portion of the
lung is probably permanently injured, even if it be viable. The
immediate danger is the
production of empyema, a danger sufficient to warrant excision of the
affected lung if recovery is doubtful.
Wounds
of the large bronchi are seldom seen, as they are usually associated
with rapidly
fatal injuries. Such wounds when not immediately fatal and those in
which lacerated tissue either
in lung or parietes has a valve-like action and permits air to be
forced or aspirated into the
pleural cavity with each inspiration and not expelled at expiration
produce the rare examples of extensive pneumothorax. A limited
pneumothorax constantly accompanies lung wounds.
Occlusion of a large bronchus causes not only a complete atelectasis of
the corresponding lung,
but leads to a fatal bronchopneumonia and purulent pleurisy by damming
back secretions in the
affected lung structures. Occlusion of a smaller bronchus causes only
an atelectasis in the por- tion of lung supplied by that bronchus,
which is evanescent if the obstruction is not permanent.
Compression of bronchi, possibly in part due to muscle spasm, aided by
the presence of
intrabronchial mucus and blood, leads to a peculiar type of collapse,
particularly where there is
added some degree of external pulmonary compression. A part of a lobe
or an entire lobe may be affected. The lung is flat and quite
bloodless, the pleural surface is in puckered ridges, and it
feels like meat. Reinflation is impossible. There is, as a rule, an
associated crushing injury of the
overlying parietes without direct injury of the affected lung. This
type of injury, carnification,
demands excision. Infection of such tissue with anaerobes is the usual
cause of the stinking
types of pulmonary gangrene.
Wounds
of the pericardium and heart and of the vessels within the mediastinum
are
rarely seen at operation. Hemopericardium, in addition to causing
serositis, diminishes the
effectiveness of the heart action by the pressure exerted. This is
demonstrable experimentally,
leads to reduction in blood pressures, and is in effect identical with
the cardiac tamponade of pericardial effusion.
INJURIES INVOLVING VISCERA ALONE
These
are limited to pulmonary collapse and intrapulmonary hemorrhages, with
or
without a complicating hemothorax. Their treatment by conservative or
radical methods is
determined by their severity.
PLATE IV
EXPERIMENTAL
SPLENIZATION IN A DOG'S
LUNG.
THE THICK FIBRINOUS EXUDATE WHICH
FORMED OVER AREA OF SPLENIZATION IN TWO DAYS INDICATES A DEFENSIVE
REACTION
AGAINST THE IRRITANT, LIGHTER COLORED PORTION TO LEFT IS NORMAL LUNG;
DARKER
COLORED PORTION TO RIGHT IS LUNG INJECTED BY BLOOD FLOWING FROM A
BRACHIAL
ARTERY THROUGH TUBE AND ASPIRATING NEEDLE. LOWER PICTURE IS A SECTION
AT LEVEL OF
DOTTED LINE IN UPPER PICTURE. THE VISCERAL PLEURA CAN BE
TRACED FROM
LEFT TO RIGHT.
BELOW THE PLEURA IN THE AFFECTED PORTION IS THE SPLENIZED LUNG; ABOVE
IT IS THE
FIBRINOUS EXUDATE THAT FORMED IN TWO DAYS AND THAT ILLUSTRATES THE
INTENSE
REACTION TO AN IRRITANT THAT MIGHT HAVE BEEN CONSIDERED ALMOST
INNOCUOUS
375
PREOPERATIVE PHYSICAL DIAGNOSIS OF
CHEST
INJURIES
Of
paramount importance in determining the approximate extent and nature
of
intrathoracic injury from a missile or a bayonet thrust is an
appreciation of the anatomic
relationships with particular reference to surface landmarks and the
vital underlying structures.
Anatomic models or charts will eliminate much uncertainty in plotting
the course of a missile
between known points of entrance and exit. Deflection by bony
structures and alterations in the
relationship of intrathoracic organs occasioned by changes in
intrapleural pressure must enter
into the proper evaluation of this determination.
Alterations
in the contour of the chest and displacement of the cardiac impulse are
common results of intrapleural accumulations. Obliteration of
interspaces may arise under the
same circumstances whether the accumulation be fluid or air. The
respiratory movements should
be carefully analyzed in their component factors, costal and
diaphragmatic. Aside from the
definite changes which would arise from alterations in the position of
the diaphragm, the
inhibitory influence of trauma on the movements of the chest, either
directly or remotely applied,
must be borne in mind.
In
general, the remaining physical signs are dependent upon air content
and sound
transmission. Air content, elicited by percussion, may be either
increased or decreased in chest
wounds. Increase in air content is denoted by a lower pitched
(hyperresonant or tympanitic) note
and, resulting from a thoracic injury, indicates emphysema or
pneumothorax. Reduction in air
content leads to a higher pitched (impaired to flat) note and under the
present consideration
suggests a pleural accumulation of fluid (blood or chyle),
intrapulmonary hemorrhage, or
pulmonary collapse. In differentiating these conditions the position of
the heart is helpful.
Pneumothorax and fluid accumulations in the pleural cavity lead to
definite cardiac displacement
toward the opposite side. Displacement of the heart toward the side of
the altered note suggests
massive pulmonary collapse. Cardiac displacement is unusual in
emphysema and uncomplicated
intrapulmonary hemorrhage.
The
final consideration in the diagnosis of intrathoracic injuries devolves
on the question
of the transmission of sound vibrations as determined by the palpating
hand and listening ear.
Alterations in tactile fremitus, breath sounds and vocal resonance are
dependent upon changes in
the conducting media between the larynx and the parietes. All
conditions introducing new media
of conduction or interfering with the normal channels of transmission,
viz, the bronchial tree,
tend to reduce or obliterate fremitus, breath and voice sounds. Thus
fluid or air in the pleural
cavity will decrease sound transmission by the introduction of an
aldded medium, while
intrapulmonary hemorrhage leads to the same result usually by
obstruction of the bronchi. An
apparent departure from this rule will be discussed under the reversed
circumstance, namely,
reduction of the media of conduction. Obviously, when the media of
sound transmission are
reduced, fremitus, breath and voice sounds are increased. For the sake
of clarity, an approach of
breath and voice sounds to the basic type in the larynx or trachea is
considered an increase
irrespective of pitch. Unification of media, such as occurs in
pneumothorax with a patent
376
bronchus, is attended bv
a great increase in tactile fremitus, breath sounds (cavernous) and
voice
sounds (pectoriloquy). Furthermore, certain cases of pulmonary
infarction and of massive
collapse may show by reason of a unified medium either increase or
decrease in these signs of
sound conduction dependent on patency or occlusion of the communicating
bronchi.
Further
development, of the physical signs in chest wounds from these
fundamentals are
suggested by an appreciation of the physics and the pathologic
physiology of fluid and air
accumulations in the pleural cavity. Skodaic resonance, movable
dullness, succussion splash,
egophony, whispering pectoriloquy, metallic tinkle, and bell tympany
are to be considered in this
relation. The peculiar crackle of mediastinal emphysema was first
described in the chest wounds of the Great War.
INDICATIONS
FOR OPERATION
The
problem may be reduced to two fundamental questions: Does the injury
warrant
intervention, particularly intrathoracic intervention? If so, what
methods are indicated?
Immediately arise the questions of diagnosis and
of prognosis. The nature of intrathoracic
injuries can be more accurately and rapidly determined by fluoroscopy
than by any other means.
The prognosis may be established at the same time.
Injuries
involving the chest wall alone usually cause a reduction of motion upon
the
affected side, and can easily be mistaken for penetrating or
perforating wounds if the patient is
not examined fluoroscopically. The danger in injuries of the thoracic
walls lies in the liabiliy to
subsequent pleurisy by extension. if infection with a virulent organism
develops. This danger can
be reduced by immediate excision, which is rarely to be regretted and
is too often at source of
serious consequences if omitted. Exploration of the tracks of rifle
bullets showing clean wounds
of entrance and exit frequently reveals severe tissue lacerations and
unsuspected rib fractures,
and occasionally also discloses foreign bodies in addition to the tar
drop blood clots constantly
present.
Wounds
of the parietes associated with intrathoracie injuries, even more than
those
involving only the parietes, demand accurate excision and primary
suture to prevent the
development of empyema. The larger the wound and the greater the
destruction, the greater the
urgency for intervention. Differences of opinion arise over the
treatment of lesser injuries.
Injuries to the lower margins of the ribs often cause hemorrhage from
the intercostal vessels with
bleeding into the chest. Penetrating or perforating w-un1s caused by
small shell fragments and
bullets not infrequently cause incomplete fractures of the ribs, with
the result that bone
fragments are driven through the pleura. perhaps into the lung. Even at
the wound of exit from
the chest bone fragments may project into the pleural cavity, and the
intercostal vessels be
injured. These slight rib injuries can not be recognized under the
fluoroscope. and frequently
escape detection whenl plates are made. Their significance lies in the
fact that bone fragments
are the most dangerous foreign bodies. From these considerations it is
evident that virtually all
wounds of the chest wall should be treated bv radical operative
methods. though not necessarilv
by thoracotomy.
377
Indications
for performing thoracotomy to cope with intrathoracic lesions are
three:
(1)Those based upon preoperative findings; (2) those based upon
operative findings; (3)
uncomplicated hemothorax.
INDICATIONS
BASED
UPON PREOPERATIVE FINDINGS
This
group includes retained foreign bodies, unless very small, particularly
if they are
free in the pleural cavity; extensive splenization (Duval)24
or serious hemorrhage appearing
externally; suspected wounds of the diaphragm (Lockwood and Nixon);23
and acute infection
(Gask) 25 which can be assumed when treatment is delayed.
INDICATIONS BASED UPON OPERATIVE FINDINGS
Gask
23 in particular advocated proceeding withoperation within
the chest, when parietal
operation disclosed serious internal lesions. Duval’s axiom, "The
general rules of surgery must be applied to wounds of the lung," gained
wider
recognition as benefits attainable by operation were realized.
Hemothorax.- If
hemorrhage may be called a wound complication, hemorrhage is the
commonest and most important complication of chest injuries. Reports
upon thoracic injuries by
internists center about hemothorax, its physical signs and symptoms,
the best time and method of
aspiration, and the late complications. Lockwood and Nixon 23
saw its dangers, although they felt
the dangers were insufficient to warrant thoracotomy. Gask 26
in a post-bellum report was
unprepared to say that simple hemothorax of moderate size should be
treated by operation. At
the close of the war there was a growing sentiment in favor of open
operation in the treatment of
extensive hemothorax, particularly if massive clotting hadsoccurred.
Aspiration remained the
method of choice in treating limited hemothorax as it led to early
recovery and return to duty.
The
arguments against operative treatment of hemothorax are that
conservative
treatment, early aspiration with air replacement as practiced by
Bastianelli,27 or aspiration after
7 to 10 days, with or without oxygen replacement, gives better results,
particularly a lower
immediate mortality rate, and reduces the pressure upon surgical
facilities during periods of
active fighting. The indications from the standpoint of morbid
physiology are definitely for the
earliest elimination of pleural irritation and pulmonary compression,
the inevitable consequences
of hemothorax and pneumothorax.
Hemothorax
is of itself seldom sufficient to cause death either through pressure
or acute
anemia. The large amount of bloody fluid which is present after a few
hours, its dilution as
compared to normal blood, its liability to increase after active
hemorrhage has ceased, prove
that a pure hemothorax has a transient existence, and that it is only a
few minutes before a
secondary pleuritic effusion is added. In the presence of clots there
is still more intense irritation, a fact which led Elliott,16
Davies28 and others to advocate open operation for their
removal.
Later
results of hemothorax are equally serious. Bradford 29
noted a decreased absorption
rate of fluid and gas from the pleura attributable to the fibrinous
exudate. Delayed absorption of
hemothorax has been repeatedly mentioned, and, according to Davies,23
it is far from being the
exception.
378
Absorption is not always
promoted by aspiration, as evidenced by the example reported lbv
Tuffier30 of a hemotliorax which persisted for 15 months
in spite of 27 aspirations.
As
the result of pulmonary compression, vicious adhesions, thickened
pleura, and an
immobile diaphragm, there is deficient expansion, shoulder drop,
scoliosis, parenchymatous
sclerosis (Tuflier),30 and incapacitating dyspnea. The
dyspnea may last for months or even
years, and, according to Leslie,31 is largely dependent
upon the degree of permanent collapse of
lung tissue.
The
possibility of secondary infection of a hemotlhorax adds another and
more
dangerous complication. Gask 25 found that nearly all war
wounds are contaminated. Soltau,32 in
his bacteriologic studies of empyema, found gas- producing organisms in
48 percent,
streptococci in 40 percent, and organisms from the lungs in 12 percent.
According to Elliott,16
one-fourth of the hemothoraces became septic no matter what type of
missile caused the wound;
of these one-half died, and one-third of those who recovered were
invalided out of the service,
making a total of 16 percent in which death or incapacity was due to
infected hemothorax.
Moreover, it is difficult to recognize the presence of infection in a
hemothorax since a simple
hemothorax usually runs a febrile course and because the bacteria, as
pointed out by Leslie,31
may be in the clotted portion of the exudate, so that the fluid portion
obtained by early aspiration may be sterile. Open drainage was
generally held to offer the best chance of recovery
from this type of pleuritis though closed drainage would have been more
efficacious. Gask 25
recommended thoracotomy with mechanical pleural cleansing and immediate
closure. Statistics
are not available to indicate the proportion of the 75 percent of
hemothoraces which did not
become infected and yet contributed to death and incapacity through
pleural irritation and
pressure. The total loss in man power due to hemothorax alone can be
reasonably estimated at
25 to 35 percent of those receiving intrathoracic injuries.
If
it be granted that thoracotomy has become a safe operation, then
cumulative evidence
indicates that immediate open operation is the sane treatment for all
but the limited degrees of
hemothorax, even if restricted to the removal of the liquid and
coagula. In addition the lung
injuries can be accurately repaired, foreign bodies removed, the inside
of the thorax inspected
and needed attention given to additional injuries not otherwise
recognizable. It is still more significant that after these precautions
have been taken the lung may be inflated to normal limits and
the chest closed, with an immediate return of nearly normal respiration
and circulation, factors
which provide the most favorable conditions for defense in a
contaminated pleural cavity and
assure the earliest resumption of activity.
The
splendid results reported by Bastianelli 27 in treating
chest wounds by immediate
aspiration and air replacement, reinforced by the wide acceptance of
the value of artificial
pneumothorax in the treatment of certain types of pulmonary
tuberculosis, demand a reasonable
answer.
According
to Bastianelli, the cushion of air separating the viscerae and parietal
surfaces
prevents the formation of pleural adhesions, and the positive
intrapleural pressure controls
hemorrhage from the wounded lung. Recovery
379
is prompt because
vicious pleural adhesions are prevented, and the repair of the
lacerated lung is
fostered by immobility and collapse.
Opposed
to these theories are definite facts. Air is a serous membrane irritant
and
elimination of irritation is a basic principle in the prevention as
well as the treatment of pleuritis.
Positive intrapleural pressure, high enough to stop hemorrhage by
pulmonary compression,
compresses the homolateral lung, produces contralateral emphysema, and
interferes with
pulmonary circulation. Compressed lung means contracted lung which is
often difficult or
impossible of reinflation. If reinflation occurs, a universal adhesive
pleuritis is certain. The exact
conditions for minimizing the resistance to the flow of blood through
the lung, as established by
Cloetta,13 a reduction of mean pulmonary inflation, are
met by diaphragmatic paralysis.
Diaphragmatic paralysis lasting four or five days can be established by
infiltrating the phrenic
nerve trunk with 1 percent cocaine. If this procedure be coupled with
closure of the chest
without residual pneumothorax, the best conditions for repair and
defense have been provided
for both lung and pleura.
SURGICAL
METHODS
PREOPERATIVE TREATMENT
An
individual suffering from a recent chest wound is in need of immediate
physical and
psychic rest. This can be provided by the administration of a full
physiological dose of morphine
to reduce coughing and to minimize respiratory effort. Care should be
taken in examining and
dressing the wound to permit the most comfortable position to be
assumed and to avoid exertion
on the part of the patient. First-aid should be restricted to
hemostasis in the parietal wound and
temporary closure of an open thorax. The latter is best accomplished by
strapping a firm, thick
broad pad over the wound with adhesive plaster, and then fixing a tight
swathe about the chest.
Provisional suturing of these wounds often leads to tissue emphysema,
which interferes with the
circulation and materially reduces resistance.
A
second dose of morphine is given one-half hour before operation. If
there is no
question of an abdominal wound, water or hot drinks should be given
freely, even just before
anesthesia begins. Smoking is a great solace and does no harm if
coughing has ceased. Anything
to reduce distress is desirable.
Uncomplicated
chest wounds are not prone to produce shock, but when there is
considerable pulmonary compression they cause a high venous pressure
due to interference with
pulmonary circulation. If intravenous medication is indicated, it must
be given very cautiously
in order to protect an overburdened right heart. It is often wiser to
give a transfusion of blood
after reinflation has been established at operation. A grave anemia is
often masked by an unusual distribution of blood because of the reduced
content of the compressed pulmonary
vessels. A blood transfusion after the evacuation of a large hemothorax
and after satisfactory
hemostasis has been effected will materially reduce danger.
A
diagnosis of the probable nature and extent of intrathoracic
involvement is furnished
by physical and fluoroscopic examinations. One should
380
determine if possible
the extent of hemothorax and pneumothorax, the presence of extensive
intrapulmonary hemorrhage, the presence of extensive clots, the
evidence of contralateral injury,
the size, position, and motility of retained foreign bodies, the
presence of bone injuries, the
position and mobility of the diaphragm, the size and position of the
heart, and the probable path
of the missile.
A
moderate-sized hemothorax where there are no adhesions darkens the
whole side of a
chest as these patients are examined in a recumbent position. Clots
when visible are apt to be
seen low along the spinel and do not move. Intrapulmonary hemorrhages
can be seen only when
the hemothorax is limited. The shadow corresponds to a lobe and moves
with respiratory effort.
Contralateral involvement, except for mediastinal displacement, is
uncommon. Gask25 warns
against operation when there is evidence of contralateral collapse, but
the danger of this
complication is avoided when positive-pressure anesthesia is used. The
location of foreign
bodies is important when theyare small and show by transmitted motion
thatthey are close to
important vessels or the heart. Otherwise there may be a temptation to
omit removing them.
Their position usually changes when the chest is opened, but as a rule
rule foreign bodies are
easily found. Positive evidence of bone injury is valuable; negative
evidence is worthless. Its
existence must be assumed until disproved by actual exposure at
operation. The position and
movement of the diaphragm help to determine the presence of injury of
that structure and the
level of operative incisions.
The
heart's position is an excellent index of mediastinal deviation: the
size of its shadow
may tell of cardiac or pericardial injury. Projection of lines between
the wounds of entrance and
exit in perforating injuries or between the wound of entrance and the
missile in penetrating
injuries indicates the structures probably involved. The character of
the injuries may be guessed
from the size and shape of a retained shell fragment, or, if a bullet,
from its shape and path.
ANESTHESIA
It
is usually held that the use of differential pressure is unnecessary.
The writer does not
hesitate to assert that positive-pressure anesthesia, or. better,
analgesia, is the most important
single factor in successful thoracotomy under war conditions. A full
preoperative dose of
morphine permits induction of an even, deep analgesia with nitrous
oxide and oxygen without
increasing the gas-oxygen ration above 3 :1. This was proved by
Cannon's 33 observations to
be the limit of safety in the presence of shock. After the induction
stage the proportion of nitrous
oxide can be reduced occasionally to less than 50 percent.
The
American Red Cross nitrous oxide-oxygen apparatus devised by Gwathmev
fulfilled
every requirement. A rough gauge to measure the flow of gases, a mixing
bag to serve as a
pressure indicator, and a close-fitting face-piece are the only
essentials. Pressure is furnished
from the gas and oxygen tanks, controlled by regulating the flow of the
gases, and delivered to
the trachea by holding the facepiece snugly in position. The pressure
can be
381
varied as gradually or
as suddenly as desired. The physical effort required is not great.
The
dangers are real. Anesthetics delivered under pressure are more rapidly
taken up by
the blood. The more rapid absorption is due to increase in the volume
of air containing the
anesthetic, in the area of air cell epithelium, in the expanse of
capillary endothelium, and in the
amount of intracapillary blood due to greater inflation from
intratracheal pressure. Anesthetics,
when given under pressure in undue concentration, produce toxic effects
which can appear
suddenly and be rapidly fatal. A second danger is too great pressure. Normal
heart and lungs can tolerate an excess pressure, but when the heart
muscle and
pulmonary circulation arc both impaired the margin of safety is much
narrower. In general,
positive pressure up to 16 mm. of mercury is safe and suffices for all
purposes. Beyond that
point compression of the pulmonary capillary bed can provoke an acute
dilatation of the right
heart. A few control observations with a manometer in the circuit show
the degree of distention of the mixing bag which corresponds to a
pressure of 16 mm. of mercury. It is rarely
expedient to exceed this limit.
In
practice the analgesia and hypertension are gradually induced with the
patient in
position for operation (fig.183). During the induction stage nothing
is done to the wound. When
deep analgesia has been reached, dressings are cut away and the skin
prepared by dry shaving
and scrubbing with ether. By this time inflation has been accomplished,
so that uncovering a
sucking wound occasions little increased respiratory distress.
Various
stages of operation can be carried out under the same light anesthesia
and the
pressure varied as required. Repeated gradual inflation and deflation
do not cause variations in
the systemic blood pressure which can be detected by clinical methods.
Both sides of the chest
can be opened without evident distress to the patient. Graham and Bell 5
showed that if an
opening in the chest wall of dogs exceeds certain dimensions, the
aspiration of air into the lungs
ceases. The size of the opening compatible with life in dogs holds
relatively true for man
provided man's circulation is deficient, c. g., with shock or acute
anemia, when the powers of
circulatory compensation are materially reduced. The use of positive
pressure obviates this
complication, as well as most of the coughing and dyspnea which occur
when a chest is opened,
particularly when a considerable hemothorax is present.
Another
important point is the avoidance of traction upon the mediastinum.
Traction
upon a lung can cause in man a rapid drop of blood pressure of 40 mm.
or even more. A deflated
lung can not be brought outside of the chest from a position of
collapse without traction, but a
deflated lobe can be guided toward the thoracotomy opening and
delivered without the least
traction as inflation is produced.
Clinical
results are confirmatory. Patients anesthetized under positive pressure
as a rule
left the operating room in better condition than at entrance, and the
improvement was not
evanescent. Operations need not be hurried. After the wound is closed
the nitrous oxide is
stopped and oxygen under decreasing pressure is given for the few
minutes required for a return
of consciousness.
382
Contrary
opinions were held by other surgeons, notably Gask,25 Duval,
24 Depage, 34 and
Lockwood, 23 who advocated open anesthesia or local
anesthesia. Surgeons using their methods
worked in the same units with others who use positive-pressure gas and
oxygen analgesia.
According to medical officers in charge of chest wards, patients of the
former were less
comfortable and had a more protracted convalescence.
EXCISION OF
PARIETAL WOUNDS
Among
the objections to routine excision of all chest wounds are the dangers
of
anesthesia and the time and extra nursing required. The use of gas as
described is a satisfactory
answer. Positive pressure is a cure and preventative of pulmonary
collapse. Pneumonia after its
use is infrequent. Excisions can be done more thoroughly, rapidly, and
without the distress of
local anesthesia. Accidental opening of the pleural cavity is of little
moment, as deflation does
not occur and the pleural rent can be accurately repaired.
Disclosure
of unsuspected deep injuries is a common experience when parietal
wounds
are excised as a routine. Frequently a sucking wound is hidden by
change of posture so that an
open thorax may be suddenly encountered. Parietal excision should
always be undertaken with a
view to primary closure, because this becomes obligatory if a
penetrating wound is encountered.
A satisfactory
method of muscle excision consists in splitting between muscle bundles
on
either side of the injured area and carrying this splitting for some
distance in both directions
before dividing transversely. This block resection permits the later
approximation of smooth
surfaces at the point of injury, removes the cut fibers farthest from
this point, and interferes least
with blood and nerve supply. Excision done in this manner, often so
restricted that bruised
muscle was retained in order to make closure possible, was not followed
in our experience by
gas gangrene in chest wounds in a single instance, though gas gangrene
occurred in other
wounds in several patients who had multiple injuries.
