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Chapter VI


Part III



Evolution of Clinical Policies in the Mediterranean (Formerly North African) Theater of Operations

Thomas H. Burford, M.D.


Until the Korean War, which broke out 5 years after World War II ended, all the wars in which the United States has been engaged were relatively widely spaced. Surgeons therefore had to approach their medicomilitary duties without practical experience of combat-incurred trauma. This meant that, in every new war, the lessons of the previous war had to be relearned.

In World War II, thoracic surgeons had to overcome three special difficulties:

1. They had to learn, as do all civilian surgeons who enter the Army, that the problems of medical care in wartime are not entirely clinical. The clinical care of battle casualties is closely related to other considerations, including supply; personnel; evacuation and transportation, which in turn are related to terrain, time factors, the weather, and other military necessities; the facilities available for medical care; and, most of all, the tactical situation, in which the enemy often plays a determining role.

2. Thoracic surgeons were practicing a relatively new specialty in World War II. Their number was limited, and the thoracic surgery of civilian life, even of the traumatic variety, had only a limited application to military thoracic surgery.

3. The experience in World War I-this aspect of it, as least, was generally known-had been so overwhelmingly concerned with empyema of non-traumatic (postinfluenzal, postpneumonic) origin that it was only natural for the chest surgeons of World War II to enter upon their duties believing that their major problem would be the prevention of intrathoracic infection. As a matter of fact, this type of infection was to prove a relatively minor problem in this war.

The management of thoracic casualties as it finally evolved in MTOUSA (Mediterranean Theater of Operations, U.S. Army), and was later carried out in the European Theater of Operations, U.S. Army, was based on sound physiologic principles and good surgical practices. The care of the casualty


began with the all-important emergency measures instituted-often heroically-on the battlefield by the company aidman, and it extended uninterruptedly through the entire chain of evacuation. Consistency of concepts underlay continuity of treatment. There were no pathophysiologic echelons. The program instituted countenanced no compromise short of ideal surgical results. The assiduous application of sound surgical and physiologic concepts made apologies for the exigencies of war entirely unnecessary. Experience in the Mediterranean theater, and later in the European theater, showed that ideal results were entirely feasible and could be achieved.

Such a program did not exist at the beginning of World War II. It was developed by a process of evolution. Furthermore, more than mere formulation of such a program was necessary. The hiatus that originally existed between the concepts at consultant and other specialized surgical levels and the practices on other, lower levels had to be bridged by didactic teaching, demonstrations, discussions, and directives. In all hospitals, as might have been expected, the single factor that contributed most to the success achieved in the management of chest injuries and the promptness with which it was attained was insistence by the chief of section upon rigid and undeviating adherence to the surgical principles and practices laid down by the chief consultant in surgery in the theater.

The policies by which thoracic injuries were managed were not, of course, instituted in their final efficient form in the early operations in World War II. Circumstances of military care varied from theater to theater and changed as the war progressed. As a result, the outstandingly good results achieved late in the war were not achieved early in the war. In the last months of fighting, however, perhaps from 70 to 75 percent of the casualties received in Zone of Interior general hospitals and thoracic surgery centers from the Mediterranean and European theaters were practically well from the standpoint of their thoracic wounds. (Casualties from the Pacific theaters always presented different problems.) Many of them were evacuated because of associated wounds. When the chest injury was the principal wound, in many instances only the original severity of the wound, the need for reconditioning, and the uncertainty regarding the man's ability to perform full military duty in an oversea theater indicated his return to the United States.


At the deliberate risk of repeating what has already appeared in published volumes of the history of the U.S. Army Medical Department in World War II and will appear, in greater detail, in volumes in the administrative series now in preparation, certain facts concerning the general care of the wounded in a combat zone must be described before the management of thoracic injuries is discussed. The repetition is necessary because chest injuries were managed according to these basic principles as well as according to principles applicable only to these special injuries.


The entire system of medicomilitary care in World War II was based on the following premises:

1. Medical care must be accomplished in echelons.

2. The mission of each echelon is both specified and limited.

3. Medical installations in combat and communications zones, as well as in the Zone of Interior, are designed, equipped, staffed, and designated for specific missions.