Fractured
ribs should be widely resected, and, when possible, the cut ends should
be
snugly covered with soft tissue, periosteum, or muscle, to reduce the
chances of bone infection.
Hemostasis may require the use of bone wax. Fractures of the scapula,
particularly those caused
by shell fragments, are less easily managed. Wide resection is
indicated, but the bony framework
and periosteum should, if possible, be preserved to make regeneration
possible. Denuded bone
must be removed; pockets should be collapsed to obliterated dead space.
Injuries to the sternum
are easily cleansed with gouge or rongeur. Compound fractures of the
spine require adequate
exposure, radical resections, and great care in removing loose
fragments. Bone fragments are the
most dangerous foreign bodies in the presence of infection. Excision of
skin should secure a
clean margin that bleeds freely and nothing more. It is safer to take
chances with slightly
traumatized skin than to run the risk of necrosis from excessive suture
tension.
THORACOTOMY
Positive
indications for thoracotomy will generally be recognized before
operation.
Occasionally a decision will rest upon operative findings. A bullet
383
may perforate a rib
without causing a complete fracture and carry with it splinters of the
compact, inner layer into the lung; or, there may be an unrecognized
comminuted fracture of the
ribs associated with pleural and pulmonary lacerations and only a
moderate hemothorax. Similar
and even more extensive injuries may be found near the wound of exit.
Usually the question is
how to proceed rather than whether or not to operate. Three
possibilities are offered: First, to do
a limited thoracotomy at the entrance and exit wounds, a compromise
between radical operation
and aspiration; second, to proceed through the wound and resect the
ribs widely enough to give
the approach needed for deep repair; third, to repair the entrance and
exit wounds and then to
open the chest through uninjured tissues at a point of election.
By
limited thoracotomy is meant: Intrathoracic operations performed
through the wounds
of entrance or exit with little or no additional enlargement, never
enough to permit exploration
by the pleural cavity. It is indicated when wounds are small, when
destruction is relatively slight,
and when the lung can be reinflated. In the absence of or after removal
of hemothorax inflation
of a deflated lung causes the wounds of entrance and exit in the
visceral pleura to approach the
corresponding wounds in the parietal pleura. A metal nozzle (fig. 187)
attached to a Potain
aspirator is introduced through the opening in the parietal pleura, and
the fluid blood removed by
directing the tip into various dependent pockets while the lung is
partly deflated. When inflation
is produced the visceral injury floats up to the parietal. If it is
small and dry, it need not be
repaired. If it is bleeding or if air is escaping, the lung can be
secured by forceps at the margin of
the wound, and a cone of lung with the wound at the apex can be gently
brought out through the
opening in the parietal pleura. A purse string suture closure, as in
intestinal perforation,
suffices. If there has been some rib injury, and bone fragments have
been driven into the lung, a small incision through the posterior layer
of periosteum exposed by the rib resection will permit
excision of the lacerated lung tissue and removal of the bone
fragments. After the lung is
repaired it is wise to suture the lung wound into the defect of the
parietal pleura. Adhesions
between these areas are certain under any condition and are restricted
by this fixation. This
simple method is particularly useful in through-and-through wounds, but
less so in penetrating
wounds. It can be applied in about 40 percent of all chest injuries,
the proportion varying with
the type of fighting. The defects of this method lie in the possibility
of leaving clots behind and
of overlooking rib fragments.
The
majority of more serious chest injuries permit no latitude in selecting
the most
desirable route for surgical approach. Parietal excision and repair
alone are a burden to a man in
weakened condition, so that the intrathoracic repair must be attempted
by enlarging the wound of
entry or exit. This avenue of approach gives a more or less
unsatisfactory deep exposure, usually better for diaphragmatic injuries
then for pulmonary because a retracted, compressed, and
uninflatable lung can not be manipulated readily. As a rule there is a
tendency to do too little
under these trying conditions. A desire to avoid immediate death of a
patient is apt to prevent the
removal of injured lung whose presence is incompatible with recovery.
384
Methods
of gaining deep exposure are deterinitied by the necessity of getting a
satisfactory parietal closure. The preservation of parietal pleura is
most essential. This layer is no
more amenable to plastic surgery than a wet drum head. Each injury is a
separate problem, the
most desirable solution of which is an approximation of the type of
repair described in the
elective operation.
Thoracotomy
of election is designed to give free access to one side of the chest in
order
to permit the dislocation and manipulation of each lobe of the lung and
repair of the diaphragm.
It may be performed before or after the plarietal excision, depending
upon the type of injurv. The chest should be opened on a level with the
root of the lung and in a manner favorable to
closure. Intercostal incisions are easiest to make but give less
satisfactory exposure, and their
healing is less certain. Cowell 35 designed a transcostal
incision which has much to recommend
it when deflation is present, but which is not applicable when
inflation is relatively normal. Rib
resection can be done very quickly and safely, gives a maximum exposure
with minimum
damage, and provides the best opportunities for repair. A piece of the
fourth or fifth rib longer
than the width of the operator's hand is removed so that the mid-point
FIG. 183.-
Patient
in position for operation. Line of incision for a thoracotomy of
election
of the defect is
slightly nearer the angle of the rib than the sternum. In this area one
may secure
the maximum effects of rib rotation with the greatest separation for
operation and the greatest
approximation for closure.
The
skin is incised directly over the rib selected (fig. 183) and the rib
exposed. A short
cut in the lower margin of the pectoralis major permits this muscle to
be retracted medially. The
latissimus dorsi is easily freed and retracted laterally. The long
thoracic nerve can usually be
saved. Incision of the periosteum along the midline of the rib is
continued posteriorly between
the fibers of the serratus magnus (fig. 184). The periosteum is
separated with care to avoid
injuring the intercostal vessels and nerve. After rib resection the
posteriol periosteum and
parietal pleura are incised along the midline, the incision extending
to within a half inch of the
rib ends (fig. 187). The release of tension by this incision permits
the intercostal muscles to
retract and allows the ribs next above and below the incision to be
rotated upon their axes and
increase the exposure. A wider opening can be obtained by increasing
this rotation by outward
traction. Exposure thus obtained is quite as good as that provided by a
mechanical rib spreader
(fig. 186, a.), which crushes the intercostal muscles and thus
interferes with subsequent healing.
Lockwood 23 believes that the use of rib spreaders adds to
shock. A headlight makes it possible
to continue most of the intrathoracic work under visual control.
385
FIG. 184.- Method of
exposing a rib for
resection. The serratus is excised parallel to its fibers; the long
thoracic
nerve is retracted posteriorly
FIG. 185.-
A,
Simple type
of rib shears;
B,.bone biting forceps or chest surgery. The severed bone fragments are
held in the bite of he forceps, and can not be sucked into the pleural
cavity.
FIG. 186.-
A, Tuffier's
rib spreader; B,
thin-bladed clamp used to secure hemnostasis, and as a tractor
386
It
must be borne in mind that this operation is undertaken in addition to
excision and
suture of the parietal wound or wounds. Its advantages are obvious. The
disadvantages are the
longer time required and the creation of another wound in the parietal
pleura opposite to normal
visceral pleura, which assures the formation of dense adhesions in an
area where otherwise only
slight adhesions would develop (fig. 182).
CLEANING THE PLEURAL CAVITY
Removal
of the uncoagulated blood and exudate is effected without delay as
clotting
occurs very rapidly after operation is begun. A curved metal or glass
nozzle (fig. 187) fitted to a
Potain aspirator, which is long enough to reach
FIG. 187.- Thoracotomy of
election. A rib has
been resected; the tip of an aspirating nozzle is being
introduced into the pleural cavity
all parts of the chest,
is satisfactory if the distal end is flanged and protected by a
coarse-meshed
sieve to prevent the aspiration of large clots which would plug the
tube and to prevent injury of
the pleura.
The
first aspiration is done with the lung deflated in order to facilitate
introducing the tip
of the nozzle into the various depressions where fluid may accumulate.
During the period of
deflation it is wise to remove clots which may be covering injuries or
foreign bodies and may be
less accessible later. Dense clots can be lifted out with forceps or
manually. The balance must
be mopped out with moist gauze. However gently this is done, an
undesirable irritation is
produced.
An
important part of cleansing is the prevention of soiling. Skin edges
should be covered
with moist gauze. As soon as the pleura is opened the
387
parietal wound should
lce covered with more gauze, which is held in place by the retractors
and
by clips. The field of operation should be isolated by gauze pads even
more carefully than in
abdominal surgery.
Thoracotomy,
however simple, is followed by the production of excess serous exudate.
Every effort should be directed to the limitation of this effusion and
to protect it from infection. The chest should be made clean and dry
before closure, and no irritants, such as bone fragments,
clots, bare ribs, or exposed muscles, should be overlooked. Washing out
the pleural cavity is a
temptation to be resisted as the subsequent healing is poor. Mopping
gently with moist gauze
gives the best results.
BLOCKING THE PHRENIC NERVE
Natural
methods of defense have proved that immobility of the diaphragm
provides
conditions essential to pleural resistance. These consist in providing
an adequate reduction of
motion and in assuring the optimum circulation of blood in the lung.
Cloetta's36 experiments
show that the least resistance to pulmonary circulation is present when
the maximum negative
intrapleural pressure is reduced to 2 to 3 mm. of mercury, and that at
this pressure the lung
contains the largest volume of blood. Middleton18 found
that in dogs an immobilized diaphragm provides this reduction.
Experimental and clinical observations prove that recovery from
thoracotomy when the phrenic nerve is blocked is more rapid, more
certain and less painful than
when it is not blocked. Operation is less difficult in the presence of
an immobile diaphragm,
particularly because acute pneumothorax causes increased re-
FIG. 188.-
A, Cow
horn rib stripper; B, Tuffier's lung forceps; C, periosteal elevator
One
percent cocaine injected in the trunk of the phrenic nerve causes a
paralysis for four
or five days. It materially reduces distress by blocking the sensory
fibers described by Capps.37
Novocaine, quinine and urea hydro- chloride, and magnesium sulphate are
unsatisfactory for this
purpose.
When
the phrenic trunk can be reached through the thoracotomy exposure, it
should be
injected before intrathoracic operation is attempted. If it is
suspected before operation that
intrathoracie injection will be impossible the nerve may be injected in
the neck. Cervical
exposure of the nerve can usually be
388
FIG.
189.- Incision
for exposure of the phrenic nerve
FIG. 190.-
Exposure of the phrenic nerve
389
accomplished with little
distress under local anesthesia. The illustrations (figs.189 and 190)
show a larger exposure than required. It may be done largely by blunt
dissection with little
hemorrhage. Relief of much of the intrathoracic pain following
injection of the nerve suggests
that blocking of the phrenic nerve should be considered an important
step in postoperative
treatment, if it has been neglected at operation and convalescence is
delayed.
BLOOD TRANSFUSION
The
indications for blood transfusion are commonly those of acute anemia,
so that
intravenous administrations of hypertonic solutions of glucose, with
and without gum acacia,
tincture of digitalis and insulin are to be considered if suitable
donors are unavailable and when
patients are suffering from the exemia of shock or need additional
protection to their circulatory
units subsequent to operation. Transfusion should be started as soon as
hemostasis is complete
and inflation can be maintained. The blood must be warm and be
introduced slowly. No harm
comes from transfusion given in this way. Many lives can be saved.
The
large amounts of blood and colored fluid removed when the hemothorax is
extensive
suggest the possibility of aspirating it into sterile bottles
containing sodium citrate, filtering, and
giving it as an autotransfusion. Tests, however, showed that the
attendant risks are prohibitive.
OPERATIONS UPON THE LUNG
Operations
upon the lung are undertaken primarily to protect the pleura.
Accordingly
accurate hemostasis and surgical repair must be obtained in such a
fashion that immediate
inflation and resumption of respiration may be established in order to
insure reapposition of
pleural surfaces and an unimpaired blood supply. These conditions
require freedom from internal
and external compression. In general, lung tissue which can not be
inflated or which is devoid of
blood supply is actually or potentially a foreign body whose presence
is virtually certain to
produce or to intensify an empyema. Excision of such lung, whether or
not it has been directly
injured, must be considered the ideal treatment, and is demanded
whenever the location and
extent of the affected area indicate the probability that the
consequent empyema will be fatal.
Our personal experience is the basis for this radical statement. No
individual recovered so far as
is known where there was failure to excise permanently injured lung.
Not all individuals
recovered where this excision was done. Post-mortem observations
indicated that the excised
lung had contributed to the fatality, but not that excision per se
could be blamed for the death.
Perforating
wounds caused by rifle bullets and small shell fragments require
closure of
the pleural defects only when there is bleeding or escape of air after
reinflation. Thev can be
inverted with a purse-string suture, and should be so inverted if they
are accessible. Penetrating
wounds are similarly treated. The missile is usually found without
difficulty and frequently lies close to the surface. A small pleural
incision and a little blunt dissection with
390
a pair of forceps makes
removal easy. Small shell fragments close to big vessels should be
carefully removed to obviate the dangers of late hemorrhage.
Large
lung wounds are usually caused by tangential violence and are
surrounded by more
hemorrhagic infiltration than the smaller wounds resulting from more
direct impact. The amount
of excision required is determined by the degree of internal
compression (infiltration). If the lung
reinflates completely, trimming the shaggy margins of the defect with
scissors and wiping them
off with gauze is sufficient. If there is a zone of splenization about
the wound which does not
inflate or bleed freely, resection must be carried back to margins
which are comparatively
normal. It is not merely the repair of lung parenchyma which is to be
considered. The integrity of
the corresponding visceral pleura is of far greater immediate
significance and is assured only if
the circulation and, therefore, the function of the subjacent lung is
restored.
Lung
tissue which is not obviously injured and which is nevertheless
dangerous because
of impaired circulation is characterized by limited inflation, collapse
or compression, although
intrapleural negative pressures are at least normal, or in spite of
positive intratracheal pressures.
Abnormal deflation, in the absence of reduced pulmonary elasticity, is
due to the failure of either
air or blood to enter the involved portion.
Massive
contralateral collapse of the lung, noted occasionally with unilateral
injury or
disease, is attributable to spasm of bronchiolar musculature producing
unilateral atelectasis or to
a shunting of blood from the pulmonary artery of the sound side to that
of the affected side, thus
temporarily incoordinating the air cell capillary mechanism. The latter
explanation, the shunting
of the pulmonary arterial blood, is the more probable and can be traced
to unusual responses to
distortions in intrapleural pressures. Our experiments show that
fluttering of the mediastinum,
noted occasionally when thoracotomy is performed without differential
pressure anesthesia, is
due to sudden and rapidly repeated shunting of blood back and forth
from one to the other lung.
Neither of these complications occurs if positive pressure analgesia is
used.
An
atelectatic area of lung is airless because ingress of air is prevented
and air previously
present has been absorbed. Atelectatic lung after reinflation would
have a normal circulation.
Occasionally, and particularly after crushing parietal injuries,
atelectasis is complicated by
destruction of the blood supply and is in effect a traumatic anemic
infarction, called
carnification. Intratracheal positive pressure anesthesia makes a
positive diagnosis of these
lesions. Atelectatic lung, noninflatable, is overdangerous.
The
more severe intrapulmonary lesions are well shown in a drawing (Plate
V) of a right
lung removed from a man who arrived dead at a field hospital. A jagged
tangential wound was
present in the inferior margin of the lower lobe. There was
splenization of nearly the whole lobe.
The middle lobe, except for one irregular area of hemorrhagic
infiltration, and the entire upper
lobe were emphysematous. The upper part of the lower lobe was
atelectatic, brownish in color
and carnified. Plate IV shows the effect of experimental splenization.
The marked fibrinous
exudate upon the pleura over the area of hemorrhagic infiltration is
proof of a defensive reaction.
The limitation of
PLATE V
LACERATED WOUND OF LOWER LOBE OF LUNG.
LOWER
LOBE IS ALMOST ENTIRELY SPLENIZED;
UPPER PORTION OF LOWER LOBE IS CARNIFIED; UPPER LOBE AND MIDDLE LOBES,
EXCEPT FOR
ONE AREA OF HEMORRHAGIC INFILTRATION, ARE EMPHYSEMATOUS
391
the exudate to the
damaged lung is evidence that such lung is especially dangerous in the
presence of infection.
Resection
of a part of a lobe should be roughly pyramidal or wedge-shaped with
the
narrow aspect of the wedge toward the hilum, in order to remove only
the parenchyma supplied
by a bronchus and its associated vessels. It may be compared to cutting
a dead branch out of a
bush. Positive pressure makes this possible by clearly outlining the
limits of normal lung. Resection is difficult only when exposure is
unsatisfactory. In the thoracotomy of necessity
dislocation of a lung is difficult because these operations are usually
done at a lower level and
since the lung is generally less pliable because of more severe injury.
Under these conditions
some traction is unavoidable.
FIG. 191.-Thoracotomy
of election. The margin of the deflated lung being guided toward the
wound with Tuffier's forceps
It
may be secured by a loop of gauze placed around the root of the lobe to
be dislocated
and caught with a clamp; or a pair of special forceps (fig. 186, b),
like an enterostomy clamp,
may be placed proximal to the margin to be removed and the resection
carried out distal to the
clamp. This is a makeshift procedure, but makes fairly accurate work
possible.
Thoracotomy
of election presents the most satisfactory exposure of the lung. After
the
chest has been opened as described above and the lung injuries have
been determined, the lobes
can be delivered into the wound for operation without traction. During
deflation a free margin of
a lobe is grasped gently with forceps of the Tuffier type (fig. 188, b) and guided toward the
parietal opening. As the anesthetist increases the positive pressure
this lobe follows the forceps
into the wound (fig. 191). Manipulation with suitable variations in
pressure allows the selection
of the most satisfactory position for operation.
392
Little
traction is required to maintain this position. which is preserved by
the requisite
inflation and the gauze packed between the lobe afnd the superficial
wound.
A
wedged-shaped resection is made through the mnargins of normal or
relativelv normal
lung. Hot compresses to the cut surfaces check excessive bleeding while
clamps are applied. Severed bronchi that can be seen or that provoke
active bubbling must be secured. All branches
of the bronchial artery spurring red blood under high pressure must be
clamped. It is necessary to
secure only the more actively bleeding branches of the pulmonary artery
and but few branches of
the pulmonary veins.
Pulmonary
inflation makes possible the accurate clamping of these various
structures,
which would be difficult or impossible to find on the cut surfaces of a
lung in deflation. Mass
sutures inserted and tied while the lung is inflated would become too
loose in deflation; if tied in
deflation, they would be too tight during inflation. Consequently,
multiple fine sutures must be used to approximate cut surfaces.
FIG. 192.- Methods of reducing the number of
stitches used in repair after a resection. At the bottom is a simple
ligature; in the middle, a suture on one surface is combined with a
ligature on the opposite side; at the top, a double
ligature is being made to serve as a suture.
The
number of sutures required may be reduced number of stitches used in
repair if the
vessels which have to be tied are ligated in conjunction with a suture
(fig. 192). The pleural
repair should become an exaggerated serosa-to-serosa approximation as a
safeguard against air
leakage. A fine catgut stitch of the Cushing type introduced one-half
inch from the margin of
the incision accomplished this satisfactorily. Little puckering of the
lung need result and only
one knot should appear upon the pleural surface (fig. 193). When
resection includes two
surfaces of a lung it is easier to suture the dependent pleural layer
first, when it can be done more
rapidly and from the inside. and then to reconstruct the lung upon this
plane.
Lung
repaired by this method heals splendidly and with the minimum of scar
tissue. Duval 24 states that the scar may be impossible of
detection microscopically. There is in consequence little influence
upon pulmonary elasticity. Vicious union is prevented so that the
functional result is nearly perfect..
FIG. 193.-
Closure
of the visceral pleura with an exaggerated
Cushing stitch
Complete lobectomy is
indicated
when an entire lobe is carnified The
possibilities of recovery are slight, not because of the operation but
on account of the other
serious injuries which are usually associated with military surgery
because, aside from the
injury, tissues are normal and individtlals healthy. Crushing with
forceps and ligation seem to be
satisfactory if an ample flap covering is provided.
393
The
unusual wounds of large bronchi should be sutured directly, and the
suture line
reinforced by a pleural graft to give additional protection against
empyema from leakage.
OPERATIONS UPON THE HEART AND MEDIASTINUM
Early operations upon
the heart and pericardium have been few because wounds affecting
them are either
promlptly fatal or are treated expectantly. Such injuries as are
disclosed by
operation are easily remedied as they require little more than simple
suturing.
Wounds
of the mediastinum are always serious, particularly because of
liability to
infection. Bleeding from mediastinal vessels, even from the azygos
veins, is not easily checked.
Foreign bodies should be removed with the least traumatism and the
resulting defect carefully
repaired. Wounds of the thoracic duct have usually been fatal in spite
of ligation.
OPERATIONS UPON THE DIAPHRAGM
When
excisions are necessary they should be as limited as safety permits and
adapted to
spare the branches of the phrenic nerve. Usually all serious
diaphragmatic injuries are well
exposed by a thoracotomy of necessity. In the repair of defects of the
diapliragmn and in
suturing it to parietal defects care should be taken to avoid including
nerve branches in the
sutures. Adhesions need not eause persistent immobility, but
diaphragmatic immobility due to
persistent paralysis commonly assures permanent adhesions.
When
abdominothoracic injuries are suspected it is easier to attend to the
chest injury
first, as this operation is better tolerated and will establish more
favorable conditions for
laparotoiny. Occasionally the entire abdominal repair can be completed
through the diaphragm.
CLOSURE OF THE CHEST WALL
Next
to positive pressure analgesia with nitrous oxide and oxygen, accurate
closure of the
chest wall, and particularly the repair of the parietal pleura, is the
most important plase of the
entire operation. No matter how excellent the rest, of the care may be
a failure to obtain air-tight
healing of the parietes results in an open pyothorax. The parietal
pleura heals more rapidly than the more superficial tissues and offers
greater resistance to the extension of inflammation either
from within or without. Failure to secure smooth healing of this layer
may lead to a persistent
and severe empyema even though the more superficial wound heals firmly.
An
illustration of the result of imperfect healing of the parietal pleura
is found in Figure
194. The pleural sutures had caused tension necrosis so that,
separation occurred with exposure
of the muscle and rib endls to the pleural cavity. This accident,
occurred in a dog but is exactly
comparable to conditions seen repeatedly at human necropsies.
A
well-controlled series of clinical and experimental observations show
that smooth
parietal healing is assured only when there is accurate pleural
approximation in the absence of
suture tension. A closure of this type is possible when the ribs next
above and below the defeet
are brought abnormally close together.
394
The
pleural approximation must extend beyond the rib ends at either angle
of the incision
in order to make certain that no denuded rib be exposed or become
exposed within the pleural
cavity.
The
method of suture has been illustrated diagrammatically to show the
steps in the
closure of a thoracotomy of election. During the period of closure the
anesthetist gradually
increases the positive pressure to produce a slight degree of
hyperinflation, so that when the
parietal pleura is hermetically closed there shall be the least
residual pneumothorax. Under these
conditions approximately normal negative pressure is immediately
reestablished.
Mattress
sutures are preferable for reuniting the parietal pleura, and usually
can be
inserted through both margins of the cut periosteum, so as to gain
double support (fig. 195).
When this is impracticable the sutures should be placed far enough
below the lower margin of
the incision to avoid the intercostal vessels. Single mattress sutures
are placed at each angle and
in the middle of the incision. The
spaces between these are closed with continuous mattress stitches. As
indicated in the diagram the outer loop of each lateral stitch is
inserted behind and lateral to the cut
rib end. When the stitch is tied, pleural approximation external to the
rib end is secured and the denuded rib excluded from the pleural
cavity.
FIG. 194.-
Inner aspect
of the chest wall,
obtained after death from purulent pleurisy without open pyothorax.