4. Medical officers must not only perform the duties specified for their particular echelons but must also limit themselves to the duties specified for them at those levels.

The surgical management of battle casualties was rendered in phases which, in general, conformed with the personnel and facilities provided by the medical installations in the several echelons of medical service. These phases included:

1. Emergency measures on the battlefield and in the battalion aid stations and other installations forward of the clearing station (division area).

2. Initial wound surgery, which was rendered, according to the condition of the casualty and other circumstances, in the field hospital (division area) or the evacuation hospital (army area).

3. Reparative surgery, which was rendered in general or station hospitals or in centers for specialized care (communications zone).

4. Reconstructive surgery, which was rendered in the Zone of Interior.

5. Reconditioning and rehabilitation, which were carried out overseas or in the Zone of Interior, depending upon where the casualty had received his final surgical care and whether he could be returned to duty from a hospital overseas or had to be evacuated to the United States.

The entire process of evacuation of the wounded man had three objectives:

1. To get him out of the way of battle, in which he was no longer useful and might never be useful again.

2. To restore him to combat efficiency, if that were possible.

3. To save life, relieve suffering, and prevent deformity.

While these objectives are listed in the order of their military importance, there was, of course, no conflict between the humane considerations of the third objective and the military necessities of the first two objectives.

The process of evacuation and the determination of the forward echelon in which the patient would receive initial care depended upon two considerations:

1. His transportability (p. 204), which was determined by the character of his injury and his physiologic reaction to it.

2. The measures required to care for his wound.

The continued backward movement of a military casualty from area to area was in sharp contrast to the management of civilian victims of trauma, who are practically always managed throughout their clinical course in the same hospital to which they are first admitted. It was also responsible for


other differences between the civilian and the military surgery of trauma:

1. In military surgery, the timelag between wounding and definitive care was many times longer than in civilian practice because of the necessity for evacuation of the casualty from the battlefield through the battalion aid station and the collecting station to the clearing station, at which level hospital facilities were first available.

2. Perhaps the most important difference between civilian and military practice concerned personnel. In civilian surgery, a single surgeon usually makes all the important decisions for a single casualty. In military surgery, these decisions had to be made by a number of surgeons. From the time a wounded man was tagged on the battlefield and removed to a battalion aid station, until the completion of his cycle of treatment, evacuation, and disposition, he was cared for not only in a series of medical installations but also by a series of medical officers whose judgment and performance were interwoven in the threads of his care. Every medical officer who treated a wounded man was called upon to evaluate the patient's status. He also had to estimate his own surgical capabilities and limitations and the facilities at hand to perform the necessary surgery. In the division area, and frequently in the army area as well, all surgery was attended with some degree of urgency, and the decisions had to be made in the light of circumstances peculiar to a field army in combat.

Two planned policies compensated for these obvious disadvantages in the care of casualties:

1. The precise definition and timing of surgery in the various echelons of medical care. Every procedure was timed and graded in relation to the total picture, including the tactical situation, the particular point in the chain of evacuation, and the wounded man's own status. Hospitals, as already noted, were designated and equipped for surgery of varying degrees of urgency and magnitude, and with due consideration of the necessary duration and other requirements of postoperative care. They were strategically placed in reference to these considerations, and professional personnel of the appropriate competence were assigned in accordance with the function of the installations and the type of surgery to be performed in them.

2. Standardization of management, or, as many medical officers fresh from civilian life preferred to term it, "regimentation." This policy was essential because of the transfer of the care of the wounded man from medical officer to medical officer as he was evacuated farther to the rear. For reasons of simplification, expedition, and safety, individual variations of any consequence could not be permitted. The surgeon who cared for a casualty in the rear area had to know exactly what had been done by the surgeon in the forward area, so that he could relate his own therapy to what had already been done and what remained to be done.

With the passage of time since the end of World War II, some of the general principles and practices just summarized may have been forgotten. It is particularly important that these principles and practices be clearly understood as the background of the discussion of thoracic wounds in World War II.