Suture tension necrosis has permitted separation of the margins of the
parietal pleura with exposure above and
below results of the muscle and bone
An
attempt to tie these sutures without overapproximation of the ribs
next above and below results either in the stitches pulling out
immediately or sloughing out later. The ribs are pulled together by
means of a wire stay passed
about them, as indicated in Figure 196, from which for the sake of
clearness, the mattress sutures
have been omitted. One loop is passed beneath the rib, and, if
possible, kept outside of the pleura
by hugging the rib with a needle, the point of which has been made
slightly blunt. As this loop of
the stitch crosses the pleural incision it takes in the margins of the
parietal pleura and intercostal
muscles to promote their subsequent apposition. The other loop is
passed over the rib and does
not include the intercostal structures.
When
this wire stay is drawn taut the ribs are so approximated that it
becomes possible to
appose pleura to pleura without tension by drawing upon the mattress
sutures. The three single
stitches are tied (fig. 197); the continuous stitches are pulled tight,
and tied at either end and in
the middle to an end of a single stitch. This closure is air-tight if
the suturing is done accurately.
If there is a leak, it will be revealed by escaping air and must be
corrected by a stitch or two to
prevent subsequent production of tissue emphysema.
395
FIG. 195.-
Closure of the
chest wall after
thoracotomy. Single and continuous mattress sutures are inserted
through
both periosteal margins on either side. The lateral sutures have the
outer loop of the stitch placed beyond the rib
ends
FIG. 196.-
Closure
of the
chest wall after
thoracotomy. In inserting a wire, rib stay, the posterior loop includes
the
periosteum, so as to aid in approximating the parietal pleura. The
anterior loop does not penetrate the intercostal
tissues.
396
Overapproximation
of the ribs likewise secures an abundance of muscle tissue for the
next layer. Healing is better if there is no dead space at the rib
ends. A single suture, placed near
the rib ends, as indicated in Figure 198, is tied and one end is cut.
The other end is now tied to
the end of the lateral mattress stitch in the parietal pleura. The
tissues are thus held snugly over and against the end of the rib. The
balance of this layer is closed with interrupted stitches, which
promote better healing than continuous stitches.
The
margins of the pectoralis and latissimus dorsi muscles are approximated
with
mattress sutures to safeguard the layer beneath from the dangers of
suppurition in the
subcutaneous fat (fig. 199). The deep layer of the superficial fascia
is united by interrupted
stitches (fig. 200), inserted opposite to the usual manner so that when
tied the knot is not
exposed superficially. The skin is closed with interrupted stitches to
permit the escape of serum.
Superficial drainage is often desirable to prevent tension. Small, soft
drains suffice, and,
removed within 24 hours, do not endanger infection of the deeper
tissues.
Such
exact methods can be criticized as time consuming and unnecessary. In a
considerable proportion of all operations these objections are valid.
However, there is another
proportion, too large to be neglected, which can not always be
recognized at the time of
operation, in which they are invalid. We observed repeatedly that when
details were neglected
during periods of extraordinary activities, the subsequent healing was
less satisfactory and led to
distress and to death which greater care might have obviated. Need to
serve greater numbers can
and perhaps should justify compromises with the excellent rule that
what is worth doing at all is
worth doing well.
The
wire rib stay is particularly undesirable, but absorbable sutures do
not hold and silk
or linen are unreliable. The wire should be removed in from four to six
weeks as it will
eventually cut through the ribs, and for this reason ought to be
insorted so as to facilitate
subsequent exposure of the twisted ends and removal through a small
incision made with local
anesthesia.
Methods
of closing the chest in limited thoracotomy and in thoracotomy of
necessity are
based upon the same principles.
DRAINAGE
The
use of primary and even of early drainage of pleural cavities after
operation was
generally condemned because open methods were employed, and because
with them collapse of
the lung is inevitable. Gray 38 cited figures to show that
closure was safer than open drainage.
The postoperative accumulation of serum was recognized as a constant
occurrence, and routine
aspiration. repeated as required, was adopted as a necessary precaution
against its dangers.
Lockwood and Nixon 23 found that interrupted drainage by
aspiration reduced the need for
subsequent rib resection and open drainage.
Experience
in the early and late treatment of pleurisy shows that air-tight
insertion of
drainage tubes provided with some device to prevent the entrance of air
is the most satisfactory
procedure, and that the earlier such drainage is established the better
the results. It is evident
from the writings of Elliott and Henry,16 Dobson,39
Mozingo,40 Blankenhorn,41 Whittemore,42
McKenna,43
397
FIG. 197.-
Closureof the
chest wall after
thoracotomy. The rib stay is drawn taut and fixd so that it can easily
be
removed
FIG. 198.- Closure of
the
chest wall after
thoracotomy. The layer of fat and muscle is closed over the defect
caused
by rib resection
FIG. 199.-
Closure
of the chest wall after
thoracotomy. The margins of the pectoralis major and lattisimus dorsi
are
united with mattress sutures to protect the deep wound
FIG. 200.-
Closure of the
chest wall after
thorarotomy. The deep layer of the superficial fascia is closed with
buried
sutures
398
and Roberts 44
and from our own experiences, that a catheter drain inserted
intercostally by
trocar and cannula, and provided with an automatic one-way check valve,
is the method of
choice. (Fig. 201.) By this means negative pressure can be maintained
until full inflation is
secured. Employment of fluctuations in intrathoracic pressure to
provide the expulsive force is
better than using suction, as it is in keeping with normal physiologic
movements. It is also very much simpler, and, being automatic, is not
dependent upon constant attention for its success.
Duval 24
advised against operating more than 30 hours after injury. The dangers
of
empyema after that time are very great but are less with operation than
without, especially if primary drainage is used. We found that early
operation, conducted by methods described above,
gave a mortality rate of 4 percent in an unselected consecutive series
of thoracotomies
performed within eight hours and the men had not been chilled. When the
operation was delayed beyond 24 hours or the wounded were cold or wet,
the
mortality rate was increased tenfold. It seems now that had primary
drainage been used more as
a routine many of these lives could have been saved. It is certain that
primary drainage after
operation for the large wounds with open thorax, foreign bodies, and
lacerations of liver and
diaphragm was effective in limiting disastrous pleurisy.
FIG. 201.- A,
Trocar, cannula, and catheter
for intercostal drainage: B, flap valve used to secure automatic oneway
drainage
POSTOPERATIVE TREATMENT MN
The
use of positive pressure anesthesia is the most important factor in
simplifying the
postoperative care, because of the decreased distress due to the
abolition of pneumothorax, the
better general condition of the patient, and the elimination of
complications.
Morphine
in generous doses is useful in reducing pain, in limiting the rate of
respiration,
and in controlling coughing. The value of posture has been over-rated.
Patients naturally take the
most comfortable position. Other things being equal lying upon the
sound side is preferable. The chief interest is in the postoperative
effusions. If primary drainage has been instituted there
is only need to see that the tube is free. If the chest has been closed
tight one of two courses is
open: Either aspiration should be done the second day and repeated
often enough to prevent any
considerable reaccumulation, or it should be done when signs of
pressure or of infection
develop, or when absorption is unduly delayed. There are objections to
all methods, least of all
to primary drainage.
The
most important feature, next to safeguarding life, is the earliest
reestablishment of
full pulmonary functions. No breathing exercises should
399
begin until the patient
is afebrile, and then if a rise in temperature should follow they must
cease
until the temperature is again normal. Holding the breath, slow
breathing, and blowing against
pressure are valuable, with particular attention given to abdominal
breathing in order to
reactivate the diaphragm. Patients should be encouraged to get out of
bed as early as safety
permits and to exercise the muscles of the thorax. Recovery is
protracted as early activity is
delayed. Active duty within six weeks of an injury serious enough to
require resection of part of
a lower lobe was achieved by one soldier, and this indicates the
possibilities of treatment.
COMPLICATIONS
Pleurisy
is to be regarded as a natural and constant sequel of an intrathoracic
injury,
including thoracotomy. Empyema is the commonest and most significant
complication. There is
no sharp line separating the two and none should be assumed. The best
treatment of empyema is
to limit the initial pleurisy, and this is more certainly accomplished
by primary drainage than by
any other method. When primary drainage or routine aspiration is
impossible exploratory
puncture is indicated by signs of sepsis or by signs of a sudden
increase in the exudate. The
probability of subsequent development of an empyema can be established
by the soiling and
reaction of the pleura present at the time of operation
FIG. 202.-
Form of
trap
to be attached to a
catheter drain. It provides both a receptacle for the discharge and a
flap
valve. If slight suction is needed, it can be provided by
collapsing the trap
and and by the
length of time elapsing between injury and operation. As
a rule, the more
virulent the infection the more rapid the development of postoperative
empyema and the less the
likelihood of limiting adhesions being formed.
Open
operation for empyema performed without differential pressure is
dangerousif done
before adhesions form, and may be futile if delayed. Catheter drainage
should be the first resort
and will usually be sufficient. If more radical intervention is
required thoracotomy with positive
pressure analgesia will permit of all necessary manipulations without
the dangers of pulmonary deflation, and with the least danger of
disseminating infection. The wound may be closed
completely, and tube or catheter drainage established elsewhere, or a
tube may be sewed in
hermetically at an angle of the incision. It is understood that some
form of valve is provided so
that subsequent irrigations may be given without permitting air to
enter the chest. Slight constant
suction will often prevent coagulation of serum within a catheter. This
suction and a receptacle to catch the discharge may be provided by a
simple apparatus (fig. 202). Fluoroscopic
control makes it easy to insert the catheter accurately and safely.
400
Pneumonia
is usually contralateral and of the bronchial type. It is rare, as is
contralateral
pleurisy, when gas-oxygen pressure analgesia is used. The probable
explanation is the less
urgent dyspnea and consequent failure of aspiration of blood and mucus
which are expelled from
the bronchi of the injured side into the bronchi of the sound side.
Contralateral
collapse, which has been so well described by Bradford,19
does not occur
when positive pressure is used.
The
presence of a foreign body may prove a serious handicap to permanent
recovery. It
has been said that every man harboring one foreign body suffers from
two, one physical and one
mental. Small shell fragments and bullets embedded in the lung may
cause pain and dyspnea
because they are sources of chronic traumatism, and because their
removal is occasionally
curative. The distress is more often due to the effects of pleurisy,
restricted motion of the
parietes, reduced intrapleural negative pressure, or to impaired motion
of the diaphragm. Under
such conditions the foreign body is an incident and its removal can
change the mental attitude
only. The indications for removing these intrapulmonary foreign bodies
are a matter of opinion.
Three
methods are available for the late removal of intrapulmonary foreign
bodies: First,
the use of forceps of the alligator type introduced intercostally and
manipulated under
fluoroscopic control. Petit de la Villeon45 introduced
this procedure and reported remarkable
results. Its dangers, particularly when the foreign body is at the root
of the lung, are obvious. It is
a blind procedure. A second method, also a compromise, consists in a
short costectomy, suture
of the parietal to the visceral pleura, and removal of the foreign body
with forceps guided by a
Hirtz compass. Like the method first described, this method is useful
in the extraction of small
superficial fragments which are of the least significance. When the
foreign bodies are deeply
placed, near the large vessels or mediastinum, an open operation should
be done, the foreign
body removed and the incidental damage accurately repaired. The best
treatnment wolldI have
been removal of the missile at the time of injury.
Foreign
bodies in the pericardiumn, in the heart muscle, and in the cavities of
the heart
have been removed. Aside from the possibilities of civil surgery
suggested by these highly
dramatic operations a very practical hint has been given toward
selecting the method of
approach. Most operators have attempted to keep out of the pleural
cavity and have generally
succeeded in provoking an empyema. An open operation, such as a
thoracotomni of election, if
done with differential pressure, gives a very satisfactory cardiac
exposure, and would make
possible better surgery and smoother recoveries.
Late,
persistent, or recurrent empyema suggests the possibility of some
chronic irritant
like a foreigni body or a costal osteomyelitis, both of which must be
excluded with the least
possible delay. Much has been and will be written about methods of
treating open pyothorax,
and various methods of irrigation and decortication. All have one
object, to convert an open into
a closed thorax by pulmonary inflation. The essential factor is the
reapposition of visceral and
parietal pleura, whether attained operatively as proposed by
Roux-Berger46 or by breathing
exercises. The general plan of procedure is
401
based upon the
elimination of infection and reduction of irritation: solutions which
favor
disintegration of fibrin are indicated. To date nothing superior to
Dakin's solution has been
found.
Treatment
of closed pvothorax is being advanced by the application of principles
established by Bowditch.7 Instead of an immediate
costectomy and the formation of an open
pyothorax it is far better to introduce one or two catheters by means
of a trocar and cannula.
Intermittent irrigation and continuous drainage, which protect and
increase pulmonary inflation,
may lead to prompt recovery. If this method be partially unsuccessful,
a less forbidding
operation is ultimately required. Encapsulated pockets may be tapped
safely if the manipulations
are done with the aid of a fluoroscope. The best treatment of empyema
is that proposed by Roux-Berger,46 early and complete
operation after injury.
Reports
by Rist, Flandrin, Bernard, Sommerville, and others,47
Pehu and Daguet,48 all
show that chest wounds are unlikely to favor early development of
tuberculosis. Tuffier30 noted
that the disease is prone to appear on the opposite side. The reasons
are clear. The injured side is
apt to be incompletely expanded and is in a condition, according to
Cloetta,36 to offer hypernormal resistance. The opposite
side, constantly affected by
compensatory emphysema, is in a
state of reduced resistance.
Physical
disability will persist in the wounded in proportion to the
interference with the
respiration and circulation. The interference may be so slight, as
merely to reduce the powers of
compensation and become apparent only under stress, or it may cause
dyspnea, palpitation and
cyanosis with slight exertion. If there is incapacity, attempts should
be made to determine the
cause, and such treatment, operative, medical, or physical, be employed
as will improve
function. It is easy to make a diagnosis of neurosis or malingering in
individuals who have
sustained chest injuries, and do them a grave injustice. Complete
physical examination before
and after exertion, controlled with it fluoroscope, and proper blood
pressure determinations, will
generally disclose reasons for the complaints of pain and disability.
RÉSUMÉ OF
THE RECORDS OF THE WOUNDED
An
analysis of the histories of patients has been made to disclose the
causes of deaths and
of the extent and duration of disabilities in those who survived in
order to determine if possible
all the factors which might influence more effective care of thoracic
injuries.
The
relative merits of divers methods may be judged from two aspects-
immediate
military necessities imposed by fighting conditions, and the welfare of
the individual which must
always be second to winning wars. However, in a protracted struggle
success is determined by
the morale and strength of an army, both of which depend to a great
extent upon each soldier
being assured the utmost consideration before and after he is hurt.
Hence, there is no reason to
consider other procedures than those offering individuals the largest
opportunities for undelayed
recoveries.
There
are several sources of error in the data presented from which
deductions must be
made. Our records are incomplete; observers may have been biased; and
there is a natural
disposition on the part of the disabled to magnify
402
their misfortunes,
particularly when financial compensation varies with the extent of
disability.
On the contrary, the details that can be established suffice to
indicate the facts essential to
drawing conclusions. The causes of death are usually easy to recognize.
The causes of
disabilities are unmistakable, viz., reduced motion of the parietes,
particularly of the diaphragm;
diminished elasticity of lung; abnormal intrapleural pressures, and
myocardial deficiencies. Not
only are these lesions demonstrable, but vital capacity also may be
used as a check upon the
extent of their composite detriments because it measures the extent of
disabilities attributable to
cardiorespiratory diseases.
METHODS
Attempts
were made to keep notes upon each wounded man, to take photographs that
would show the nature of wounds and postoperative conditions, to make
routine post-mortem
examinations, to trace survivors after they were evacuated from forward
hospitals, and finally to
ascertain the nature of their ultimate disabilities.
Some
patients were treated and no notes were kept; some notes were lost. But
it is
improbable that these breaks in our records (not above 25 percent) are
of material significance,
since enough information is available to give a dependable average.
Unfortunately the
photographic and X-ray films were stolen from the central laboratory at
Dijon. They would have
shown details that can not now be described. It was impossible to trace
the wounded in France,
so there was no control of their later and most important postoperative
treatment. It has since
developed that except for necessary surgical care they got none.
Although unfortunate for the
individuals, this neglect is of great value in demonstrating the
limitations of operative procedures
alone as means to restoration of function.
Through
the intercessions of the Surgeon General of the Army and the generous
cooperation of the United States Public Health Service a member of the
unit was enabled in 1921
to visit a number of patients in Government, hospitals who had had
chest wounds and to see
certain others living near by who came in voluntarily for examination.
This officer secured
sufficient accurate information to determine the extent, nature, and
causes of disabilities in those
whom he examined and to make it possible to estimate dependably the
conditions of others not
examined but whose records could be found. Here again, although our
records are incomplete, it
is probable that enough has been learned to give a reliable average of
results, since the more
seriously incapacitated were hospitalized, and they form a larger part
of the observations.
The
series here recorded consists of 104 patients whose records are
available. They have
been divided into four groups, according to the nature of the first
operation performed: (1)
Excision of parietal wound; (2) limited thoracotoiny; (3) thoracotomy
of necessity; and (4)
thoracotomy of election.
The
history of each patient is outlined, the cause of death presented, or
the nature and
causes of disabilities stated. The treatment of each patient is
criticized. Similarly, the treatment
of each group is criticized. Finally, reasons are given to show how the
entire series could have
received better care from the time injuries were inflicted until the
final results were established.
403
GROUP I. EXCISION OF PARIETAL WOUND
1. W. M. July 22, 1918: Bullet, perforating
wound, left chest. Entrance below and mesial to angle of right
scapula; thence through tissues of back, through left chest, to lodge
in left side of neck. Duration, unknown.
Hemopneumothorax moderate. Condition good (?). Operation: Excision of
parietal wound. Removal of foreign
body. Pleural wound not exposed. Closure without drainage. July 24,
1918: Fluid not increased; partial
pneumothorax persists. Evacuated in good condition. Returned to duty in
three months.1921: Records available.
Disability less than 10 percent and due to chronic pleuritis.
Recovery
would have been more certain, rapid, and complete had hemothorax been
removed and lung sutured at time of operation.
W.
B. July 27, 1918: Bullet, through-and-through, sucking wound, left
chest. Entrance, posterior triangle
above left clavicle; exit, in fourth interspace, lateral to
midclavicular line. Hemopneumothorax; heart slightly
displaced to right. Condition good (?). Duration, unknown. Operation:
No rib injuries recognized. Wounds excised
and closed without drainage. Hemothorax not aspirated. Pressure
anesthesia disclosed no air leakage. August 1,
1918: Uneventful recovery. Healing smooth. Left lung slightly cloudy.
Left diaphragm excursions reduced one-half.
Bight chest clear. Estimated disability less than 10 percent and due
to pleuritis.
Hemothorax
should have been aspirated at time of operation and again later if
persistent.
Absence of rib injuries and of air leakage contraindicated thoracotomy.
3.
D. C. July 27, 1918: Bullet, penetrating wound, left chest. Entrance,
upper anterior aspect of chest;
lodgment, just to left of aortic arch; moves with respiration, probably
intrapulmonary. Moderate hemopneumothorax;
heart displaced to right. Duration, six hours. Condition good (?).
Operation: Entrance wound excised. Pleural wound
not found. No rib injuries. No air leakage recognized. Closure with one
gutta-percha drain. Hemothorax not
aspirated. July 31, 1918: Smooth convalescence. Both sides of chest
cloudy; left more so. Left diaphragm moves,
though but slightly. Foreign body at root of left lung. Tissue
emphysema. Early removal of drain showed that
drainage of superficial tissues can be helpful and harmless. August 2,
1918: Evacuated in good condition. Estimated
disability less than 10 percent and due to pleuritis.
Perforation
in pleura should have been located and accurately closed with muscle to
prevent emphysema. Hemothorax should have been aspirated. Removal of
foreign body not
indicated.
4. E. L. D. July 28, 1918: Shell fragment,
penetrating wound, left chest. Entrance through left scapula;
lodgment in left lung, where foreign body 1 cm. in diameter can be seen
to move with respiration.
Hemopneumothorax moderate. Duration, 24 hours. Condition, poor.
Operation: Gutter wound, left arm, excised.
Wound through left scapula excise and drained, as patient's condition
did not permit of thoracotomy. Gum acacia
given before and during operation. August 3, 1918: Smooth recovery.
Pleuritic exudate still present and heart
displaced to right. Evacuated in good condition. Disability, estimated
at less than 10 percent, as this man returned to
active duty, can be attributed to pleuritis.
No
radical operation was possible under the conditions. Aspiration of
hemothorax
should have been done.
5.
R. E. H. July 30, 1918: Shell fragment, perforating wound, left chest.
Entrance second left interspace,
midelavicular line; lodgment beneath skin of back at eighth interspace.
Massive hemothorax; heart much displaced
to right. Duration, 30 hours. Patient treated 6¾ hours because of
shock. Gum salt intravenously raised systolic blood
pressure 30 mm. and made operation feasible. Operation: Excision of
both entrance and exit wounds with removal
of foreign body. No rib damage. Positive-pressure analgesia forced out
part of hemothorax, which was not aspirated.
No air leakage from lung recognized.
404
Pleural openings closed with muscle. Wounds
closed without drainage. August 3, 1918: Convalescence
and healing smooth. Pleuritic exudate subsiding, but heart still
displaced to right. Evacuated in good condition. July
20, 1921: Passed through several hospitals in France. No further
treatment. Discharged from service March 7,
1919. Disability, 10 percent. Dyspnea on extraordinlary exertion.
Utnable to lift heavy weight. Limited expansion
at left base. X-ray shows chronic pleuritis; adhesions between left
diaphragm and ninth rib and little mobility of
diaphragm. Heart competent. Vital capacity, 71 percent.
Disability
due to pleuritis. Rating at 10 percent is seemingly too low in view
of vital
capacity. Conditions at time of operation prevented more radical
treatment. Aspirations should
have been performed; possibly one-way catheter drainage. Systematic
breathing exercises
would have reduced disability to less than 10 percent. Limited
thoracotomy might have been
employed.
6. J. F. M. July 31, 1918: Shell fragment,
penetrating wound, right chest. Entrance above and mesial to
spine of scapula. Large hemothorax; heart displaced to left; foreign
body one cm. in diameter in lung hilum close to
aorta. Duration and condition not noted. Operation: Entrance wound
excised. No rib injuries. Hole in pleura plugged
with muscle. Superficial wound drained with gutta percha. August 1,
1918: Toxic and uncomfortable. Pleural
effusion increased; heart displaced to left anterior axillary line; 500
c. c. bloody fluid aspirated. Immediate relief.
August 3, 1918: Condition good. Fluid not reaccumulating. Evacuated.
July 30, 1921: A second aspiration was
subsequently performed at a base hospital in France. Returned to
United States September 15, 1918. No further
treatment. Disability rating
20 percent. Dyspnea on slight exertion. Chronic eough. Fibrous
pleuritis right side,
marked above. Diaphragm deformed and movements restricted.
Peribronchial thickening right side. Foreign body in
lung in front and lateral to aorta. Myocardium slightly defective.
Vital capacity 63 percent.
Disability
due to pleuritis, pulmonary sclerosis, and myocardial deficiency.
Unable to
follow active occupation. Disability rating of 20 percent is
apparently low. More radical
operation and removal of foreign body had man's condition permitted
would have been wiser. Man states he had suffered from dysentery for
two days precedIing injury so his condition may
have been unfavorable. Immediate aspiration, perhaps catheter drainage,
should have been used. Subsequent breathing exercises could have
reduced disability.
7. F. J. S.
August 10, 1918: Shell fragment,
through-and-through wound, right chest. Entrance to left of
spine at level of angle of scapula, thence through vertebre and ribs
up- ward and to right to exit through posterior
triangle of neck, fracturing first rib. Duration 21 hours. Condition
critical. Operation: Entrance and exit wounds
excised. Pleural defects plugged with muscle and superficial wounds
sutured; 500 c. c. of gum salt given
intravenously during operation raised pressures from 98/60 to 108/64.
Soon after operation pressures had fallen to
60/30. Transfused 500 c. c. citrated blood. Pressures raised to 100/60,
temporarily. Death within a few hours.
Necropsy: Kissing wound at apex of right lung. Splenization right upper
lobe. Moderate hemothorax. Dilatation of
right heart.