They greatly affected the management of these wounds. There were no other combat-incurred wounds in which alterations of physiology could be so rapidly fatal, and no others in which physiologic disturbances could be corrected so simply and so rapidly by the proper measures. When these disturbances had been corrected, the majority of chest casualties became safely transportable. The corollary was that a casualty who, in his original status, would have required definitive treatment far forward could be treated with safety and convenience farther to the rear, thus relieving the strain on the medical installations that were always most heavily taxed.

The continuous system of triage (p. 202) in the chain of evacuation made it possible for a casualty to receive adequate treatment, as he required it, at each hospital along the evacuation route. The hospitals were in no sense stopping-off places. Each was established for the specific purpose of treating the casualty at the optimum time that his wound and his reaction to it required some special measure, including surgical measures.


When the United States entered World War II, the only official policies for the management of chest wounds were laid down in military manuals then in preparation and in a manual, also in preparation, by the Subcommittee on Thoracic Surgery of the Committee on Surgery, Division of Medical Sciences, National Research Council (1).

Military Manuals

War Department Field Manual 21-11, First Aid for Soldiers, published on 7 April 1943, was intended to teach the soldier what he could do for himself or for a fellow soldier if injury or sickness occurred when no medical officer or medical corpsman was nearby. The material on wounds of the chest was, in substance, as follows:

If the chest wound is one in which air is sucking in and blowing out, the life of the injured man may depend upon the speed with which a dressing, large enough to cover the wound and stop the flow of air through it, is applied. If the dressing applied does not completely stop the back-and-forth movement of air, additional dressings should be applied. A large piece of any available material (raincoat, overcoat, blouse, or shirt) applied tightly over the dressing may be useful in making it airtight.

The casualty with a wound of the chest is more comfortable and can breathe more easily if he lies on the injured side.

War Department Technical Manual 8-210, Guides to Therapy for Medical Officers, published on 20 March 1942, contains, in reduced form, essentially the same material appearing in the thoracic surgery section of the National Research Council military surgery manual entitled "Neurosurgery and Thoracic Surgery" (1).


National Research Council Manual

Plan of manual-When a manual on chest surgery was first under discussion, it was the desire of Dr. Evarts A. Graham, who served as Chairman of the Subcommittee on Thoracic Surgery, that it should not exceed 50 pages. When it was finally published, in 1943, it had exceeded this length by 29 pages. It is unfortunate that this manual did not fulfill its potential usefulness. It did not appear until policies were being evolved as combat necessities developed. It had no general circulation among medical officers, and no official instructions for its use were issued. The thoracic surgeons in the Mediterranean theater, who had most to do with the evolution of policies for chest injuries, were not even aware of its existence as such, though the substance of the material in it, as just stated, was available to them after March 1942 in War Department Technical Manual 8-210.

It was stated in the preface to the National Research Council manual that the high mortality rate of chest wounds-33 percent on the field, 25-30 percent in dressing stations, and 20-25 percent in ambulances-made it clear that if any reduction were to be achieved in the number of deaths from these injuries, the improvement must take place in the combat zone. The desired improvement would not be brought about by the indiscriminate application of heroic surgery in advanced surgical stations. It could be achieved only by accurate appraisal of the individual patient, prompt emergency measures, and definitive attention to special aspects of thoracic wounds.

Among the subjects specifically excluded from the manual was the complete exposition of the physiopathology of the cardiorespiratory mechanism, on the ground that this information could be obtained from standard texts. This, of course, is true, but in view of the complete change of emphasis in the management of wounds of the chest between World Wars I and II and the emphasis in World War II upon physiologic derangements, it is unfortunate that space was not utilized to emphasize this important phase of these wounds.

The book is divided into four parts. The first concerns the general principles of management of chest injuries. The second is a synopsis in outline form of the treatment and disposition of these injuries. The third deals with their complications and sequelae. The fourth deals with operative surgery.

The substance of the recommendations was as follows:

First aid measurers.-First aid measures outlined in this manual include arrest of hemorrhage from the thoracic wall, physical correction of physiologic disturbances, and measures to prevent infection. In the brief discussion of these measures, both sucking wounds and their closure are specifically mentioned, as in stove-in chest. It is recommended that hemorrhage from a lacerated lung should be treated by aspiration and simultaneous artificial pneumothorax, although the practice of air replacement had long since been discontinued when this manual appeared. Aspiration is recommended for pericardial tamponade.