This
man could have recovered had it been possible to operate when hewas in
good
condition. Removal of right upper lobe would have been necessary. An
illustration of the need to
protect the pulmonary circulation.
8. N. E. L. September 12, 1918: Shell
fragment, penetrating, right chest. Entrance wound at tip of right
clavicle. Moderate hemothorax. Foreign body 1.8 cm. in diameter within
lung. Cough and hemoptysis marked. Duration five hours. Condition good.
Operation: Entrance wound and tract excised. No rib damage. Entrance
intopleura not found. Superficial drainage. No aspiration. September
14, 1918: Healing smooth. Pleuritic effusion
reducing. Heart no longer displaced to left. Evacuated in good
condition. 1921. Records available. Disability less
than 10 percent.
405
Immediate
aspiration should have been performed.
9. W. J. McC. September 12, 1918: Shell
fragment, penetrating wound, right chest wall. Entrance in
third interspace at right sternal margin to lodge beneath skin over
fifth rib in anterior axillary line. Small
hemothorax; heart not displaced. Some hemoptysis. Duration unknown.
Condition good. Operation: Excision of
wound of entrance; resection of upper right margin of sternum and of
fractured third rib. Pectoralis major muscle
split for exposure. Foreign body 2 cm. in diameter removed. Pleura not
opened. No suture closure. Gutta-percha
drain. September 17, 1918: One aspiration removed straw-colored
serofibrinous fluid. X ray shows some cloudiness
at right base. Diaphragm and its excursions normal. December 24, 1918:
Returned to active duty. August 3, 1921:
Little disability. No cough. Rating 10 percent. Heart normal. In lungs
there is slight increase in peribronchial strive;
otherwise normal, as is the diaphragm. Basal chronic pleuritis, right.
Vital capacity, 90 percent.
Disability
is due to pleuritis which could have been eliminated with aspiration at
time of
operation and subsequent breathing exercises. This is an example of
pulmonary injury caused
probably by indirect violence. In this instance thoracotomy was not
indicated as it would have
been had there been splenization of the lung.
10. F. K. September 12, 1918: Bullet,
through-and-through wound, left chest wall. Entrance at anterior
axillary line, level of fourth rib; exit at posterior axillary fold at
level of sixth rib. Small hemothorax; dyspnea.
Duration seven hours. Condition good. Operation: Wounds of entrance and
exit excised; connecting tract laid open
and excised. No rib injury nor pleural laceration. Superficial wound
closed with drainage. September 18, 1918:
Pleuritic effusion persists in small amount, but is decreasing.
Evacuated in good condition. No further records.
Estimated disability less than 10 percent.
Aspiration,
perhaps repeated, should have been employed.
11. P. O. September 26, 1918: Bullet,
through-and-through wound, right chest wall. Entrance just below
right sternoclavicular joint; exit below and external to right nipple.
Small hemothorax. No dense shadows. Duration
five hours. Condition fair. Operation: Ten and a half hours later.
Wounds of entrance and exit resected; connecting
tract opened. No rib or pleural damage. Lacerated outer one-half of
pectoral muscle removed. Partial closure.
Superficial drain. September 30, 1918: Condition excellent. No increase
in pleuritic effusion. Evacuated. No further
records. Estimated thoracic disability zero.
Aspiration,
especially if performed under fluoroscopic control, would have been
wiser.
12. E. L. October 1, 1918: Bullet,
through-and-through wound, neck and right chest. Entrance above inner
third clavicle; exit, right axilla, level of fifth rib. Cold,
exhausted; pulse feeble and rapid. Extreme interstitial
emphysema of face, neck, arms, and thorax. Grunting dyspnea. Exhaustion
due to long, hard ride. Duration 12 hours
plus (?). Operation: Excision of entrance wound. Air escaped from
tissues in bubbles. Wound packed with gauze and
a tube drain inserted. Condition prevented further intervention. Death
14 hours later. Necropsy: Left pleural cavity,
negative pressures persist. Right pleural cavity, positive pressure;
lung compressed and diaphragm depressed by
large hemopneumothorax. Through-and-through wounds of trachea in
episternal notch and of left upper lobe.
Peritracheal emphysema; trachea not obstructed. Death due to
obstruction of venous return from head.
This
man arrived too exhausted to stand operation. If he had been received
earlier
tracheal repair or tracheotomy would have been effective.
13. R. M. October 13, 1918: Shell fragment,
through-and-through wound, left chest wall. Entrance
beneath anterior axillary fold; exit below angle of scapula. Much bone
406
damage. Small hemothorax. Condition good.
Duration 22 hours. Operation: Entrance and exit wounds excised. No
pleural injury. Wide resection of scapula. October 19, 1918: Evacuated
in excellent condition. No further records.
Estimated thoracic disability zero.
Even
this limited hemothorax should have been aspirated.
14. W. J. W. October 14, 1918: Shell
fragment, penetrating, right chest wall. Entrance wound right axilla,
level of fifth rib. Foreign body, 0.3 by 0.7 cm., beneath right nipple.
Operation: Entire wound excised. Foreign body
removed. No rib or pleural injury. Partial closure. October 16, 1918:
Wound clean. No abnormal chest findings. Excellent condition.
Evacuated. No further records. Estimated thoracic disability zero.
15.
G. S. October 14, 1918: Shell fragment, penetrating wound, left chest.
Entrance just below spine, left
scapula. Moderate hemothorax. Foreign body 0.6 by 0.8 cm. in lung.
Intrapulmonary hemorrhage. Duration, nine
hours. Condition, fair. Operation: Two and a half hours later. Wound of
entrance excised. Fractured scapula
resected. Pleural defect closed with muscle. Partial closure. October
15, 1918: Comfortable. Stations changed. No
further records.
If
this man's condition had permitted, a thoracotomy of election should
have been
performed, as it would have caused less risk than a splenized lung.
16. B. W. November 1, 1918: Shell fragments,
0.5 by 0.8 cm., and 0.5 by 0.12 cm., penetrating wounds of
back and right chest. Sucking wound at entrance at ninth rib below
angle of right scapula. Small
hemopneumothorax. Heart displaced to left. Complete section of cord.
Duration, 24 hours. Condition, poor.
Operation: Wound of entrance excised. Contused muscle, broken ribs, and
vertebrae resected. Closure with muscle
flaps. Superficial drainage. Died within six hours. No necropsy.
Lethal
injury. Treatment with morphine would have been wiser.
17. H. G. H. November 2, 1918: Shell
fragments, penetrating; seven wounds of back and right chest.
Moderate hemothorax; hemoptysis. Duration, six hours. Condition, poor.
Operation: One and a half hours after
admission. Multiple wounds excised and superficial foreign bodies
removed. Fractured spinous processes resected.
Wound in pleura closed. November 18, 1918: Condition, fair. Fluid in
chest despite previous aspiration. No
pneumothorax. Febrile. Died some days
after evacuation. No further notes.
This
man's life might have been saved by proper drainage, as he died
presumably from
emphysema.
18. H. C. H. November 12, 1918: Bullet
through-and-through wound, right chest. Entrance over third rib,
right parasternal line; exit, right posterior axillary line at level of
fifth rib. No hemoptysis. Moderate
hemopneumothorax and cardiac displacement. Some tissue emphysema.
Duration, 34 hours. Condition, fair.
Operation: Exit wound excised. Slight sucking. No rib injury. Closure
with superficial gutta percha drain. Entrance
wound excised. No rib injury. Closed. Chest aspirated. November 16,
1918: Temperature normal. No cardiac
displacement. Small pleuritic effusion. Condition, excel- lent.
Evacuated. February 5, 1919: Discharged from
service. No further treatment. August 12, 1921: Dyspnca on slight
exertion. No cough. No limitation in respiratory
excursions. Slight fibrosis at right apex. Diaphragm free. Heart: Rapid
action; otherwise normal. Vital capacity,
110 per cent. Disability rating, 25 percent.
Disability
granted is due to cardiac excitability and not to previous injury. This
man's
treatment, in view of the duration of injury before operation, has been
justified by the results. An
intercostal catheter drain might have done harm and accomplished no
more good.
407
SUMMARY OF GROUP I
The
number (18) treated by extrapleural excision is 20 percent of the
entire series. It
would have been much larger had not so many of the less seriously
wounded been sent to
hospitals farther away.
Fatalities.-There
were four deaths (22 percent). Two (7, 12), lethally affected at time
of
operation, could have recovered if operated upon earlier. One (16) was
fatally injured because
of a cord lesion; one (17), despite multiple injuries, might have
recovered had the principles of
primary drainage been under-stood and suitable apparatus been
available. One (17) was operated
six hours after injury; the others after 24 hours. No death can be
attributed to the operation itself.
One is chargeable to surgical error, the failure to provide drainage.
This gives a surgical
mortality of 5 percent.
Disabilities.-The
ultimate disabilities of 13 of the 14 who recovered are quoted from
allowances made by the War Risk Insurance board or by estimates made in
comparison
therewith. Three (11, 13, 14), recovered without disability from
thoracic lesions. Five (1, 2, 3, 4,
10) had disabilities of less than 10 percent. Two (5, 9) had ratings
of 10 percent. One (6) was
rated at 20 percent and one (18) at 25 percent. The ratings of two
(5, 6) are low and the rating
of one (18) is high. The result in one (15) can not be surmised. A
generous estimate of the
average disabilities for this group is 10 percent. The average
interval before return to duty was
about 90 days. Pleuritis, arising from hemothorax, caused the
disabilities in all but one (18,
disordered action of the heart). In four, hemothorax was caused by
transmitted violence as the
parietal pleura had not been punctured. Three of these (11, 13, 14)
recovered without disability,
and in the fourth (10) it was less than 10 percent. On the average 24
hours had elapsed between
receipt of injury and operation.
Had
it been possible to have hospitals close to the zones of conflict or to
have had
effective sifting of the wounded and expeditious transportation, the
mortality rate would have
been less. Had the proper use of intercostal catheter drains been
understood or had the members
of this unit been permitted to give patients individual postoperative
attention, particularly in
earlier and perhaps repeated aspirations, the disability rate (10
percent) would have been
reduced. Also had continued after-care, especially breathing exercises,
been a routine, the
average duration of disabilities (90 days) would have been less.
DEDUCTIONS
Virtually
all wounds of the chest should be treated by prompt excisions of
injured
extrapleural tissues, which without adding to immediate dangers give
protection against
inflammation in parietal tissues that can cause pyothorax and
frequently reveal unsuspected
deeper lesions demanding more radical operation.
Parietal
excisions should be performed under positive pressure gas analgesia,
because
these minor operations can thus be more rapidly and safely conducted.
Discomforts are less than
when local anesthesia is employed; there is less likelihood of
spreading infections and the
exposure of a sucking wound is not accompanied by pulmonary collapse.
Administration of ether
by open methods is unwarranted.
408
Aspirations
or suitable drainage of hemothorax should be almost routinely employed
with parietal excisions to reduce pleuritis and be followed by
systematic exercises to minimize
the effects of pleuritis. This combination assures the most complete,
undelayed recoveries.
CONCLUSIONS
The
chief objections to routine parietal excision have been: (a) It
increases immediate
dangers; (b) it is too
time-consuming, especially during periods of
active fighting when simple
aspiration with or without air replacement suffices: (c) it overburdens
the forward hospitals and
nurses.
(a)
Immediate dangers are not increased and ultimate dangers are reduced.
(b) Less time
and attention are required to obtain healing if wounds receive prompt
attention. Reasons have
been given to show why simple aspiration is inadequate and ofttimes
dangerous in spite of the
many excellent recoveries that may be secured. Air replacement is
unsound therapy. Its one
excuse is to stop hemorrhage from lacerated lung and can only be
effective by producing pulmonary compression. Not only is pulmonary
compression undesirable from every standpoint,
but also it must be controlled by manometric determinations which are
time-consuming. (c)
Virtually all wounds must be given some attention and all but those
receiving trivial injuries
must be hospitalized. Hospital facilities of an army have physical
limitations which can be
increased only by reducing the durations of disabilities. When the
numbers of severely wounded overtax forward hospitals, those suffering
from less severe chest wounds can be sent as
far back as they can be delivered within 24 hours while still in good
condition. This plan in the
long run would be more effective than the giving of makeshift early
treatment that assures more
prolonged and less complete recoveries. Parietal excisions, with and
without immediate
aspiration or primary drainage, are applicable to the least severe
chest wounds or to those in such critical condition that no further
intervention may be attempted.
GROUP II. LIMITED THORACOTOMY
1. E. B. July 20, 191S: Bullet,
through-and-through wound, both sides of chest. Entrance at left
nipple; exit
above right nipple. No physical signs of intrapleural involvement. No
X-ray examination. Duration nine hours.
Condition (?). Operation: Entrance and exit wounds excised and
connected. Fractured ribs and sternum resected.
Wounds in lung sutured and in pleura closed with muscle. No aspiration.
July 23, 1918: Hemothorax with increased
pleuritic exudate, right side. Dyspnea. July 24, 1918: Aspiration
unsuccessful. Condition poor. Hospital moved
forward. Patient left in poor condition August 2, 1918. Died. No
further notes.
Notwithstanding
severe injuries affecting both pleural cavities and anterior
mediastinum,
this man had the power to recover had proper primary drainage been
employed.
2. A. R. July 20, 1918: Shell fragment,
penetrating wound, sucking, right chest. Entrance over scapula.
Large hemothorax. Foreign body present. Duration (unknown).Condition
(?). Operation: Lacerated tissue excised;
fractured scapula and rib resected. Muscles closed over sucking wound
in pleura. Foreign body not removed.
Severed supra-scapular nerve sutured. July 24, 1918: Uncomfortable
convalescence. Pleuritic exudate disappearing.
Evacuated in good condition. 1921. Records available. Disability
below10 per cent.
409
This
man's recovery was due to good luck rather than to good management.
Hole in lung
should have been repaired; chest aspirated, possibly drained if the
wound was of long duration
because of the sucking type.
3. A. F. G. July 21, 1918: Bullet,
through-and-through, sucking wound, left chest. Entrance over sixth
rib,
anterior axillary line; exit, paraspinal line, level of twelfth rib.
Hemopneumothorax moderate. Duration (unknown).
Condition (?). Operation: Excision of wounds of entrance and exit.
Resection of fractured ninth, tenth, and eleventh
ribs. No lung injury recognized at operation. Closure of parietal
defect. July 24, 1918: Rapid convalescence. Still
some heniopneumothorax though disappearing. Evacuated in excellent
condition. No further records. Disability (?).
Immediate
aspiration was probably employed but not recorded. Sub- sequent
aspiration
was indicated, possibly primary drainage if the sucking wound was of
more than a few hours'
duration.
4. C. J. D. July 22, 1918: Shell fragments,
multiple wounds, right jaw, neck, shoulder, and right chest,
sucking, perforating. Wound of entrance in second interspace
anteriorly. Moderate hemopneumnothorax. Heart
displaced to left. Duration (unknown). Condition good. Operation:
Extrathoracic wounds excised and packed.
Wound of entrance excised. Foreign body, thought to be in lung, not
sought. Hemothorax aspirated. Parietal wound
closed. July 24, 1918: Condition good although pleuritic exudate is not
receding. Evacuated in good condition.
August, 1918: Phlebitis right leg. August 30, 1918: Returned to United
States. February 6, 1919: Discharged from
service. August 5, 1921: Disability attributable to leg alone. Vital
capacity 87 per cent. Slight pleural thickening at
right base. Heart competent. Foreign body in posterior chest wall.
Another
recovery attributable to good fortune. An undrained sucking wound
causing no
pyothorax. Quite probably this man's condition after excision of
multiple wounds prohibited
more radical intervention.
5. W. D. S. July 22, 1918: Bullet,
perforating wound, left chest. Entrance fifth interspace, midelavicular
line; lodgment in ninth interspace, close to vertebra. Moderate
hemopneumothorax. Duration (unknown). Condition
(?). Operation: Excision of wound of entrance. No rib injury. Opening
into pleura closed. Incision over foreign body
posteriorly. Foreign body removed. No rib injury. Hemothorax aspirated
through defect in parietal pleura which was
then closed. July 24, 1918: Easy convalescence. Evacuated in good
condition. November 20, 1918: Returned to
organization (Infantry). December 20, 1918: Readmitted to hospital
because of trouble in knee, supposed to be
synovitis. May 10, 1919: Discharged from service. Given a disability of
but 10 per cent because of chronic synovitis; none because of chest
injury. August 5, 1921: Synovitis proved to be due to sclerosis of
pyramidal tract
due to injury to spine. Heart and lungs quite normal. Vital capacity,
98 percent.
Without
knowledge of man's condition at time of operation, or duration of
wound, it is
unwise to say that more radical treatment would have assured better
repair. It could have
secured none as a zero disability attests.
6. J. H. T. July 23, 1918: Shell fragment,
penetrating, sucking wound, right chest. Entrance over scapula;
compound fracture of scapula and three subjacent ribs. Small
hemothorax. Duration (unknown). Condition fair.
Operation: Excision of entrance wound; resection major portion of
fractured scapula and ribs. Very large foreign
body removed from pleural cavity. Hemothorax aspirated. No lung injury
required repair. Closure of pleural defect
with muscle flaps and subcutaneous fat. July 24, 1918: Superficial
healing good. Some pneumothorax persists.
Uncomfortable but otherwise in excellent condition. Evacuated later
much improved. 1921: Official record show
disability less than 10 percent.
410
This
recovery is another to be attributed to good fortune as the pleural
cavity was much
soiled because of a large sucking wound. Suitable drainage would have
hastened recovery and
made it the more certain.
7. M. D. July 27, 1918: Shell fragments;
wounds of left neck and arm with penetrating wound of left chest.
Entrance over eighth rib near angle of scapula. Moderate-sized
heinothorax. Duration (unknown). Condition (?).
Operation: Excision of entrance wound. Fractured eighth rib resected.
Inner table of rib found extending into pleural
cavity. Hemothorax evacuated. No note on foreign body. Lung distended
normally. Muscle closure of pleural defect.
Layer closure of superficial structure; drained with gutta-percha. July
31, 1918: Excellent recovery. Pleuritic exudate
slight and diminishing. Hemothorax here due to bleeding from rib. Left
chest slightly hazy. Foreign body 0.5 by 0.5 cm. in lung. Diaphragm
motion present; restricted on left. Evacuated in good condition. Later
returned to duty
and then lost. Disability (estimated) 10 percent.
Removal
of so small a foreign body from the lung is contraindicated. The case
illustrated
the wisdom of exploring all chest wounds. The rib injury would
otherwise have escaped
attention until late complications arose. This man would have benefited
by a day or two of
primary drainage or one postoperative aspiration.
8. L. E. July 28, 1918: Bullet,
through-and-through, sucking wound, right chest. Entrance over right
third
rib, parasternal line. Exit over ninth rib below angle of scapula.
Small hemothorax. Condition poor. Duration
(unknown). Operation: Excision of en- trance and exit wounds. Fractures
of fourth, fifth, sixth, seventh, eighth, and
ninth ribs resected. Hemothorax evacuated. Splenized lung not resected
because of patient's poor condition. Pleural
defect closed with muscle. Death within 12 hours. No notes on necropsy.
This
man was lethally injured by the time he came to operation. Nevertheless
the
splenized lung should have been resected, as allowing it to remain
could at the best only
postpone death. Earlier operation and multiple transfusions could have
been effective.
9. M. S. September 26, 1918: Shell fragment,
perforating right chest. Entrance right upper chest, anterior.
Exit right lower chest, at level of tenth rib, posterior. Foreign body
under skin near vertebra. Right hemothorax,
moderate. Abdomen rigid, indicating possible injury to diaphragm.
Duration 9 ½ hours. Condition good. Operation:
Eight and a half hours later. Wound of entrance excised. No rib injury.
Pleural defect closed by stitching inflated
lung to margins and by muscle flaps superimposed externally. Incision
over foreign body which was removed and
dark blood evacuated. Again no rib injury. Hemothorax aspirated through
pleural defect. No lung injury found.
Pleura closed with muscle. September 30, 1918: Condition good. Little
pleuritic fluid evacuated. January 15, 1919:
Returned to duty. Disability (estimated) 10 percent.
Growing
experience led to more effective operations and attempts were made to
expose
lung injuries. Same fault of not using primary drainage is noteworthy.
10. S. F. S. September 26, 1918: Shell
fragment, through-and-through, sucking wound; right chest.
Entrance at eighth rib, posterior axillary line. Exit at third rib
above scapula. Small hemothorax. Duration 14½
hours. Condition poor. Operation: Begun after six hours' treatment for
shock. Entrance wound excised. No rib injury.
Hemothorax aspirated. Pleural opening closed. Exit wound excised.
Fractured rib resected. Chronic adhesive
pleuritis prevented any exploration. Large intrapleural cavity drained.
Incomplete layer closure. October 4, 1918:
Has done fairly well except for persistent effusion in lower chest from
which 1,300 c. c. of blood-stained fluid was
aspirated. Culture
411
negative.
Hereafter
improvement was more rapid. Evacuated in good condition. Returned to
duty
in six months. Disability (estimated) 10 percent.
Recovery
would have been hastened by earlier aspiration of pleuritic effusion,
though
primary drainage would have been still better.
11. M. S. September 26, 1918: Bullet,
through-and-through wound, right chest. Entrance wound, anterior,
at margin of rectus muscle; exit wound posteriorly over seventh rib.
Small hemothorax. Splenization in right lower
lobe suspected. Duration 10 hours. Condition fair. Operation: After six
and a half hours' preparation. Entrance
wound excised. No rib injury. Pleural opening and superficial wound
closed. Exit wound excised. Fractured seventh
rib resected. Hemothorax aspirated through this pleural opening. Lung
injury not repaired. No splenization
noted.
Parietal pleura defect plugged with muscle. Wound closed in layers. No
drainage. October 5, 1918: Wound healing
good. Pneumothorax absorbed. Pleuritic effusion persists, but not
aspirated. Pneumonia left upper lobe. October 6,
1918: 500 c. c. bloody fluid aspirated from right chest. October 7,
1918: Partial pneumothorax evacuated; condition
fair. August 4, 1921: No treatment subsequent to evacuation. Suffers
from dyspnea and cyanosis on exertion.
Chronic bronchitis, peribronchitis, fibrous pleuritis; dome of
diaphragm adherent to ninth rib; myocardial deficiency.
Vital capacity, 57 percent. Disability allowance of 10 per cent much
too low; should be 40 percent.
This
man's treatment was improper partly because of battle pressure. A more
finished
operation with suture of lung wounds should have been performed and
with drainage and
postoperative care would have hastened recovery and reduced disability,
notably in preventing
recurrence of pneumothorax. An excellent example of
the wisdom of exploring all through-and-through wounds to exclude or to
remedy rib injuries. The occurrence of a contralateral pneumonia is
noteworthy because so infrequent with positive pressure gas analgesia.
12. J. G. September 27, 1918: Bullet,
through-and-through, sucking wound, left chest. Entrance at second
rib, parasternal line; exit below and posterior to angle of scapula.
Fluoroscopic diagnosis: Moderate hemothorax.
Both lobes perforated; splenization of lower part of upper lobe; heart
displaced to right; no rib injuries recognized.
Duration 12 hours. Condition poor. Operation: Nine hours later during
which he was treated for shock. Wound of
entrance excised. No rib damage. Closed without drainage. Exit wound
excised; revealed sucking wound, fractures
of sixth and seventh ribs, which were resected. Fragments of sixth rib
had penetrated visceral pleura and were
removed; 200 c. c. of fluid blood aspirated. Clots not removed and lung
not repaired because of weak condition of
patient. October 5, 1918: Stormy convalescence. Considerable effusion
with pneumothorax. Evacuated in fair
condition. No subsequent treatment. October ?, 1918: Returned to United
States. January 23, 1919: Discharged from
service. July 29, 1921: Underweight. Dyspnea on extra exertion.
Pleuritic thickening base of left lung. Dome of
left diaphragm adherent to sixth rib. Shallow pneumothorax cavity
beneath seventh, eighth, and ninth ribs covered
by thick scar. Lung parenchyma corresponding to injury and to
pneumothorax cavity does not function. Myocardium
fair. Vital capacity 90 percent effected by compensatory emphysema.