Definitive treatment-Subsequent surgery is to be carried out under intratracheal anesthesia, to provide differential pressure. Debridement, by a somewhat elastic definition of the term, might include removal of high explosive fragments from the lung, though in


some instances, their delayed removal is wiser; resection of devitalized or bleeding pulmonary tissue, a policy that was seldom employed in chest wounds in World War II hemostatic suture; airtight closure of divided bronchi; removal of foreign bodies and devitalized tissue from the pleura and thoracic wall; reexpansion of normal pulmonary tissue; and airtight closure of the thoracic wall.

Prompt intervention is urgently necessary in the presence of progressive bleeding, early open pneumothorax, pressure pneumothorax, and cardiac tamponade. The early control of infection is desirable but much less imperative and is never an excuse for an inadequately equipped medical officer to undertake thoracotomy. If empyema occurs, in spite of efforts to prevent it, proper drainage is to be administered, to prevent a chronic phase.

The question of whether or not intervention is carried out in a forward installation often rests upon the ease or difficulty with which evacuation can be accomplished. Air transportation is desirable but, unless oxygen is available en route, it must not be employed in anoxemia or in wounds associated with large closed pneumothoraces.

Special types of injuries-Injuries and conditions covered in the second chapter of this manual include tangential or nonpenetrating wounds, in which the pleural cavity has not been entered and which may or may not be associated with hemoptysis; similar wounds associated with simple rib fractures; compression injuries with traumatic asphyxia; extensive mobilization of the chest wall by rib fractures; massive atelectasis; penetrating injuries, with and without serious hemorrhage and shock and sometimes associated with subcutaneous emphysema; perforating injuries pleuroabdominal wounds; rupture of the diaphragm; and blast injuries. Treatment under each of these headings is divided into first aid measures and definitive treatment. As will be evident later, both the nomenclature and the emphasis in a number of these injuries differ from the nomenclature and the emphasis in the injuries encountered in World War II.

Complications and sequelae-Complications and sequelae dealt with in the third chapter of the manual include pneumothorax, emphysema, hemothorax, empyema, retained foreign bodies, infections of the chest wall, lung abscess, massive hemorrhage into the subfascial spaces of the thoracic wall, and complications of wounds of the heart.

It is striking that hemothorax, the management of which proved so highly important in World War II, receives little attention in this volume. In chapter I, it is pointed out that hemorrhage into the pleural cavity may be fatal "without serious disturbance of respiration being caused by encroachment on pulmonary volume"; that the mechanical effects of hemothorax are delayed because they are produced by a traumatic effusion superimposed upon an initial collection of blood; and that the tendency to spontaneous hemostasis is the result of a low head of pressure in the pulmonary circulation plus the collapse of the lung from attendant hemothorax or pneumothorax.

In the chapter on complications and sequelae, hemothorax is covered in a page, practically all of which is devoted to differential diagnosis (massive pulmonary collapse, rupture of the diaphragm with displacement of the abdominal viscera into the thoracic cavity, pleural effusion of infectious origin, and consolidation of a contused or pneumonic lung). Treatment is limited to cross-references to hemorrhage and shock; penetrating injuries with shock and hemorrhage from pulmonary lacerations; and infected hemothorax, which receives only half a page of the 3˝ pages devoted to empyema. Neither clotted hemothorax (vol. II, ch. I) nor decortication (p. 27) is mentioned.

Technique.-The final chapter of this manual describes the techniques for autotransfusion, bronchoscopy and tracheal intubation, thoracentesis, pericardicentesis, artificial pneumothorax, intercostal catheter drainage, elevation of stove-in chest, pericostal suture for hemorrhage from the intercostal artery, ligation of the internal mammary artery, rib-resection drainage in empyema, thoracotomy for penetrating wounds, exteriorization of the lung, drainage of lung abscess, removal of foreign bodies from the lung, cardiorrhaphy, pericardiostomy, management of mediastinal emphysema and wounds of the trachea, tracheotomy, mediastinotomy, repair of thoracoabdominal injuries, repair of traumatic diaphragmatic hernia, and the management of cardiac arrest.