Disability allowance of 18 percent is low
because heart muscle is only competent at rest and has narrowed reserve
power.
This
man's experience emphasizes important points. The folly of conservatism
in treating through-and-through wounds. These rib fractures untreated
would have led to
persistent pneumothorax. Under favorable circumstances open thoracotomy
and radical
treatment of lung defects would have been indicated. Splenization may
not always cause death
but by the resultant scar restricts pulmonary elasticity and causes
disability. The
412
persistent partial
pneumothorax is an example of the permanent total pneumothorax that
occurs
when differential pressures are not employed. Suitable drainage would
have corrected this fault.
Neglect of breathing exercises through absence of all continued
treatment increased the total
disability materially and perhaps prevented this man from returning to
his pre-war occupation.
13. H.
B. September 27, 1918: Shell fragment,
penetrating left chest. Entrance wound second left
interspace, parasternal line; small foreign body moves with
respiration. Hemoptysis marked; hernothorax large;
considerable pneumothorax. Duration 24 hours. Condition good.
Operation: Two hours later. Wound of entrance
excised. Fractured fourth rib at costochondral junction resected. 1,000
c. c. of blood and some clots removed. Wound of entrance into lung not
found. Foreign body not sought. Closure without drainage. October 2,
1918: Rapid
recovery. Pleuritic exudate slight. No pneumothorax. Evacuated.
November 5, 1918: Returned to duty 39 days after
injury. April 21, 1919: Discharged from service. No further treatment.
August 20, 1921: Complains of pain in left
chest and dyspnea with slight exertion. Chronic pneumonia left upper
lobe. Chronic pleuritis left base. Adhesions
between diaphragm and ninth rib restricts its motion Myocardium,
subcompetent. Vital capacity 112 percent, due to
contralateral emphysema Foreign body present near base of lung.
Disability 25 percent, due to heart.
This
man's disability is due to scar tissue inside the lung and out. His
prompt recovery
indicates that the immediate treatment was adequate. The ultimate
results show that proper
postoperative care, including well systematized exercises, would have
brought such a recovery
as would have permitted him to return to his original occupation of
farming. Again and again the
heavy toll placed upon the wounded through failure to provide suitable
after-care is exemplified.
14. E.
McF. September 27. 1918: Bullet,
through-and-through, sucking wound, right chest. Entrance, third
rib anteriorly; exit, ninth rib posteriorly. Small hemothorax; large
pneumothorax. Duration nine and a half hours.
Condition grave. Resuscitation for 25 hours. Operation: Thirty-six
hours after injury. Excision of wound of entrance
and of exit in posterior axillary line. Compound comminuted fractures
of fourth, fifth, sixth, seventh, eighth, and
ninth ribs exposed and resected. Lung badly lacerated and splenized.
Lacerations trimmed and sutured. Patient's
condition was thought to contraindicate resection of splenized lung.
Hemothorax removed. Pleural defect closed
with muscle flaps over incompletely expanded lung. September 29, 1918:
Transfusion 400 c.c. citrated blood.
October 5, 1918: Partial pneumothorax above pleuritic exudate. Four
hundred c.c. serosanguinous fluid exudate
aspirated. Cocci in clumps. October 8, 1918: Somewhat improved. October
21, 1918: Died. Double empyema and
peritonitis.
Shock
prevented earlier operation and was thought to contraindicate resection
of
splenized lung. Obviously, resection should have been performed and
with suitable drainage
demanded by a sucking wound of this duration (36 hours) would have
saved
this life.
15. I. D.
September 28, 1918: Shell fragment,
0.5 by 0.3 cm., penetrating, sucking wound, right chest.
Entrance over spine of right scapula, thence through lung, diaphragm
and liver to lodge in upper pole of right
kidney. Large hemothorax. Duration eight hours. Condition poor.
Resuscitation for seven hours. Operation: Fifteen
hours after injury. Entrance wound excised. Comminuted fracture of
tenth rib resected. Wound in lung insignificant
and not repaired. Hemothorax aspirated and clots removed. Parietal
defects closed with muscle flaps. No drainage.
October 3, 1918: Had done well for a few days. Signs of
bronchopneumnonia developed yesterday in left lung and
fluid in right chest increased. Foul-smelling fluid containing many
bacteria aspirated from pocket near angle of right
413
scapula. Open drainage. October 4, 1918: Died
(sixth day after operation). Necropsy: Open drainage had caused
some collapse. A second encapsulated empyema had not been reached. Left
lower lobe and lower part of left upper
lobe almost solid with confluent patches of bronchopneumonmia. Abdomen
contained small amount of blood. No
peritonitis.
Another
of the exceptional instances of bronchopneumonia after positive
pressure
analgesia. Otherwise this man might not have succumbed not,
withstanding his poor condition.
Should have been drained.
16. O. O. M. September 2S, 1918: Shell
fragments. Wounds of legs and head, and penetrating, sucking
wound, left chest. Entrance over ninth rib below angle of scapula.
Moderate hemothorax. Heart displaced to right.
Foreign body in left lung. Duration 39 hours. Condition poor. Long
journey, exposure and anemia. Resuscitation five
hours. Operation: Forty-four hours after injury. Wounds in scalp and
thigh excised Wound of entrance to chest
excised. Fractured ninth rib resected. Hemothorax aspirated through
defect in parietal pleura. Inflation of lung
brought lacerations in left upper lobe into view which were bleeding
profusely and so were sutured. Foreign body
could be felt in lung but removal was not attempted as patient's
condition was critical. October 18, 1918: Uneventful
recovery. Diffuse pleuritis, left lung. No consolidation. Foreign body,
1.1 by 0.8 cm., present near hilum. Evacuated
in good condition. December 28, 1918: Returned to duty (three months).
No subsequent record. Disability
(estimated) 10 percent.
This
recovery when operation on a sucking wound had been delayed 44 hours
illustrates
the wisdom of denying none of the wounded the chance to live no matter
what the operative
mortality rate might be. It would have been wiser under the conditions
to have employed
primary drainage as the recovery without empyema was most fortunate
under the conditions.
17. S. G. October 12, 1918: Bullet,
through-and-through wound, left chest. Entrance at tip of left
clavicle;
exit at vertebral border of left scapula at level of its spine. "Small
hemnothorax. Hemoptysis. Mustard gas burns,
right side of face. Duration seven and a half hours. Condition good.
Operation: Six hours later. Wounds of entrance
and exit excised. Fracture of (?) rib resected. Muscle closed into
pleural defect to protect exposed lacerated but
adherent lung. Gutta-percha drain. October 14, 1918: Mustard gas burns
on face much worse. Few rHles noted in
right chest. Slight left pleuritic effusion. Evacuated in good
condition.
Official
records show death from bronchopneumonia (mustard gas) 25 (lays later.
Chest
disability would have been less than 10 percent.
18. H. B. October 15, 1918: Bullet,
through-and-through wound, left chest. Entrance over second rib
anteriorly; exit over fourth rib posteriorly. Moderate hemothorax.
Duration 16 hours. Condition poor. Operation:
Entrance and exit wounds excised. Fractured second rib anteriorly and
third and fourth ribs posteriorly resected.
Hemothorax aspirated. No lung repair. Pleura closed with muscle flaps.
October 16, 1918: Patient continues cyanotic.
Tachycardia. No increase in pleural effusion. Died at noon.
No necropsy. Death attributed to myocardial fatigue.
Less
extensive operation incompatible with recovery; more extensive not
indicated.
Digitalis before and after operation with hypertonic glucose
intravenously might have been
effective. May be called a lethal injury.
19. J. C. October 15, 1918: Bullet,
through-and-through wound, right chest. Entrance at inner end of
clavicle; exit beneath spine of right scapula. Small hemothorax. Much
bone damage. Condition grave. Duration 29
hours. Resuscitation 10 hours. Operation: Thirty-nine hours after
injury. Entrance wound ignored. Exit wound
excised. Scapula turned forward. Comminuted fracture of scapula and one
rib resected. Hemothorax
414
aspirated. No
lung injury repaired. Closure with superficial drainage. Stations
changed.
Learned of death but not its cause. No necropsy. Death
attributed to
shock.
Another
example of a simple injury made lethal by delay and exposure.
20. L. L. October 19, 1918: Shell fragments,
multiple wounds; compound fracture right femur; penetrating
right chest. Entrance eighth interspace posterior axillary line.
Foreign body, 2 cm. by 2 cm., immobile in right upper
chest. Small hemopneumothorax; heart displaced to left; middle and
upper lobes involved. No hemoptysis. Duration
20 hours. Condition serious. Operation: Entrance wound excised.
Fractured ninth and tenth ribs resected. Small
hemothorax. Clots and fibrin removed. Hole in lung sutured. Foreign
body not removed. Area of splenization not
resected because of lack of space. Closure .with superficial drain.
Wound of thigh excised. Compound fracture of
femur splinted. October 22, 1918: Pleuritic effusion increased and was
aspirated. Bronchopneumonia and pleurisy,
both lobes of left lung. Death. Necropsy: Bronchopneumonia left upper
and lower with fibrinous pleurisy. Right
lower lobe contained a tunnel wound in which were bone fragments;
widely splenized. Fibrinous pleurisy. Upper
and middle lobes normal.
This
man's chance for recovery depended upon his chest repair. It would have
been wiser
here to have opened the chest widely, excised the lower lobe and
neglected the thigh wound even
if this meant ultimate sacrifice of leg. Another example of the serious
import of splenization and
of contralateral bronchopneumonia.
21. R. H. November 2, 1918: Shell fragments,
left wrist; through-and-through wound, right chest. Entrance
wound upper anterior chest; exit, posterior. Small hemothorax.
Superficial wound left wrist. Condition good.
Duration 24 hours. Operation: Entrance wound excised. Lung adherent.
Closure with muscle flap. Exit wound
excised. Slight rib injury resected. Hemothorax aspirated. Closed
without drainage. Wrist wound dressed. November
11, 1918. Easy convalescence in spite of right-sided pleurisy and
return of partial pneumothorax. Evacuated. Could
not be traced.
A
more radical operation at exit would have repaired lung injury,
prevented recurrence of
pneumothorax, and reduced the pleuritic effusion which should have been
aspirated. Drainage
would have been better.
SUMMARY OF GROUP II
The
number treated by limited thoracotomv (21) was about 20 percent of the
series. The
number would have been larger had the unit had more of the less
severely injured to treat and
had the possibilities of such operations been appreciated.
Fatalities.-There
were eight deaths (40 percent). One (17), slightly wounded, died on
the
25th day from bronchopneumonia due to mustard gas. His chest disability
would have been less
than 10 percent. Three (8, 18, 19) were lethally affected at time of
operation because of delay
and exposure. One (18) died from myocardial exhaustion which had been
incurred before injury.
Three developed pyothorax (1, 14, 15). Two (1, 14) might well have
recovered had more radical
surgical treatment and primary drainage been employed. The third (15)
had advanced
contralateral pneumonia which possibly was traceable to failure to
drain. One (20) suffered from
other injuries, including a compound fracture of a thigh. Had the thigh
wound been given less
attention and the splenized portion of a lung resected, a recovery,
perhaps with amputation, was
conceivable. Duration from injury to operation was
415
from 9 to 39 hours,
average 23 hours. Mortality chargeable to surgical errors, too
conservative
treatment of injured lung, and failure to drain is 15 percent.
Disabilities.-Late
disability ratings are dependably established for 11 of the 13 who
recovered. Two (4, 5) made complete recoveries. Two (2, 6) are rated at
less than 10 percent;
five (7, 9, 10, 11, 16) at 10 percent; one (2) at18 percent, and one
(13) at 25 percent. Two (11,
12) have unjustly low ratings. The disability of one (13) is due to
cardiac incompetence. Two (3,
21) were not estimated. The average disability is probably not far from
10 percent, but is set at
13 percent to err on the safer side. The few notes available showed
from 39 to 180 days interval
before return to duty, average about100 days.
Pleuritis
is the cause of disability in all but the one (13) due to myocardial
deficiency. An
average disability of even 13 percent is gratifying when it be
considered that some of these
wounds were "suckers" and their duration about 24 hours, and also that
none received proper
postoperative care. The two who received unfairly low ratings had
complications, one (11) had
pneumonia and the other (12) a persistent pneumothorax and a lung scar
resulting from
splenization.
It
is again evident that a reduction of the interval between injury and
operation would
have reduced mortality and disability rates; the latter (13 percent)
would also have been
favorably influenced by less conservatism in operating, a more general
use of primary drainage
and constant after-care. The duration of disabilities estimated at one
hundred days upon the few
notes at hand is higher than the truth and avoidably high.
DEDUCTIONS
Operations
that can be classed as limited thoracotomies are applicable to those
wounds
that can not be safely treated by parietal excisions and to those
severely wounded who can
tolerate but little more than parietal excisions. The same methods,
especially positive pressure
gas analgesia, are indicated. Limited thoracotomy gives opportunity to
repair less significant
lung injuries, to aspirate pneumothorax with a cannula instead of a
needle and at times to remove
clots. Its disadvantages are incomplete exposures and the consequently
great dangers of
overlooking lesions that should be repaired. Its advantages are shorter
and less trying operations
and less interference with parietal integrity.
CONCLUSIONS
The
more severe the injury, the greater the necessity for prompt
intervention. Operations
of the limited thoracotomy type were employed too infrequently and
possibly can be used more
generallv and more effectively hereafter if the routine after care is
improved so that
postoperative complications would receive prompt recognition and
correction.
During
periods of active fighting many of the wounded who might be well served
by
limited thoracotomy could be transported to evacuation hospitals for
first treatment. A great
danger lies in too conservative operating upon lung wounds. The
objection to limited
thoracotomy is its ease and rapidity of performance
416
formance and apparent
safety when real conservatism would be a more radical operation.
The
need for preoperative resuscitation of those in shock and the
prevention of
postoperative shock becomes more and more evident. Gum acacia proved of
value when
properly used and was a source of danger when improperly used, which
was the rule. Hypertonic
glucose and other solutions may be of more benefit than gum and should
be provided. The most
help comes from blood transfusions. Larger amounts of blood should be
made available.
GROUP III. THORACOTOMY
OF NECESSITY
1. A. B. July 21, 1918. Shell fragment,
large, freely bleeding, sucking, tangential wound, left chest.
Entrance at fifth interspace, midelavicular line. Tissue emphysema.
Large pneumothorax. Small hernothorax.
Condition poor. Duration unknown. Operation: Lacerated soft parts
excised; broken ribs resected. Lung wounds
repaired. Flap closure. Death in 12 hours. Necropsy: Slight hemothorax.
Lung repair and parietal closures adequate
and apparently secure.
Multiple
transfusions might have prevented this death.
2. H. K. July 27, 1918: Shell fragments;
penetrating and through-and-through sucking wounds both chests.
Main wound entrance seventh rib, right scapular line; exit seventh rib,
left scapular line. Bilateral
hemopncumothorax, right larger. Condition (?). Duration unknown.
Operation: Entrance wound excised, exposing
sucking wound. Fractured seventh rib resected. Crater defect in lung
contained bone fragments. Fragments removed,
bleeding controlled, lung approximated over defect but incompletely as
man's condition contraindicated wider
exposure. Pleural defect closed with aid of wire rib stay. Superficial
wound drained. Wound of exit excised. No rib
damage. July 31, 1918: Good recovery. Postoperative tissue emphysema
showed that repair of lung wound had not
been airtight. Left side, effusion absorbed. Right side, effusion is
increasing. August 1, 1918: Spontaneous discharge
of serum from right side. Partial plletlmothorax. Evacuated in good
condition. February 1, 1919: Returned to duty in
180 days. Disability 10 percent.
Slightly
wider exposure, more accurate closure of lung wound, right-sided
drainage and
aspiration of left chest would have been wiser.
3. V. I. P. July 27, 1918: Shell fragment,
through-and-through, sucking wound, left chest. Entrance over 6th
rib lateral to mnidelavicular line; exit ninth rib, posterior axillary
line. Moderate hemothorax; heart displaced to
right. Splenized lung seen fluoroscopically. Condition (?). Duration 30
hours. Operation: Entrance and exit wounds
excised; fractured eighth and ninth ribs resected. Splenized lung
excised. Pleural closure effected with wire rib stay.
Layer closure. Superficial drain. July 31, 1918: Fluid in left chest
receding. Patient sitting upright. Evacuated.
Condition good. August 15, 1918:Pneumonia, left side, followed by
empyema and treated with rib resection.
Drainage tract closed spontaneously. February 8, 1919: Discharged from
Army. July 21, 1921: Under-weight,
languid, dyspneic. Scoliosis, reduced expansion, left chest; chronic
pleuritis, limited motion and adhesions of
diaphragm. Vital capacity 78 per cent. Disability 40 percent
(estimated).
Pneumonia
caused by compressed lung because of effusion.
Drainage
would have lessened, had it not prevented this complication.
4. T. B. B. July 28, 1918: Shell fragment,
through-and-through wound, left chest. Entrance seventh
interspace anterior axillary line; exit tenth rib posterior
axillaryline. Condition (?). Duration unknown. Operation:
Wounds excised; fractured ninth and tenth ribs resected; lacerated and
splenized portions of lower lobe resected.
Two tears in diaphragm sutured. Wound in liver not treated. Pleural
closure incomplete even with
417
rib stay so reenforced with muscle. July 31,
1918: Slight effusion; no peueinothorax. Motion of diaphragm reduced.
Evacuated. July 30, 1921: Pain and dyspnea on extraexertion. Chronic
pleuritis at left lease with adhesions between
dome of diaphragm and eighth rib. Excursions of diaphragm restricted.
Wire rib stay has parted. Vital capacity 81
percent. Heart competence slightly reduced. Disability rating of 35
percent is too high.
Wire
stay should have been removed. Primary drainage and postoperative
exercises
would have reduced disability.
5. M. D. August 1, 1918: Shell fragment,
penetrating right chest. Entrance wound ninth rib, paravertehral
line. Foreign body, two cm. by three cm., in lung, which is cloudy.
Moderate hemothorax; heart slightly displaced;
diaphragm immobile. Condition good. Duration (?). Operation: Entrance
wound excised; ninth rib, fractured just
anterior to its angle, reseated; heniothorax evacuated; foreign body
removed from posterior aspect lower lobe. Lung
wounds sutured. Pleura closed after ribs were approximated with wire
stay. Layer closure of soft parts. No drain.
July 21, 1918: Effusion to level of angle of scapula. Good condition.
Healing satisfactorily. Subsequently evacuated
ingood condition. No further treatment. January 31, 1921: Discharged
from service. August 19, 1921: Slight pain
and dyspnea on exertion. Fibrous pleuritis at right base. Diaphragm
adherent to eighth rib and excursions reduced.
Heart competent. Wire rib stay broken. Vital capacity 81 percent.
Disability of zero is too low.
Wire
rib stay should have been removed. Aspiration, or better still
drainage, would have
reduced pleuritis. Lack of proper exercises prevented a perfect
recovery.
6. M. P. August 1, 1918: Shell fragments,
multiple, penetrating, sucking wounds, right chest, liver and
colon. Entrance chest, ninth rib, anterior. Condition poor. Duration 10
hours. Operation: Resection compound
fracture ninth rib. Multiple lung wounds, liver and colon. Wounds
sutured as rapidly as possible because of man's
condition. August 2, 1918: Died. Necropsy: Hemothorax right,
splenization of middle lobe, collapse of lower lobe.
Wound repair adequate.
Lethal
injury at time of operation.
7. A. H. B.
August 1, 1918: Shell fragment,
left scapula, sucking, penetrating wound, chest. Bullet wound,
right shoulder, penetrating. Foreign body, 1.5 cm. by 3 cm. in left
utpper thorax. Chest hazy; diaphragm fixed.
Condition desperate. Duration 12 hours. Operation: Excision entrance
wound; resection left scapula and fractured
fourth rib. Excision and suture of bleeding wound in upper lobe.
Foreign body removed. Rib stay and muscle flap
closure. Bullet wound ignored as patient had been carried this far with
two gum-salt infusions. August 2, 1918:
Slightly better. Blood transfusion. Fluid up to angle of scapula.
Slight pneumiothorax. August 3, 1918: Condition
about the same. Unit moved to another station. August 5, 1918: Died. No
notes. No necropsy.
Severely
wounded man in shock. Death probably due to pyothorax. Should have had
primary drainage and blood transfusions before operation.
8. E. K. August 8, 1918: Shell fragments,
right wrist, superficial, and through- and-through, suicking
woIund, right chest. Entrance just to right of spine above angle of
scapula. Tissue emphysema here. Exit at second
rib midclavicular line. Right chest hazy. Condition poor. Weather hot,
water scarce, troops fatigued. Duration 12
hours. Operation: Entrance wound excised. Compound fracture eighth rib
resected. Lung adherent, lacerated and
contains many bone fragments, resected and repaired as well as exposure
and adhesions permitted. This area was
drained as there was no connection with pleural cavity. Exit wound
excised; fractured second rib resected. This tract
also drained for same reason. August 15, 1918: Pyothorax and septicemia
caused death. Aspirations, open drainage,
and transfusions were futile. No necropsy.
418
This
man was operated upon during a pestilence of flies that could not be
kept off
dressings or out of wounds; doubtful if it would have been possible to
avoid this death.
9. J. F. C. August 8, 1918: Shell fragments,
through-and-through wound, right arm and right chest. Notes
few and vague. Entrance at angle of tenth rib; exit, anterior aspect of
chest. Condition (?). Duration 55 hours.
Operation: Entrance wound excised; fractured tenth rib resected. Large
hemothorax and many clots removed. Lung
sutured. Pleural defect repaired by stitching diaphragm to margins.
Anterior entrance wound excised; rib not injured.
Tear in lung not found. Wire rib stay used to obtain closure of pleural
defect. Wound in arm excised and
packed with
gauze. August 17, 1918: Slight effusion persists. Evacuated in good
condition. August 17, 1921: Notes by Doctor
Byrne. "No parenchymatous lesions; dome of diaphragm adherent to
seventh rib is flattened." Disability, vital
capacity and myocardial competence unknown. Disability (?).
This
patient illustrated the need of breathing exercises to reactivate a
diaphragm,
particularly after it has been sutured to the parietes. An excellent
example of the wisdom,
accepting all risks with faintest chance for recovery. Without
operation this man's life
expectancy would have been zero.
10. W. B. August 8, 1918: Shell fragment,
large, penetrating, sucking wound, left chest. Entrance ninth rib,
costochondral juncture. Condition good. Duration unknown. Operation:
Wound excised; fractured ninth rib
resected. Foreign body, found on diaphragm which was lacerated, was
removed. Diaphragm sutured. Hemothorax
and clots removed. Lung and diaphragm sutured. Closure with wire rib
stay. August 17, 1918: Uncomfortable
convalescence. Slight pneumothorax. Pleuritic effusion moderate and not
aspirated. Suppuration occurred but did not
cause pyothorax because the repair of parietal pleura had been
adequate. Evacuated in good condition. February 13,
1919: Discharged from service having had otitis media which caused
deafness. August (?), 1920: Wire rib stay
removed. August 31, 1921: Some pain. No dyspnea. Underweight. Chronic
pleuritis left base; diaphragm adherent to
parietes. Reduced myocardial reserve power. Disability, 38 percent,
not all due to chest. Vital capacity, 78 percent.
Disability, 15 percent, due to chest, is liberal.
Wire
rib stay should have been removed earlier. Excellent example of
obtaining firm
parietal pleural healing to prevent pyothorax. Aspiration and breathing
exercises would have
limited disability.
11.
G. F. August 8, 1918: Shell fragment, perforating left chest. Entrance
below middle
of left clavicle; exit into soft parts beneath scapula. Condition poor.
Duration six hours.
Operation: Wounds excised; fractured ribs (second, third, and fourth)
resected. Laceration and
splenization left upper lobe. Laceration repaired; splenized lung not
resected. Hemothorax
aspirated. Pleural defect closed with muscle flaps. Posterior wound
drained after removal of
foreign body. Returned to shock ward with pulmonary edema. No
response
to treatment. Death
in 16 hours. Necropsy: Pulmonary edema, hypostatic congestion both
lungs. Dilatation, right
heart. Splenization left upper lobe. Suture line intact.
This
patient might have been saved, probably would, had he been wounded
later when
experience was larger. He would have been better prepared for
operation. Splenized lung should
have been resected. Too high positive pressures were used in a futile
attempt to reinflate lung.
Abruptly increased peripheral resistance added to that already present
sufficed to cause dilatation
of right heart and thus to provoke pulmonary edema.
12.
German soldier. August 8, 1918: Shell fragment, seton wound over
anterolateral
aspect sixth rib, left. Condition poor. Duration 56 hours. Operation:
Wound excised.
419
Fractured sixth rib resected. Lower one-half
of upper lobe and most of lower lobe splenize. Fibrinous exudate on
visceral pleura. Pleural cavity contained thin, red fluid
(streptococcus?). Pericardium used to assist closure of pleural
defect. Death soon after operation. No necropsy.
Illustrates
severe types of splenization caused by tangential injury without
laceration of
lung. Also shows the greater reactability of visceral pleura upon which
the fibrinous exudate had
been formed. It is doubtful if prompt operation could have prevented a
fatal issue because
removal of almost all of the left lung would have been necessary.
13. M. S. August 9, 1918: Shell fragment,
penetrating wound, left chest. Wound of entrance over sixth
costal cartilage at sternal articulation. Moderate hemopneumothorax.
Condition (?). Duration four hours.
Operation: Wound of entrance excised. Margin of sternum and sixth
costal cartilage resected. Hemothorax
evacuated. Foreign body removed. No notes on lung injury and repair.
Lung completely inflated. Closure difficult
because of a defect close to sternum. August 16, 1918: Interstitial
emphysema about wound and reappearance of
pneumothorax showed that pleural closure had been inadequate. Moderate
pleuritic exudate. By this time,
emphysema, pneumothorax and effusion all were less. Excellent general
condition. January 4, 1919: No further
operative treatment; indeed, none of any kind. Discharged from service.
Disability 80 percent. August 17, 1921:
Tachycardia and dyspnea follow
slight exertion. Frequent pain referred to lower left chest. Dome of
left diaphragm
adherent to parietes. Chronic pleuritis left base. Cardiac response to
exercise poor. Left heart enlarged. Vital
capacity, 55 percent.
Disability
due in part to myocardial incompetence which in part is attributable to
intrathoracic lesions. Rating of 80 percent is too high. Aspiration
after operation and suitable
care would have hastened convalescence and reduced disability.
14. E. K. K. August 11, 1918: Shell fragment,
perforating wound, left chest. Entrance second interspace just
lateral to sternum. Exit through scapula to lodge in infraspinatus
muscle. Condition poor. Duration five hours.
Operation: Excision entrance wound; resection second costal cartilage
and part of second rib. Hemothorax aspirated;
clots removed. Lung drawn out and perforation sutured. Lung sutured to
close defect in parietal pleura which could
not be approximated even with two wire rib stays. Foreign body removed
from infraspinatus muscle. No attempt
made to open chest posteriorly, as no rib injury was present and
patient's condition was poor. Despite blood
transfusions and infusions, patient died within 12 hours. Necropsy:
Moderate splenization left upper lobe. Posterior
perforation not closed. Hypostatic congestion right lung.
Extent
and duration of anatomic injuries and severity of operation do not
explain death,
which must be attributed to general and myocardial exhaustion previous
to injury. Splenization
should have been noted at operation.
15. W. S. August 12, 1918: Shell fragment,
penetrating wound, right chest. Entrance sixth interspace
anterolateral aspect. Condition good. Duration four hours. Operation:
Wound excised; ninth and tenth ribs,
fractured in posterior axillary line, resected. Tangential wound of
lung. Moderate splenization. Hemothorax
evacuated. Resection and suture of lung. Pleural closure obtained with
two wire rib stays. Layer closure of soft parts.
No drainage. August 17, 1918: Limited pleuritic effusion. Condition
excellent. November -, 1918: Returned to duty.
Disability less than 10 percent.
Aspiration
should have been performed. Wire rib stays should have been removed.
Despite errors and omissions in treatment, the man is reported to have
participated in active
fighting again.
16.
P. F. M. August 17, 1918: Shell fragments (three), penetrating wounds,
right chest. No notes on condition or duration. Condition probably
unsatisfactory, as was
420
the rule with the wounded from this division.
Moreover, the hospital facilities were wretched. For example, when
this man was treated the electrical plant was not working. There was no
X ray; no current for headlight. Operation:
Wound of entraiiec over tenth rib in midaxillary line excised;
fractured rib resected; pleural cavity opened widely
and heinothorax evacuated. Injuries to lung not severe. Two small
foreign bodies not removed. One perforating
wound of diaphragm and penetrating would of liver. Exploration failed
to locate foreign body. Tract in liver packed
with gauze which was brought out through laceration in diaphragm. The
diaphragm was then sutured to parietal
pleura for partial closure and to protect pleural cavity from bile.
Operation unsatisfactory cause of no headlight.
Balance of closure secured with aid of a wire rib stay. August 20,
1918: Condition excellent. Slight pleuritic
exudate. Evacuated shortly. February 28, 1919: Passed through several
hospitals in France. No further surgical
treatment until today when wire rib stay was removed. April 29, 1919:
Because of persistent pain two shell
fragments were removed from lung. September 18, 1919: Pain still
persists. Foreign body removed from liver.
August 4, 1921: Pain in lower right chest; dyspnea on exertion;
hemoptysis at intervals. Parietes affected
by sear and
removal of two ribs, one additional rib and part of sear from futile
removal of foreign bodies. Restricted expansion
of right lower chest; restricted motion of right diaphragm; chronic
adhesive pleuritis. Heart competent. Vital capacity, 66 percent.
Disability of 35 percent is fair.
Foreign
bodies might better have been removed at first operation, although they
did no
harm. Wire rib stay should have been removed in a few weeks. Subsequent
care would have
reduced disabilities. It is noteworthy that removal of foreign bodies
did not relieve pain,
introduced hemoptysis, an increased disability.
17. J. T. A. September 12, 1918: Shell
fragment, sucking, tangential wound, left chest; entrance fourth
interslace, left midaxillary line; exit ninth interspace, mid-scapular
line. Moderate hemopneumothorax; tissue
emphysema; heart displace to right; left diaphragm motionless.
Condition poor. Duration five hours. Operation
three hours later: Wounds of entrance and exit excised and united.
Fractured eighth and ninth ribs resected. Multiple
tears in parietal pleura. Wound of entrance in upper lobe not exposed.
Wound of exit, lacerated and contained many
bone fragments, was resected and repaired. Hemothorax removed. Closure
obtained with one wire stay; suturing
lung to parietes, vas unsatisfactory and assured subsequent emphysema.
Superficial closure also incomplete. Shock
prevented exact methods. September 21, 1918: Recovery in spite of
complications. Interstitial emphysema
developed, followed, as it commonly is, by suppuration, and finally an
open pyothorax. Evacuated in fair condition.
February 18, 1919: Suppuration continued. Ribs resected and wire stay
removed. July 7, 1920: Hospitalized for three
months because of suspected, but not proved, pulnmonary tuberculosis.
August 11, 1921: Underweight; frail; pain
and disability upon exertion. Parietal scars and defects limit
expansion of lower left chest. Pericardium adherent to
diaphragm and diaphragm to parietes; pleural thickening. Heart
competent. Vital capacity, 106 per cent. Disability
rating of 75 per cent is higher than findings warrant.
A
more finished operation should have been performed to secure better
healing. Drainage
could have been employed to reduce dangers of pyothorax. This patient
illustrates the harm
coming from provisional suturing of sucking wounds. His after-care was
not satisfactory.
18.
F. F. September 12, 1918: Shell fragment, perforating wound, left
chest. Entrance
posterior axillary fold at level of angle of scapula. Foreign body, .4
cm. by 1 cm., in erector
spinae muscles. Condition (?). Duration six hours. Operation: Entrance
wound excised.
Fractured ninth rib resected. Hemothorax evacuated. No lung injury
seen. Second incision
posteriorly over shell fragment failed to discover tile foreign body
but revealed more serious rib
injuries. A third incision made lateral to the second. Rib fractures
resected; pleura opened,
revealing tangential injury in lung containing bone fragments.
Fragments removed; lung resected
and sutured; more blood and many large clots
421
removed. Closure obtained with One rib stay.
September 21, 1918: Some pneumothorax persisted. Slight pleuritic
effusion absorbed after aspiration of 75 c. c. sterile bloody fluid.
Temperature varied from 99 0 to 102 0 in spite
of
smooth healing; 97 0 on evacuation. 1921: Records show
disability less than 10 per cent.
Another
illustration of the more serious injury occurring at exit wound and of
the wisdom
of thorough exploration of all possible parietal injuries. Had the
posterior wound been neglected,
pyothorax and possibly death would have occurred. The wire rib stay
should have been
removed.
19. J. R. September 12, 1918: Shell fragment,
penetrating wound, left chest; entrance lateral to spine at
level of tenth rib. Foreign body in lung (3.5 cm. by 3.5 cm.).
Considerable hemothorax. Shock treatment. Duration
unknown. Operation: Entrance wound excised. Fractured ribs resected.
Entrance wound into lung not found. Foreign
body not removed because patient's condition was critical. Large
hemothorax evacuated. Closure with wire stay
unsatisfactory. Prognosis for healing, poor. Shock treatment. September
21, 1918: Stormy convalescence.
Superficial suppuration but no open pyothora. Pneumothorax with
pleuritic effusion; 600 e. c. serosanguinous fluid
aspirated and superficial drainage instituted. Convalescent four
months. Final records not available. Estimated
disability 15 percent.
Attempt
should have been made to repair entrance wound into lung. Primary
drainage
should have hastened recovery.
20. H. W. September 12, 1918: Shell
fragments, multiple wounds, viz, compound fracture upper third,
right tibia, foreign bodies in knee, calf and thigh; sucking wound,
left chest. Entrance at eighth rib, anterior axillary
line; foreign bodies in upper left chest and below dome of diaphragm,
thought to be in lung tissue. Hemoptvsis and
hematemesis. Condition so
critical that thorough examination was impossible. Shock treatment for
eight hours
before operation. Duration (?). Operation: Wounds in extremities
excised and foreign bodies removed. Entrance
wound into chest excised. Fractured eighth rib resected. Foreign body
not found. Search for perforation in diaphragm
unsuccessful. Large hemothorax evacuated. Closure with one wire stay.
Transfused. September 13, 1918: Condition
continued fair until sudden weakening at noon. Transfusions unavailing.
Died at 2.30 p. in. Necropsy: Peritonitis,
lesser cavity, hemoperitoneum, through and through wounds of spleen and
stomach. Chronic nephritis.
This
patient's condition was so critical that preoperative examinations were
restricted. Intra-abdominal injuries were suspected but a laparotomy
was impossible. His one chance was
that he could take care of his peritoneal wounds spontaneously. His
injuries were lethal when he
reached the hospital.
21. H. B. (German soldier). September 13,
1918: Shell fragment, perforating wound, right chest. Entrance,
ninth rib posteriorly; foreign body beneath right clavicle. Condition
fair. Duration 15½ hours. Operation: Entrance
wound excised. Fractured ninth rib resected. Upper lobe adherent,
previous pleurisy. Lower lobe, craterlike defect, excised and sutured.
Hemothorax evacuated. Wire rib stay. Inflated lung sutured into
parietal pleural defect. Foreign
body removed from beneath clavicle. No rib injury. Closure without
drainage. September 21, 1918: Evacuated;
condition excellent. Disability estimated at 10 percent.
22. M. R. S.
September 17, 1918: Bullet,
through-and-through wound, right chest. Entrance just below
angle of scapula; exit just above nipple, both sucking. Slight
hemothorax. Condition good. Duration unknown.
Operation: Entrance wound excised. Ninth rib, incompletely fractured,
resected. Large laceration, lower lobe,
resected and repaired. Hemothorax evacuated. Pleural repair incomplete.
Lung sutured into defect. Wound of exit
excised. No rib injury. Lung wound closed with purse-string suture and
sewed into parietal defect. September 20,
1918: Condition remarkably good. Healing excellent. 1921: Records show
disability of less than 10 percent.
422
Treatment
given to this man was effective except for postoperative exercises.
Another
example of the value of exploring all through-and-through bullet wounds
even though the
wounded are in splendid condition.
23. O. B. (German soldier). September 13,
1918: Shell fragment, through-and-through wound, left chest.
Entrance below outer third of clavicle; exit below angle of scapula.
Condition (?). Duration unknown. Operation:
Excision of entrance and exit wounds revealed fractures of second,
third, fourth, fifth, sixth, seventh, and eighth ribs
in axillary line. Resected ribs exposed deep gutter wound in left upper
lobe which was adherent and made lung
resection and repair difficult. Large hematoma evacuated from beneath
pectoralis major muscle. Plastic closure.
September 20, 1918: This man's recovery was remarkable. None others
survived such severe multiple rib injuries.
Another example of the wisdom of operating despite unfavorable
prognosis.
24. H. D. B. September 26, 1918: Shell
fragments, through-and-through wound, left thigh, and penetrating
wound, right chest. Foreign body, 8 cm. by 10 cm., beneath lower
sternum. Entrance posteriorly over twelfth rib.
Condition (?). Duration five hours. Operation two hours after
admission: Through-and-through wound left thigh excised and drained.
Large entrance wound of chest excised. Fractured eleventh and twelfth
ribs resected. Foreign
body had lacerated diaphragm and liver and lodged in diaphragm beneath
sternum. No lung injury. Bile in pleural
cavity. Large hemothorax removed, likewise foreign body. Wounds in
diaphragm sutured. Drain inserted between liver and diaphragm and
diaphragm sutured to parietal pleura to aid in closure and to exclude
drain from pleural
cavity. October 8, 1918: Satisfactory convalescence. Slight pleuritic
effusion. Suppuration in superficial wound but
no open pyothorax. Disabled for six months. Ultimate disability less
than 10 per cent (estimated).
Delayed
recovery due to lack of proper exercise. Primary drainage indicated
because of
bile in pleural cavity and tendency to cause empyema.
25. C. P. F. September 26, 1918: Shell
fragments, through-and-through wounds, left arm near axilla, and
left chest. Entrance, seventh interspace, midaxillary line; exit, tenth
interspace midscapular line. Paresis of flexors of
first finger. Moderate hemopneumothorax. Heart displaced to right.
Condition poor. Resuscitation 6½ hours.
Duration 11 hours. Operation: Excision wound in upper arm; suture of
injured nerve trunk. Wounds of entrance and
exit excised and joined. Fractured tenth rib resected. Lacerations in
lower lobe and in diaphragm repaired. Parietal
closure without drainage. September 29, 1918: Condition and healing
satisfactory. July 28, 1921: Duly severe
symptoms referable to arm. Slight fibrous pleuritis, left base;
diaphragm free. Vital capacity 97 percent. Disability
(chest) zero.
Operation
not only protected this man from death, but initiated a perfect
recovery.
Illustrates advantage of exploring all wounds and giving deep injuries
proper treatment.
Thoracotomy, even when patients are in poor condi- tion, can be less
dangerous than
hemothorax.
26. W. S. September 26, 1918: Bullet,
penetrating left chest; entrance, third interspace, parasternal line.
Bullet beneath sternum moves with respiration, but not with heart beat.
No hemoptysis. No hemothorax. Friction rub
audible over precordium. Mediastinal emphysema (?); hemopericardium
(?); pulse slow but irregular. Condition
fair. Duration five hours. Operation six and one half hours later:
Entrance wound excised. Bullet found with its nose
penetrating the wall of a serous cavity, probably pericardial. Bullet
removed and hole closed with suture. Path of
bullet extrapleural. Wound closed tight. September 29, 1918: Signs and
symptoms cleared since operation. Healing
excellent. 1921: Disability less than 10 percent.
Removal
of this foreign body was required. Result shows methods were good.
27. M. J. T. September 29, 1918: Bullet,
through-and-through, sucking wound, right chest. Entrance, ninth
rib, posterior axillary line; exit, slightly lower in anterior axillary
423
line. Both plugged with gauze. Hemoptysis.
Moderate hemopneumothorax. Resuscitation for four hours. Duration
nine hours. Operation: Entrance and exit wounds excised and joined.
Portion of ninth rib, found dangling into pleural
cavity, removed, and ends of ninth rib resected. Gutter wound in lung
excised and sutured. Lung could not be
entirely reinflated, so stitched to parietes. Large hemothorax
evacuated. Closure unsatisfactory. Patient's condition
prevented a finished operation. Given 700 c. c. of gum salt solution on
operating table. October 18, 1918:
Complicated convalescence ending in open pyothorax. December 1, 1918:
Drainage ceased. No further operations.
July 29, 1921: Suffers from pain and dyspnea on moderate exertion.
Chronic pleuritis. Diaphragm attached high to
parietes. Myocardial competence slightly impaired. Vital capacity, 77
percent. Disability allowance of 20 percent is
low.
Partial
inflation of lung at operation indicated need of one-way drainage, as
it suggested
probable empyema. Even this imperfect operation, made possible by
exploration, contributed to
recovery as it eliminated bone fragments and osteomyelitis of ribs as a
complication of
empyema.
28. C. H. September 26, 1918: Bullet,
perforating wound, right chest. Entrance close to spine at level of
angle of scapula; exit from chest at second rib to lodge beneath the
skin. Small bemothorax. Condition poor.
Duration 14½ hours. Operation: Sixteen hours later; delay for
resuscitation. Wound of entrance excised. Incision
made to remove foreign body. Wounds united. Fractured second, third,
fourth, fifth, and sixth ribs resected. Parietal
pleura lacerated; visceral pleura intact. Hemothorax (1,500 c. c.)
removed. Airtight pleural repair. Wound closed
without drainage. October 2, 1918: Rapid recovery. Healing smooth.
August 19, 1921: No treatment subsequent to
operation. Pain with sudden exertion. Overweight. Myocardium competent.
Restricted parietal mobility due to
malunion of fractured ribs. Vital capacity 87 per cent. Disability of
20 per cent is high.
No
better results obtainable without after-care. Removal of rib fragments
and immediate
reinflation protected this man against empyema and pulmonary
compression.
29. T. E. L. September 26, 1918: Bullet,
through-and-through wound, right chest. Entrance at level of
twelfth rib posteriorly; exit at fifth interspace, anterior axillary
line. Moderate hemothorax. Paralysis of right
diaphragm. Hematuria. Condition fair. Dura- tion nine hours. Operation
four hours later: Entrance wound excised;
incision carried along twelfth rib, which was fractured and was
resected. Kidney delivered. Subeapsular clots
removed and large transverse tear repaired. Laceration in liver drained
and in diaphragm sutured. Hemothorax
evacuated. Puncture wound of lung not repaired. Parietal pleura closed.
Exit wound excised; no rib injury found.
Closed tight. October 18, 1918: Good recovery. Slight amount of
pleuritic effusion. Free drainage of urine and bile,
but temporary. Evacuated in good condition. Later suffered from
influenza. July 30, 1921: Complains of pain and
weakness in right chest. Some fibrosis of lower lobe of lung. Diaphragm
but little affected. Pronounced scoliosis.
Vital capacity 92 per cent. Disability rating 100 per cent is
ridiculously high. Needs only vocational training to be
self-supporting.
Suitable
postoperative care would have reduced this man's disability and enabled
him to
enter a profitable occupation.
30. J. A. September 27, 1918: Bullet,
perforating, sucking wound, right chest. Entrance over eleventh rib,
midscapular line; exit through diaphragm into liver. Large hemothorax.
Condition fair. Duration 14 hours.
Operation: Twelve hours later: Entrance wound excised; fractured
twelfth rib resected. Perforations in lower lobe,
diaphragm and liver repaired. Foreign body not found. Hemothorax,
bile-stained, evacuated. Closure unsatisfactory.
October 3, 1918: Residual pneumothorax absorbed. Slight pleuritic
exudate. Condition good. July 29, 1921:
Suffered from influenza before leaving France. Otherwise recovery
without complications or after-care. Complains
of pain in right chest
424
and is easily fatigued. Cardiac competence is
fair. Fibrous pleuritis at right base. Dia- phragmatic excursions
limited
by adhesions. Disability of 20 percent is adequate.
Recovery
by good fortune. Bile in pleural cavity usually produces an intense
reaction and
needls primary drainage.
31. C. C. September 26, 1918: Bullet,
penetrating, sucking wound, right chest. Entrance, sixth interspace,
midaxillary line, lodgment back of heart. Condition wretched. Blood
pressure 68/50. Duration 9½ hours.
Resuscitation treatment, pressures raised in 3 hours to 90/65.
Operation: Eleven hours later: Entrance wound
excised; fractured sixth rib resected. Three holes in lung repaired;
fourth could not be reached. Bullet removed from
behind heart. Difficulty in checking hemorrhage from azygos vein.
Large, clotted hemothorax removed. Tight
closure obtained. Gum salt given at close of operation. October 10,
1918: Developed contralateral pneumonia after
operation. Empyema developed; wound opened revealing a bronchial
fistula, the probable cause of empyema and
possibly attributable to unclosed perforation. Death fourteenth day. No
necropsy.
Man's
condition thought to be too precarious to justify opening chest widely
enough to
repair fourth perforation. This might have saved life. So far as known
this is the only bronchial
fistula that occurred. This is an excel- lent example of resuscitation.
32. G. S. (German soldier). September 27,
1918: Shell fragment, sucking, penetrating wound, right chest.
Entrance over tenth rib anterior axillary line. Foreign body three cm.
by three cm. lodged in liver. Large
pneumolielnotlhorax. Condition (?). Duration 25 hours. Operation 5
hours later: Entrance wound excised; fractured
rib resected. Hemothorax removed. Two holes in lower right lobe
sutured. Foreign body removed from liver; hole in
diaphragm sutured. Wound closed without wire rib stay. September 30,
1918: Aspirated; no fluid obtained. October
6, 1918: Wound ruptured; seropurulent fluid escaped. Tube inserted; end
covered with gutta-percha valve. October
18, 1918: Evacuated in good condition. Lung expansion excellent.
Sucking
wound, 30 hours old; bile in pleural cavity; all indicated primary
drainage. Rupture of incision from within of wound closed without rib
stay indicates the value of that
suture.
33. M. L. September 28, 1918: Bullet,
through-and-through wound, right chest. Entrance, third rib,
parasternal line; exit, costal margin, anterior axillary line from
which bile was escaping. Condition poor. Duration 38
hours. Operation: Entrance wound ignored. Fractured sixth, seventh, and
eighth ribs resected. Hemothorax
evacuated. Holes in lung and diaphragm sutured. Drainage to liver
wound. No notes on convalescence or at
discharge. January 7, 1919: Small amount of fluid aspirated. August 28,
1921: Pain and dyspnea only after sharp
exertion. Fibrous pleurisy. Diaphragm fixed. Costophrenic sulcus
obliterated. Disability 20 percent. Vital capacity
71 percent.
This
man's condition prevented complete operation. Had primary drainage
been used
with proper after care disability would have been less. Aspirated
second day, vet fluid was
withdrawn four months later. An example of slow absorption of effusions
as well as the wisdom
of operating even if there has been delay.
34. S. D. September 28, 1918: Bullet,
through-and-through wound, left shoulder and chest. Entrance just to
left of vertebra; exit, high in axilla. Condition very poor. Duration
23 hours. Operation: Seven hours later. Wounds
excised; fractured second and third ribs resected. Laceration in lung
repaired. Large hemothorax evacuated. Closure.
Blood transfusion. Died in one hour.
425
Earlier
operation would have been effective. Other risks quite as forbidding
had
recovered.
35. H. H.
September 28, 1918: Bullet,
through-and-through, both wounds sucking, left chest. Condition
poor. Duration 36 hours. Operation: Resection sixth, seventh, and
eighth ribs. Excision of splenized ling; suture of
hole in pericardium; repair of laceration in diaphragm; evacuation of
hemothorax. Closure. Five hundred c. c. gum
salt for shock. Death in two hours. Necropsy: Small amount of blood in
pericardium. Left lung partially collapsed.
Splenization incompletely removed. (Exposure inadequate at operation.)
This
man's death due to delay and exposure, as he could have been saved with
early
operation. Another example of the necessity to secure adequate exposure.
36. F. McC. September 29, 1918: Shell
fragment, through-and-through, sucking wound, right chest.
Entrance below sixth rib, anterior axillary line; exit over eleventh
rib below scapula. Condition bad-cold and
shocked. Duration 10 hours. Operation: Three hours later. Entrance
wound not treated. Exit wound excised;
fractured rib resected. Lower lobe lacerated; contained indriven rib
fragments and was bleeding profusely.
Fragments removed; sutured; chest closed tight. October 2, 1918: Wound
opened spontaneously; discharged 300 c.
c. turbid fluid containing streptococci. October 5, 1918: Dyspneic,
cyanotic, delirious. Contralateral pneumonia.
October 6, 1918: Died. Necropsy: Purulent bronchitis, right; fibrinouss
pleuritis, right; collapse and splenization of
lung, right; massive bronchopneumonia, left; pericarditis; vegetative
endocarditis; infarction of kidney.
Man's
condition prevented extensive operation. The small chance there was was
forfeited
by failure to drain.
37. J. A. L.
September 30, 1918: Shell
fragment, penetrating wound, right chest. Entrance, seventh rib,
posterior axillary line. Large hemothorax. Condition grave. Duration 55
hours. Operation: Five hours later. Wound
excised. Perforated rib resected. Hemothorax evacuated. Much bile
present. Foreign body in liver. Thick fibrinous
pleuritic exudate. Liver tear repaired. Diaphragm sutured. Man too low
to stand further operation. Peritonitis present.
October 5, 1918: Homolateral bronchopneumonia. October 6, 1918: Died.
Necropsy: One thousand three hundred c.
c. fluid in chest; lung collapsed. Tract of projectile in liver led to
large thrombosed vein. Foreign body found,
covered with fibrin, Iying between columiiiae cariiete of right
ventricle.
Lethal
injury at time of operation after 60 hours. Early and more complete
operation
would have saved him.
38. O. W. September 30, 1918: Bullet,
penetrating wound, sucking, right
chest. En- trance, seventh interspace, posterior axillary line.
Condition bad. Duration 66 hours. Operation
four hours later: Entrance wound excised; fractured eighth, ninth, and
tenth ribs resected.
Pleural cavity cleaned and closed. October 4, 1918: Incision opened
spontaneously. October 5,
1918: Died. Necropsy: Lower lobe collapsed except where splenized.
Empyemia. Wounded
lung contained bone fragments.
Lethal
injury at time of operation after 70 hours. Illustrated a common error.
Operation
should be sufficiently radical to give chance for recovery even at risk
of death on table Early,
complete operation would have saved.
39. C. K. October 14, 1918: Shell fragment,
perforating vound, left chest. Entrance, eighth interspace,
midaxillary line; exit, eighth interspace, midscapular line. Foreign
body under skin. Moderate hernopneunmothorax.
Condition good. Duration 8 1/2 hours. Operation: Excision of entrance
wound. Fractured ninth rib resected. Bone
fragments driven into diaphragm, which was repaired and sutured into
defect to close pleura after evacuation of large
hemothorax. Foreign body removed. 1921. Records available. Disability
less than 10 percent.
426
Early
operation led to prompt recovery.
40. (German soldier.) October 12, 1918:
Bullet wounds, right arm, and penetrating, right chest. Entrance
over tenth rib, posteriorly. Condition poor. Duration 54 hours.
Operation: Amputation arm; gas gangrene. Excision
of entrance wound; resection fractured tenth rib. Repair of lacerated
diaphragm. Evacuation of hemothorax. Closure.
Death within a few hours.
Injury
lethal at time of operation.
41. H. C.
October 15, 1918: Shell fragment,
sucking, penetrating wound; right chest. Entrance, third rib,
high in axilla. Condition poor. Duration 28½ hours. Resuscitation 72
hours. Operation: Entrance wound excised;
fractured third rib resected. Oldpleuritic adhesions and patient's
condition made radical operation impossible.
Foreign body in upper lobe not sought. Hole in lung sutured. Gauze
drain. October 29, 1918: Died. Necropsy:
Abscess in lung and liver.
Rare
instance of abscess forming about foreign body. Hole in lung should
have been left
open. Fear of bronchial fistula is not well founded.
42. W. L. October 15, 1918: Shell fragment (1
by 1.2 cm.), penetrating wound, right chest. Entrance
through middle of clavicle; lodgment in right, upper lobe. Condition
poor. Duration 22 hours. Operation three hours
later: Entrance wound excised; com- minuted fractures of clavicle,
first and second ribs resected; fragments
removed from lung. Lung repaired. Hemothorax evacuated. Pleural defect
closed with muscle. Died during night;
cause unknown. No necropsy.
Severe
injury made lethal by exposure and delay.
43. L. B. October 15, 1918: Bullet,
through-and-through, sucking wound, left chest. Entrance just above
left
nipple; exit, ninth rib, paravertebral line. Moderate hemothorax.
Condition poor. Duration 24 hours. Operation:
Entrance wound not treated. Exit wound excised; fractured ninth rib
resected; wound in lower lobe sutured; pleura
closed; no drainage. October 16, 1918: Died. Cause of death probably
shock.
Another
moderately severe injury made lethal by exposure and delay.
44. J. K. November 1, 1918: Bullet,
through-and-through, sucking (exit) wound, right chest. Entrance in
anterior axillary fold; exit above eighth rib, paravertebral space.
Small hemopneumothorax. Condition (?). Duration
11 hours. Operation one and one-half hours later: Wound of entrance
untreated as it was found to be smooth on
inside. Exit wound excised. Fractured eighth rib resected. Liquid and
clotted blood removed. Wounds of entrance
and exit in lower lobe sutured. Wounds in upper lobe not found.
Parietal pleura closed fairly accurately with aid of
one wire rib stay. November 16, 1918: Convalescence stormy. Despite
aspiration, wound broke down from within
with spontaneous discharge of pyothorax. Had asthmatic attacks.
Returned to duty in 90 days. Disability (estimated)
10 percent.
Imperfect
closure of parietal pleura is always a source of danger. Fortunately,
this rupture
occurred after adhesions had formed so that collapse was obviated.
Primary drainage was
indicated.
45. A. R November 2, 1918: Bullet,
through-and-through wound, left chest. Entrance, fifth interspace,
posterior axillary line; exit, ninth rib, midscapular line. Slight
interstitial emphysema about exit wound. Fluoroscope
revealed moderate hemopneumothorax; fracture of ninth rib and
involvement of left lower lobe. Condition fair.
Duration 11 hours. Operation: Exit wound excised; shattered rib
resected; pleura opened widely; many rib fragments
removed. Splenized and lacerated lower lobe resected and sutured after
evacuation of hemothorax. Wound of
entrance found on internal examination to be smooth so not disturbed.
One wire rib stay. Pleural closure incompleted
so reinforced with muscle. November 8, 1918: Uneventful recovery. Wire
rib stay removed. November 11, 1918:
Evacuated in excellent condition. No further records obtainable.
Disability estimated at 10 percent.
427
Treatment
here was good. Illustrates the wisdom of attacking worst wound first
and
thoroughly, and letting the internal examination determine whether any
further operation is
needed. Early removal of wire rib stay was beneficial. Resection of
injured lung assured
recovery. Primary drainage had been safer because pleural closure was
inadequate and pyothorax
would likely have led to spontaneous opening.
46. F. K. November 2, 1918: Multiple wounds;
shell fragments, one, through-and-through, three penetrating
right chest; one bullet, penetrating abdomen. Chest woundsucking and
emphysematous. Condition poor. Duration
unknown. Prolonged resuscita-tion. November 3, 1918: Operation: Exit
wound over ninth rib excised and fractured
ribresected. Wounds in lower lobe sutured. Two wounds in diaphragm
sutured to excluded herniated and wounded
liver, in which foreign body was not sought because of patient's
condition. Bile-stained hemothorax evacuated.
Drained with tube armed with flap valve obtained from gas mask. Fair
approximation of pleura. Skin closure not
attempted because of empyema. November 4, 1918: Died in spite of
attempts at resuscitation. Necropsy: Valve
drain had functioned perfectly. Wounded lung inflated notwithstanding
pulmonary edema. Bullet found in
retroperitoneal tissues, only injury to kidney. Death due to myocardial
incompetence.
Severe multiple injuries with cold and
exposure made condition lethal by time of admission to hospital.
Recovery with early operation possible. Operative treatment good.
47. J. R. A. November 2, 1918: Shell
fragment, through-and-through, left chest. Entrance, third interspace,
nipple line; exit, seventh rib, posterior axillary line. Wounds dirty.
Condition serious. Duration 27 hours. November
3, 1918: Operation: Both wounds excised. Fractured rib at exit
resected. Bone fragments in lung. Four injuries
repaired. Liquid and clotted hemothorax (800 c.c.) removed. Both
pleural reflections hemorrhagic. Entrance wound
on inner aspect not examined. Pleural closure satisfactory. Operation
hastened and terminated by patient's condition.
November 5, 1918: Never regained strength. Seven hundred and fifty c.c.
thin, bloody fluid aspirated. Streptcoccus
(?). Cyanosis and dyspnea. Died. Necropsy: Left chest contained 500
c.c. thin, bloody fluid. Fibrinous pleurisy.
Pericarditis with effusion. Acute dilatation of right heart; pulmonary
edema. Fracture of fourth rib at entrance
wound.
Wounds,
not of themselves lethal, had become so through cold and delay.
Recovery was
easily attainable with early operation. Drainage should have been
employed, but could not have
altered, merely postponed, the outcome.
48. J. C. November 2, 1918; Bullet wound,
through-and-through, right chest. Entrance, sixth interspace,
midaxillary line; exit, twelfth rib, paravertebral line. Moderate
hemothorax. Mitral insufficiency. Dirty wounds.
Condition poor. Duration 46 ½ hours. Operation: Entrance wound
excised; no rib injury. Exit wound excised;
fractured eleventh rib resected. Large hemothorax removed. Laceration
in diaphragm and upper pole of kidney
repaired. Lung inflated and laceration repaired. Pleura closed tight.
Gutta-percha drain to kidney and liver.
November 7, 1918: Developed jaundice, edema of extremities and
pleuritic effusion. Died. Necropsy: Large pleuritic
effusion. One laceration in diaphragm had been overlooked. Acute
diffuse hepatitis. Liver wounds necrotic. Acute
fibrinous pericarditis.
Another
reparable injury made fatal by delay. Line far in advance and
transportation of
wounded almost impossible. Drainage should have been employed.
49. A. D. November 4, 1918: Bullet,
through-and-through wound, left chest. Entrance above left clavicle;
exit, ninth rib, paravertebral line. Large hematoma at entrance
wound. Left radial pulse absent. Condition poor.
Duration (?). Operation:
428
Wound of exit
excised
and fractured ninth rib resected when patient stopped breathing. Oxygen
had given out. Injection of adrenalin into heart and direct massage
started cardiac contractions.
Incision closed. Death in two and one-half hours. Necropsy: Hematoma at
entrance wound and
absent radial pulse due to section of subclavian artery.
Positive
pressure analgesia too rich in nitrous oxide when oxygen supply failed.
Cardiac
resuscitation not prompt enough to save central nervous system from
fatal degeneration. Man
was probably lethally injured.
SUMMARY OF GROUP
III
Operations,
called thoracotomies of necessity, were performed upon 49, or
approximately
55 percent of the series. Included are many of the most serious
wounds, thus treated because
more ideal methods were impossible not- withstanding the exposures
obtained were inadequate
for deep repair.
Fatalities.-There
were 22 deaths, mortality rate of 45 percent. It is noteworthy that
the
mortality rate in the first half of the series is 32 percent and in
the second 58 percent despite the
fact that after greater experience the later treatments were better.
The difference is due to the
colder weather, rain, and greater difficulties in transportation.
One-half
of the deaths occurred within 24 hours after operation. One (1) was due
to acute
anemia and could have been avoided with multiple transfusions; one (11)
was due to too high
positive pressures; one (49) to too high concentration of nitrous oxide
(failure of oxygen supply)
in the administration of analgesia. Four (6, 12, 14, 46) had received
injuries sufficiently serious
to cause death even if treated promptly. Operation was performed 10,
56, 5, and 24 hours after
injury; average 26 hours. Five (34, 35, 40, 42, 43) had received
injuries not severe enough to
jeopardize life if promptly relieved, but were rendered lethal by
exposure and delay. Operation
was performed 30, 36, 54. 25, and 24 hours after injury; average 33
hours.
Two
(20, 47) of the half of deaths that occurred more than 24 hours after
operation took
place within 3 days. One (20), within two days, was lethally injured,
the other (47), within three
days, had become fatally affected by delay. The balance (7, 8, 31, 36,
38, 39, 41, 48) survived
operation from 5 to 14 days. Five developed pyothorax (7, 8, 31, 36,
38), which was due to
incomplete opera- tion, e. g., failure to excise splenized lung (38),
to close a bronchial fistula
(31). the only one in the series, and to institute primary drainage.
The average duration before
operation was 34 hours. One (37) died because a shell fragment that had
not been removed from
a liver was transported to the heart and contributed to a fatal
septicemia. Another shell fragment
not removed from a liver (42) caused a fatal acute hepatitis. A shell
fragment in a lung (41)
caused a lung abscess because the track was sutured; this was the only
lung abscess noted.
Four
deaths were caused by obvious surgical errors-a failure to
transfuse(1), too high
pressures with administration of anesthetic (11), too high
concentration of anesthetic (49), and
suturing instead of draining the tract of a foreign body in an adherent
lung (41).
Five
deaths which occurred in the second half (31,36,37,38,48) were operated
upon on
the average of 43 hours after injury. None were given the benefits of a
429
complete operation, yet
they survived on the average one week. Operation was hurried and
unfinished in each instance because condition of the individuals was so
poor. Hindsight seems to
teach that one or two might have survived, if at the cost of greater
immediate risk an opportunity
for ultimate recovery had been provided. Mortality chargeable to
surgical errors and accidents
(limited supply of blood for transfusions, exhaustion of supply of
oxygen, use of too great
positive pressure in analgesia, closure of tract in lung, failure to
complete operations in spite of
impending death and to use primary drainage) is 13 percent.
Disabilities.-Late
disability ratings are available for 23 of the 25 survivors. Two were
zero (5, 25); six less than 10 percent (15, 18, 22, 24, 26, 39); four
at 10 percent (2, 21, 44, 45);
two at 15 percent (10, 19); two at 20 percent (27, 28); two at 35
percent (4, 16); one at 40 percent (3); 75 percent (17); 80 percent
(13); and 100 percent (29).
Two ratings are low (25, 27)
and five are high (4, 13, 17, 28, 29) as shown by physical examination,
fluoroscopy, resistance
exercises and estimations of vital capacity.
According
to the figures the average disability was 21 per cent. This is higher
than the
facts would justify, but is accepted to be safe. Only four were
returned to duty, 2 in 90 days (15,
39) and 2 in 180 days (2, 24), giving an aver- age of 135 days, which
also is too high, but may
be accepted as a safe estimate.
Pleuritis
remains a constant factor in producing disability, but there is added,
because of
the increased severity of injuries, greater interference with parietal
integrity, notable in multiple
rib injuries, more frequent diaphragmatic lacerations, and greater
destruction of lung tissue
requiring resections. Like- wise more complicating lesions
appear--liver, kidney, pericardium,
and peritoneum. A disability rating even of 21 percent is not entirely
discreditable when it be
considered that the average duration before operation was 19 hours and
that none of these men
received proper after-care. The evil effects of pre-operative delay in
the more serious injuries is
apparent. Those who recovered with disabilities of 20 percent or less
were operated upon in 15
hours on the average; those above 20 percent in 27 hours.
It
was noted above in discussing fatalities that more finished operations
and more
frequent use of drainage would have reduced the mortality rate. The
same applies even more
directly to reductions in duration and extent of disabilities because
sucking wounds are common,
soiling of pleura with bile is frequent, and with urine is occasional.
The need for better
immediate and continued after-care is self-evident.
DEDUCTIONS
Thoracotomies
of necessity will be performed upon the less severely injured when
parietal excisions and limited thoracotomies reveal unexpected lesions
that require more radical
immediate intervention and upon those so severely injured that parietal
and deep repair must be
made through one opening. Advantages are the greater rapidity, avoiding
making a separate
incision and thus not impairing parietal integrity by surgical wounds
added to the projectile
destruction. Disadvantages are the frequent failures to obtain
satisfactory exposure to make
proper intrathoracic repair and the temptation
430
to avoid risks of
operative deaths by performing incomplete operations when finished
operations
are needed to obtain ultimate recoveries.
CONCLUSIONS
Operations
of this type will inevitably be more frequent than other serious
procedures
and demand greater consideration. Improved facilities in advance of
mobile hospitals and the
establishment of a thoracic surgical division would make better methods
possible. If the thoracic
wounded were provided with proper treatment from front to base, not
only could the less
severely injured be shunted to hospitals farther toward the rear when
the fighting is active, but
the more severely injured could be evacuated earlier. This might well
provide for two-stage
operations that would secure recoveries in types that now seem to be
almost hopeless.
The
need for more effective prevention and treatment of shock which
includes
promptness as a first requisite as well as continued and consecutive
care under unified control is
indisputable. Simplifying and perfecting the technical details appear
now to be easy. The
combination is desirable and attainable. Returns to active duty were
few and delayed.
GROUP IV. THORACOTOMY OF ELECTION
1. F. P. July 30, 1918: Shell fragment,
penetrating wound, left chest. Entrance, left sternoclavicular
articulation; foreign body lodged in lower lobe. Large hemothorax.
Heart displaced to right. Condition (?). Duration
(unknown). Operation: Entrance wound excised; sternum resected; pleural
defect closed with muscle. Fourth rib
resected. Hemothorax evacuated. Lacerated lung repaired. Hematoma in
lung and foreign body not removed. Wire
rib stay. Layer closure. No drainage. Postoperative interstitial
emphysema from wound of entrance. Moderate
pleuritic effusion. Later was operated upon at a base hospital,
anterior and posterior drainage for empyema. May 19,
1919: Drained again at Walter Reed Hospital and wire stay removed.
November 14, 1919: Discharged. July 28,
1921: Dyspnea and pain on exertion. Deficient expansion, multiple
parietal scars, chronic pleuritis, immobile
diaphragm, heart displaced to left, cardiac competence fair. Disability
50 per cent. Vital capacity 58 per cent.
This
an early experience; battle rush; no assistant. Operation incomplete.
Foreign body
should have been removed and intrapulmonary hematoma evacuated. This
with drainage would
have prevented empyema. Proper after-care would have reduced disability
at least by half. Rib
stay should have been removed early.
2. D. July 31, 1918: Shell fragment,
penetrating wound, left chest. Entrance wound over (?) rib, foreign
body in upper lobe. Moderate hemothorax. Condition (?).Duration
(unknown). Operation: Entrance wound excised;
fractured rib resected; pleural defect closed. Thoracotomy at site of
election. Hemothorax evacuated. Foreign body
removed. Lung repaired. Wire rib stay. Layer closure. No drain. August
3, 1918:Limited pleuritic effusion.
Continued improvement. Lost.
Notes
too meager for any judgment.
3. A. L. B. August 8, 1918: Shell fragments,
left arm, shoulder, leg, penetratingleft chest, which contained
two foreign bodies. Entrance over fourth rib, axilla. Largehemothorax.
Condition (?). Duration 18 hours. 'Operation:
Foreign bodies removedfrom leg, elbow and shoulder. Entrance wound
excised; fractured fourth rib
resected;thoracotomy at site of election. Large hemothorax evacuated.
Lacerations in upper lobe
431
repaired. No note of foreign bodies. Two wire
rib stays failed to provide satisfactory closure at anterior angle. No
drainage. August 10, 1918: Much interstitial emphysema from incomplete
closure. August 13, 1918: Chill. Increased
pleuritic effusion; 650 c.c. blood-stained fluid aspirated. August 16,
1918: Fluid reaccumulating. Aspirated and
found to contain much fibrin. Rib resection and open drainage. August
17, 1918: Subsequent progress excellent.
Disability for seven months. Ultimate disability 15 percent
(estimated).
Primary
drainage would have hastened recovery and reduced disability.
4. W. S. August 9, 1918: Shell fragment,
perforating, right chest; entrance wound, posterior axillary line
at level of angle of scapula; foreign body lodged in mediastinum
posterior to aorta. Enormous hemothorax.
Condition bad. Duration eight hours. Operation:
Thoracotomy at site of election to give immediate opportunity to check
bleeding because of severe and increasing acute anemia. Injured azygos
vein found and ligated
with great difficulty. Death occurred as bleeding laceration in upper
lobe was being sutured. Hemostasis imperative but attempted too late
even at eight hours.
Transfusions
might have been effective. A serious and usually fatal injury.
5. M. B. August 11, 1918: Shell fragment,
through-and-through wound, lower left chest. Large
hemothorax. Burns to head and face. Both ear drums ruptured from shell
explosion. Condition bad. Blood
pressures 90/50. Duration six hours. Resuscitation attempted; pulse
became barely perceptible. Chance of any
recovery lay in immediate hemostasis. Operation: Thoracotomy at site of
election to expose bleeding points
surely and with least delay. Lacerations in lower lobe sutured. Death
from acute dilatation of right heart.
Injuries
lethal at time of operation. Questionable if earlier intervention could
have
succeeded.
6. L. G. September 12, 1918: Bullet,
perforating wound, left chest. Entrance wound, second interspace
below middle of clavicle. Foreign body under skin below angle of
scapula. Large hemotborax. Free hemoptysis.
Heart widely displaced. Interstitial emphysema more prominent
posteriorly. Condition (?). Duration unknown.
Operation: Entrance wound excised. No rib damage. Closed. Bullet
removed. No rib damage. Closure. Thoracotomy
at site of election. Hemothorax evacuated. Wounds in upper lobe
sutured. Entrance wound surrounded by zone of
splenization which was not excised. One wire rib stay. Layer closure.
Superficial drain. September 13, 1918:
Greater emphysema about entrance and exit wounds because closure had
not been effective. Good condition. September 16, 1918: Aspiration of
sterile, pleuritic effusion. Continues to improve. Five months later he
developed
empyema and was treated by open drainage. Notes on present condition
not obtainable.
Imperfect
closures of entrance and exit wounds was poor surgery. Splenized lung
should
have been excised. Note the late empyema. Phrenic nerve should have
been blocked.
7. J. J. M. September 12, 1918: Shell
fragment, penetrating, left chest. Entrance, sixth interspace
midaxillary line. Foreign body lodged near heart, moving with each
contraction. Moderate hemopneumothorax.
Heart slightly displaced. Condition good. Duration five hours.
Operation: Six hours later: Entrance wound excised.
No rib damage. Pleural defect plugged with muscle. Fourth rib resected,
hemothorax evacuated Wounds in upper
and lower lobes sutured. Foreign body at hilum, close to pulmonary
artery and not removed for fear of injuring
vessel. Phrenic nerve blocked with 1 per cent cocaine. September 14,
1918: Interstitial emphysema from wound of
entrance. Considerable pleuritic effusion. Diaphragm on left side seen
with fluoroscope to be in extraordinarily high
position. September 17, 1918: Exceptionally comfortable convalescence
but usual
432
amount of pleuritic effusion. Absorption of
fluid not noticeably favored by diaphragmatic paralysis. Diaphragm now
crowded into low position by fluid. September 18, 1918: Six hundred and
fifty cubic centimeters fluid aspirated,
contained cocci in pairs and chains. December 18, 1918: Discharged from
service. Disability 15 percent.
Foreign
body should have been removed as immediate risks are less than ultimate
dangers. Plugging of pleural defects with muscle again unsatisfactory.
In this instance the
visceral pleura might have been sutured to the parietal at close of
operation. Comforts of phrenic
nerve block demonstrated. Effusion due rather to bacterial irritation
than to faulty absorption.
Primary catheter drainage would have been safer and hastened recovery.
8. H. G. (German soldier). September 13,
1918: Shell fragments, multiple injuries to right chest and arm.
Entrance to chest over fourth rib laterally. Large foreign body 0.3 by
3.5 cm. deep in chest. Right diaphragm
unaffected. Moderate hemothorax. Subcutaneous emphysema. Condition
poor. Duration unknown. Operation: Arm
wound excised and foreign bodies removed. Wound of entrance excised.
Many foreign bodies, including bits of
clothing, removed. Fractured fourth rib resected. Hemothorax evacuated.
Upper lobe not exposed because of old
adhesions. Bleeding had ceased. No note of removal of foreign body.
Collasped lower lobe was inflated nearly to
normal. Good closure obtained with one wire rib stay. Postoperative
shock. Systolic pressures were raised from 60
to90 with 600 c. c. gum salt intravenously. September 20, 1918:
Evacuated in good condition. Two aspirations and
opening of focus of suppuration in superficial wound.
Man's
poor condition precluded completed operation. Superficial wound,because
of
emphysema, should have been drained. Proof that inflatable lung is
trustworthy.
9. N. P.
(German soldier). September 13,
1918: Shell fragment, through-and-through, left chest. Entrance at
angle of scapula; exit, above scapula. Moderate hemothorax. Left
diaphragm moves one-half as widely as right.
Condition (?). Duration unknown. Operation: Entrance wound excised.
Fractured scapula and fourth rib resected.
Tunnel wound in upper lobe resected and sutured. Exit wound above
scapula resected. Closure with one wire rib
stay. September 17, 1918: Uncomfortable. Some-residual pneumothorax and
pleuritic effusion. September 21, 1918:
Conditions little changed. Evacuated.
Lung
repair imperfect else no pneumothorax. Serious injuries warranted
primary
drainage.
10. G. A. September 14, 1918: Shell fragment,
penetrating, left chest. Entrance oversecond rib below
middle of clavicle. Foreign body, 3 by 0.7 cm. substernal and deflected
with each heart beat. Large hemothorax
clouding left chest. Heart displaced to right. Very dyspneic. Condition
fair. Duration seven hours. Operation: After
five hours' resuscitation: Entrance wound excised. Thorax opened by
resecting fourth rib. Hemothorax, 600 c. c.,
evacuated. Perforations in lower margin of upper lobe repaired. The
exit wound in lung revealed by escaping air
with positive pressure. Foreign body removed from contact with aorta.
Closure with one wire rib stay. Condition
good. September 17, 1918:Very uncomfortable. Two hundred centimeters
dark bloody fluid aspirated. No bacteria
found. September 21, 1918: Small pleuritic effusion persists. Disabled
for 180 days. No other information. Estimated
disability 15 percent.
Primary
drainage. Phrenic block and exercises would have been wiser.
11. F. J. C. September 18, 1918: Shell
fragments (grenade) right hip, through back and chest. Entrance
wound not found. Foreign body in right lung, seven cm. in diameter.
Pleural cavity obscured. Diaphragm immobile.
Heart displaced to left. Condition (?). Duration 12 hours. Operation:
Superficial wounds excised and foreign bodies
433
removed. Entrance wound to chest not found.
Thoracotomy at site of election; 2,000 c. c.of bloody fluid evacuated,
little clotting. Long, edematous laceration, posterior aspect right
lower lobe resected and sutured. Multiple areas of
contused lung. Foreign body not found. Pleural closure perfect. One
wire rib stay. Preoperative blood pressures,
115/94. Postoperative blood pressures, 100/94. Six hours later systolic
pressures suddenly fell to 60. Seven hundred
cubic centimeters gum salt elevated pressures to 78/50. In 45 minutes
they fell to56/40. Transfused 600 c. c. citrated
blood; rose to 88/60, where they remained for two hours, then sudden
collapse and death. Necropsy: Repair of both
pleura is good. Small area of splenization in lower right. Wound of
entrance to chest posteriorly from two injured
vertebrae. Small hemothorax. Serofibrinous pleurisy. Death explained
neither by anatomic lesion nor operative
procedure. Attributed to medullary anemia.
Operation
alone could have led to recovery. Multiple and large transfusions
required to
rehabilitate circulation.
12. J. L. September 27, 1918: Bullet,
perforating, right chest. Entrance through back of neck; bullet lying
beneath skin over eighth rib lateral to scapula. Condition poor.
Duration 53 hours. Operation after five hours'
resuscitation: Entrance wound in neck notdisturbed. Incision over
eighth rib; evacuation of hematoma; removal of
foreign body; resection of fractured rib (eighth). Pleural closure.
Thoracotomy at site of election. Large hemothorax
evacuated. Splenized gutter wound with bronchial fistula in lower lobe
excised. One rib stay. Layer closure.
October 4, 1918: Aspirated fluid containing many streptococci. Chest
drained. Local anesthesia. October 8, 1918:
Evacuated. Condition bad. October 13, 1918: Died. Septicemia. No
necropsy.
Severe
wound, long duration, bronchial fistula, feeble patient. Should have
been drained
at operation. No less complete operation would have provided
opportunity for recovery.
13. A. B. R. September 30, 1918: Bullet,
penetrating, left chest. Entrance at left costovertebral angle.
Foreign body lodged beneath left clavicle and moves with each heart
beat. Dyspneic though hemothorax is small.
Condition fairly good. Duration 24 hours. Operation: Entrance wound
excised. Fractured twelfth rib resected. Pleural
closure. Thoracotomy at site of election; 500 c. c. bloody fluid
aspirated. Two holes in lower lobe and one hole in
upper lobe sutured. Bullet removed from left apex. One wire rib stay.
Layer closure. No drainage. October 6, 1918:
Smooth convalescence. Small effusion. July 10, 1919: Wire rib stay
removed. Graduated exercises begun, which
were beneficial even at this late date. September 14, 1919: Discharged
from service. July 26, 1921: Below normal
weight; lacks endurance. Fibrous pleuritis. Obliteration of costo-
phrenic sinus. Defective expansion. Disability of 30
percent is low. Vital capacity 71 percent.
Early
and continued breathing exercises would have reduced disability. Wire
rib stay
should have been removed promptly.
14. P. McG. October 10, 1918: Bullet,
penetrating, right chest. Entrance outer one-third of right clavicle.
Foreign body in liver. Interstitial emphysema. Moderate hemothorax.
Heart displaced to left. Three lobes of lung
perforated. Condition poor. Duration eight hours. Operation: After
three and one-half hours' resuscitation: Entrance
wound not touched. Thoracotomy at site of election. Inner aspect of
entrance wound smooth. Wound at apex of lung
could not be exposed. Three tears in lung repaired. Hemothorax
evacuated. Bullet could not be felt in liver. Hole in
diaphragm sutured. Layer closure. One wire rib stay. Superficial wound
of entrance excised and drained because of
emphysema. During convalescence developed empyema which was drained and
wire stay removed. February 1,
1919: Drainage ceased. August 11, 1921: Dyspnea after sharp exertion.
General condition good. Chronic adhesive
pleuritis at right base limits excursions of diaphragm. Disability,
22½ percent. Vital capacity, 96 percent.
434
Primary
drainage indicated, particularly by liver injury. Proper exercises
would have
reduced duration and extent of disability which is due to pyothorax.
Bullet in liver is not
harmful.
15. WV. B. November 2, 1918: Bullet wounds,
penetrating right arm and through-and-through, right chest.
Entrance, sternoclavicular joint; exit, sucking at right anterior
axillary fold. Hemothorax slight. Pneumothorax large.
Provisional sutures in exit wound showed this to have been a "sucker."
Foreign body in right forearm. Operation:
Wound in forearm excised and bullet
removed. Wound of exit excised; compound fracture of fourth rib
resected and
chest opened; 60 c. c. fluid blood and no clots evacuated. Focus of
splenization at extreme tip of middle lobe and
adjacent triangle of upper lobe. No lung operation. (Patient probably
in critical condition.) Wire rib stay. Layer
closure. Defect in parietal pleura reinforced with muscle. November 17,
1918: Stormy convalescence after good
immediate recovery. Finally a pyothorax developed containing anaerobes
and streptococci. Rib resection and
drainage. Continued improvement. Ultimate result unknown.
Incomplete
operation, probably because of patient's condition, not justified. If
it were,
leaving splenized lung assured pyothorax and demanded primary drainage.
16. R. B. November 5, 1918: Shell fragment,
through-and-through wound, right arm, penetrating wound,
right chest. Entrance, anterior axillary line over fourth rib. Foreign
body (0.8 by 1 cm.) resting on diaphragm.
Moderate hemothorax. Cold and severely shocked. Duration unknown.
November 6, 1918: Continued hemoptysis.
Fair recovery from shock. Blood pressures 110/82. Operation: Entrance
wound and fractured fifth rib resected; 120
c. c. liquid and 1,200 c. c. clotted blood removed. Foreign body
removed. Two holes in middle lobe sututred. Wound
in lower lobe not found because old adhesions prevented exposure. Wound
in forearm excised. November 8, 1918:
Exploratory aspiration, putrid fluid. Local anesthesia. Rib resection.
Insertion of air-tight glass tube armed with
check valve. November 16, 1918: Evacuated in good condition. Little
pneumothorax. Still draining. No further
record.
Wound
of long duration, weak patient, chronic pleurisy-all demanded primary
drainage,
which could have been effective in preventing pyothorax.
SUMMARY OF GROUP IV
Thoracotomies
for the repair of intrathoracic lesions were performed at the sites of
election, i. e., through the middle portions of the fourth or fifth rib
upon 16 patients, 15 percent
of the entire series. The injuries were serious enough to require
prompt attention and permitted
or demanded wide exposure so that repair of all lesions might be
possible immediately.
Fatalities.-There
were four deaths, a mortality of 25 percent. Three (4.5, 11) of the
four
deaths occurred within six hours; two (4, 5) during operation. Each was
in critical condition,
each suffering from acute anemia or exemia, and in each it was
essential to secure prompt
hemostasis for which thoracotomy of election offers largest
opportunities. The 4th (12) lived 16
days, dving of septicemia from pyothorax which primary drainage might
have prevented. Mortality chargeable to surgical shortcomings is 6
percent. Operations were performed 8, 6, 12,
and 58 hours after injury, average 21 hours. It is noteworthy that the
one who lived the longest
and who might have recovered is the one (12) whose wound was of the
longest duration.
Disabilities.-Late
ratings are available for only 6 of the 12 survivors. Three (3, 7, 10)
at
15 percent; one (14) at 222 percent; one (13) at 30 percent; and
435
one (1) at 50 percent,
giving an average of 20 percent. Six (2, 6, 8, 9, 15, 16) are not
estimated.
Two were returned to duty (10, 3) in 180 and 210 days, average 195
days' duration of
convalescence. The average late disability (20 percent) and duration
of immediate disability
(195 days) are obtained from insufficient data to be reliable but as
both are high they are
accepted as safe.
Pleuritis
is the chief cause of disabilities as the parietal destructions and
lung lesions are
less severe than those in Group III and there were fewer complicating
injuries. Pleuritis was the
cause of immediate distress to all but two (2, 13); six (1, 3, 6, 14,
15, 16) developed pyothorax
which had to be drained; four (7, 8, 9, 10) were aspirated one or more
times. The average
duration of wounds prior to operation was 16 hours for those who
recovered and 21 hours for
those who died. The wounds in the men who received less than the
average disability rating of
20 percent had been of 13 hours' duration; in those above 20 percent,
18 hours; in those who
developed empyema, 20 hours. The evil effects of delay are again
illustrated; likewise repetitions
of indications for primary drainage, notably in duration of injury.
An
average disability rate of 20 percent will not reflect upon the nature
of thoracotomy of election when it is recognized that 50 percent of
the survivors developed
pyothorax because of failure to employ primary drainage and that only
one (13) received any
nonsurgical after-care. Disabilities from pyothorax alone usually
exceed 40 percent. Breathing
exercises, though delayed for months, benefited one patient materially.
Again it is evident in this
group that more finished operations and the use of drainage, in brief,
more radical treatment,
would have reduced both mortality and morbidity rates. Likewise earlier
treatment promises
better results than later. Blocking the phrenic nerve should have been
a routine. It was not done
often enough to prove or to disprove its apparent aid to defense.
Reduction in discomfort alone
warrants its use.
DEDUCTIONS
Thoracotomies
of election will be performed more frequently as their value is
demonstrated by the better results obtained when more radical measures
are employed. They can
be used most effectively in the following varieties of wounds: When
immediate hemostasis is
required, the lesion deep-seated and a generous exposure of all
possible sources of hemorrhage
must be obtained by the shortest and surest approach; when the nature
and location of injury make a thoracotomy of necessity coincide with
the site of a thoractomy of election: when the
exposures obtained by parietal excisions or attempted limited
thoracotomies, and the condition
of the patient warrant employment of the most adequate means to effect
deep repair. The
advantages of being enabled to examine the entire side of a chest and
to effect all repair possible in intrathoracic procedures are
sufficient to compensate for certain disadvantages. These are the
occasional occurrence of chronic pleuritic adhesions sufficient to make
pulmonary mobilization
impracticable, the additional impairment of parietal integrity and more
prolonged operations.
Pleuritic adhesions occur so infrequently in soldiers as to be an
almost negligible handicap. A
few observations indicate that the parietal injuries occasioned by
thoracotomy of election performed even with rib resection, if properly
treated subsequently, will not
436
add appreciably to
disability. Moreover, it is probable that the provision of suitable
primary
drainage with consequently lessened dangers of pyothorax will justify
intercostal thoracotomy
unless rib fractures are present. Important as the time factor may be
in operating upon seriously
distressed patients, the other factors of better work done with less
added handicaps of limited
exposure often obtained with harmful traction make slightly more
prolonged operations the
safer.
CONCLUSIONS
Thoracotomies
of election will prove more serviceable now that principles are better
understood, means for primary drainage are at hand, and technical
abilities in intrathoracic
operations are developing widely and rapidly. Indeed, it is reasonable
to predict that
improvement in operative procedures coupled with more competent care of
the wounded will
show that reductions in both mortality and morbidity rates will be such
that even the less
seriously wounded, having more than limited hemothorax, will be better
served by thoracotomy.
Thoracotomy of election would be the method
Returns
to active duty were few and long delayed. There was no suitable
after-care and
the need for replacements never became acute in our Army. It is perhaps
idle to guess what
might have been accomplished. Few, indeed, of the wounded, who will be
fit again for duty, will
require more than 90 days for recovery, which must be within 10 percent
or 15 percent of
normal. Smooth healing and suitable after-care would make such
recoveries from thoracotomy
of election the rule rather than the exception.
SUMMARY FOR ENTIRE
SERIES
It
is desirable to learn from all failures, ignorance of proper methods,
lack of facilities for
ideal care, faulty organization and administration and the like, the
remedies that will assure
better protection of the wounded hereafter.
FATALITIES
The
following table correlates the essential facts.
CHART
A
mortality rate of 37 percent will appear to be woefully high until it
benoted that 53 percent of the deaths resulted from injuries initially
lethal or made so
by delay, hemorrhage,
infection and exposure. The 18 remaining deaths are charged to
therapeutic failures which
include not only operative mistakes but also lack of adequate supplies
of blood for transfusion,
of hypertonic
437
glucose solutions,
and insulin, failure to employ the intravenous administration of
digitalis,
and proper immediate and remote after-care. In other words 47 percent
of the deaths might have
been reduced had materials and method snow available been used.
Operations have been held
entirely responsible for12 deaths (10 percent for the series and 30
percent of the fatalities)
inasmuch as this number survived long enough to die from complications
which more exact
methods could have obviated. The incompleted operations were not
finished because the patients
were in such critical condition that continuation appeared to be
unwise, yet survival for several
days is assumed to prove such conclusions to have been erroneous.
Criticism
will be directed at the large proportion (53 percent) classed as
lethally affected
who were subjected to operation. In some of these patients the fatal
involvement was not
recognized and could not have been recognized until exposures obtained
by operation revealed
irrecoverable lesions. Other men apparently equally or even more
severely handicapped made
excellent recoveries. Errors in judgment were numerous and because
decisions must be made
promptly without full information they will always be frequent.
The
orders of the chief consultant, surgical services, A. E. F., to operate
on every man
who had the least chance for recovery, were proved to have been based
upon sound surgical
judgment as well as upon a high conception of obligation. A few of the
men who died during or
soon after operation conceivably might have survived without operation
or had the operation
been less exact. There was no proof of this. In several instances,
postoperative blood trans-
fusions would have averted death, but this was too often impossible
because donors were not
available. As experience grew and methods became more radical, the
results improved. In
retrospect, our regrets are that supposed conservatism allowed us to
evade the responsibility of
performing forbidding but necessary operations and thus to deny some
men their only chance to
survive.
DISABILITIES:
Interpretation
of the causes of disability is most important. It will determine the
chief
factors in producing death, the greatest disability, as well as show
how more complete recoveries
could have been hastened.
CHART
438
Disabilities
due in part to irreparable defects include destruction of parietes,
costal and
diaphragmatic, or such costal lesions as required the use of the
diaphragm in effecting closure,
cardiac lesions and injuries ordinarily remediable but not repaired
because conditions prevented
finished operations. These and the following estimates are based upon
the results actually
obtained and not upon what might have been done in the light of present
knowledge. Therapeutic failures consist mainly of omissions of
postoperative aspirations and transfusions
which would have favored defense and repair. They are by no means to be
charged to ignorance
and neglect since it was frequently impossible to give desirable
individual attention and donors
were often not to be had when most needed. No account has been taken of
the failure to provide
suitable exercises to aid in reestablishing the conditions for normal
respiration. There is record of
but one instance (Group IV , 3) in which breathing exercises were used
and then 10 months after
operation. Some of the men possibly continued the training advised,
and, when possible,
instituted before evacuation after operation.
Operative
failures, with a few exceptions, were omissions. Incomplete procedures
and
neglect of drainage were the worst faults to which probably can be
added the failure to introduce
two-stage operations.
The
worst showing is in the extended period of immediate disability (130
days). It shows
that recoveries were more protracted and less complete than they should
have been. On the other
hand the permanent disability ratings, an average of 16 per cent for
the series which errs on the
higher side, is proof of what was accomplished.
In
order that the full significance of the ultimate disability ratings and
the reasons
therefor are appreciated three facts are emphasized: (1) An average
disability of 16 percent was
obtained in 66 men; 63 percent of them had been subjected to major
thoracotomies, some with
multiple rib resections, some with resections of part or most of a lobe
and in some the diaphragm
was used to secure parietal closure. (2) An understanding of what this
means will be easy when it
is known that the average disability rating of soldiers treated in the
camps in the United States
for post-pneumonic empyema was reported as being approximately 50
percent. (3) The results
obtained in treating the wounded can not be attributed to unusual
operative skill or to especially
effective after-care, but only to the employment of methods which had
been determined by
intrathoracic physiologic actions and reactions.
CONCLUSIONS
The
principal secondary influences that determine recoverability from chest
wounds are
(a) the condition of men when wounded, (b) the promptness with which
relief is provided, and
(c) its effectiveness.
Fighting
men can not always be well fed and watered or kept free fromfatigue and
the
mental depression inevitable with reverses, all of which have untoward
effects upon the
wounded. Our Army experienced no continued and but few localized
defeats, so this factor was
eliminated. Cheerfulness was an almost unbroken rule.
439
Promptness
depends upon getting the wounded back to hospitals and in keeping
hospitals
as close to zones of conflict as relative safety permits.
Transportation is essential to both.
Transportation handicaps, however avoidable or unavoidable, caused
great hardships to the
wounded and materially increased mortality and morbidity rates.
Early
wound dressing was very good. Sucking wounds should seldom be sutured
provisionally. Firm pressures swathes to provide support and fixation
would have been helpful.
Morphine should be given in full doses and repeated. Prophylaxis and
treatment of shock can be
improved. In addition to means to get men warm and dry, provisions are
needed for more
general employment of intravenous remedies, particularly in advance of
mobile hospitals.
A satisfactory method of
preserving blood, based upon the work of Weil,49 will
provide for a
limited number of transfusions. In addition some hyper-tonic
carbohydrate solution, insulin and
digitalis now seem to be essential and should be used in spite of the
less dangers of inducing
secondary hemorrhage to combat certain death from prolonged
hypotension.
The
need for further preoperative care, including physical and fluoroscopic
examinations,
and of consecutive after-care, providing similar examinations, early
and progressive activation
has been established.
The
efficacy of surgical procedures based upon physiological principles in
providing
opportunities for recovery with the least danger, delay and disability
has been proved and
warrants positive statements.
All
chest wounds, severe enough to demand more than temporary dressings,
should be
treated by operations conducted under positive pressure gas analgesia.
Parietal
excisions, usually with paracentesis, suffice to protect the least
seriously injured
and to hasten recoveries without added danger. They may likely prove a
first-stage operation in
the care of those so seriously wounded that any additional primary
intervention except perhaps
aspiration or the insertion of an intercostal drain is prohibited.
Limited
thoracotomy is applicable in the treatment of the less severely wounded
in whom
deep repair can be effected through slight enlargements of entrance and
exit wounds and from
whom the bulk of hemothorax can be aspirated by large cannulte
introduced through a defect in
parietal pleura.
Limited
thoracotomy can be employed as a first-stage operation when deep
injuries
require an amount of repair that could not then be tolerated. Under
such conditions, hemostasis
and primary drainage would be required.
Thoracotomy
of necessity, a more extensive application of limited thoracotomy, must
be
used when immediate deep repair is required and when there are reasons
for using the wound
defect in the parietes to secure exposure. If it be found that the
repair required can not be
effected with obtainable exposure or if the patient's condition
prevents satisfactory operation,
hemostasis, primary drainage and parietal closure can be secured and
the complete operation
postponed, to be performed through a separate incision.
Thoracotomies
of election will find wider application as primary procedures, and if
two-stage procedures are practicable, they will be the preferable
secondary
440
operations. They afford
sufficient exposure for a satisfactory examination of a pleural cavity,
permit repair of most visceral and diaphragmatic lesions, heal well and
impose little disability.
Indeed, with the development of simple and effective methods of primary
drainage
thoracotomny of election may prove to be the safest treatment of
massive pneumothorax unless
the patient's condition be poor.
The
value of two-stage operations, should they prove feasible, will be
greater than in
affording better care. A good proportion could be sent, after the
primary operation, to evacuation
hospitals where the final operation would be performed. Thus the mobile
hospitals could be
relieved for more strictly emergency service.
We
have attempted to indicate our therapeutic failures so positively that
similar mistakes
need not be repeated. Contributory causes for failure will be mentioned
for the same reasons,
namely, so that repetitions may be avoided.
Success
can be realized if personnel competent to give treatment and the
materials
essential to that treatment are so organized and disposed that the
wounded may be well and
promptly served. From a medical viewpoint, service to the wounded men
is all important; from a
military standpoint, service to the fighting men is most important. The
exaggerated
individualism of civil surgeons lead them to misunderstand or to fail
to appreciate the
responsibilities of their colleagues in the Regular Service to Army
organization and
administration. Similarly, the medical officers of the regular service
apparently underrated the
personal aspirations of doctors and nurses to provide their patients
with the best care. Both sides
were unprepared to fulfill their obligations and neither hesitated to
hold the other responsible,
justly and unjustly, for their own deficiencies. Jealousy, suspicion,
distrust, and resentment
prevented cooperation. The wounded man paid the bill with avoidably
high mortality and disability rates.
There
was a rapidly progressing improvement in all departments which showed
that had
the war continued solutions might have been found for even the most
involved problems.
Thereby was indicated a means to preparedness.
An
army must be an autocratic organization, but many evils peculiar to
autocracies can
be minimized. This can be accomplished effectively so far as the
Medical Corps of the United
States Army is concerned by developing cooperation in advance. Civil
surgeons can and should
prepare themselves not merely to give professional services but to give
them under the
restrictions of military methods, the worst attribute of which is
inflexibility. Similarly, the
officers in the Regular Medical Corps, kept directly in contact with
progress and changing
requirements of surgical practice, will find more liberal
interpretations of regulations, which are
fixed products of past experiences and often are literally opposed to
immediate necessities.
National security should be enough of an incentive to produce the
necessary personal adaptation
and coordination of effort.
441
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