There are some techniques in this list that were abandoned in World War II because better methods were found or because there was no need for them. Exteriorization of the lung, for instance, was never practiced. Pericostal sutures for any purpose were found harmful. Lung abscess was very infrequent. It will be observed that, again, there is no mention of decortication in this list of procedures.

Anesthesia.-Differential pressure anesthesia is recommended for all major operations in which the pleura is widely opened. It is preferably carried out by tracheal intubation. Agents combined with a high percentage of oxygen are preferred to those whose use is associated with anoxia. Regional block or infiltration anesthesia may be used for operation on the thoracic wall, and local anethesia may be employed to supplement general anesthesia.

Adjunct therapy-The infusion of blood substitutes rather than whole blood is recommended in any injury that reduces pulmonary volume and causes shock accompanied by hemoconcentration. By the time this manual appeared, a great deal more had been learned about shock, and it had long since been found that plasma was not an acceptable substitute for whole blood in seriously wounded men. The advice to delay blood replacement as long as possible in the presence of continuing intrapulmonary hemorrhage was sound if steps were taken to control the hemorrhage at once, and the warning against overhydration of casualties with chest injuries was also sound.

Oxygen is recommended for "asphyxia." Morphine is to be used cautiously, because the advantage of relief of pain may be counterbalanced by abolition of the cough reflex or the production of respiratory depression. Atropine may be used to lessen vagal reflexes and diminish the secretion of mucus, though it has the disadvantage of increasing the viscosity of bronchial secretions and making it more difficult to clear the bronchial tree by coughing. Barbiturates are usually contraindicated. Codeine or cough mixtures are not used when it is necessary to evacuate purulent secretions by coughing. Respiratory stimulants are seldom required or effective. Carbon dioxide is used with caution. If tobacco does not incite coughing, it may be used in moderation during recovery. Early ambulation and deep breathing are stressed.

A crystal sulfonamide is used in the pleural cavity and in the wound of the thoracic wall, and systemic chemotherapy is also employed. The manual warns that the sulfonamides are not a substitute for proper surgery.

Some of these measures were used in the management of chest injuries in World War II, but many of them were replaced by far more energetic measures, including catheter suction, and bronchoscopy as indicated, to clear the tracheobronchial tree. Even before penicillin had become available in World War II, local sulfonamide therapy had been generally discontinued.

Comment-Excellent as are many of the recommendations in this manual, the book suffers from the same fault that surgeons in other specialties have attributed to other manuals in the series: It is somewhat removed from the realities of combat, and the World War II experience did not bear out some of the statements in it, as the following example indicates: "* * * Necessity for prompt evacuation need not be understood to contraindicate treatment at advanced stations, for men wounded in the manner considered here often stand transportation better in the first twenty-four hours after operation than they do a few days later."

In the World War II experience, casualties with chest injuries stood transportation well after the correction of their cardiorespiratory disturbances and were also less susceptible to infection. Provision was made in both field and evacuation hospitals for holding patients after operation; the disasters of


the prompt evacuation practiced in the first months of the war had proved conclusively that casualties with serious chest injuries do not tolerate transportation well at this time.

The warning against radical forward surgery was in agreement with the World War II experience with that variety of management:

Choice of station at which definitive surgical treatment of thoracic injuries with severe laceration of the lung is instituted is governed by military exigencies and the equipment and assistance available. Decision between operation and conservative treatment must be shaped by the facilities at hand and the competence of the surgical team. Remember that infection of the pleural cavity may be dealt with later, while open operation under unfavorable circumstances may lead to disaster.

This means, as is pointed out in more than one place in this manual and as was proved by the early experience in World War II, that early open thoracotomy by an inexperienced surgical team is extremely hazardous.


North Africa

There was considerable confusion in the management of all combat injuries in the early days of the fighting in North Africa, for several reasons:

1. Official policies, as just pointed out, did not yet exist. The manuals in which they were described appeared late and were incorrect, in a number of areas, in both emphasis and techniques.

2. The lessons of World War I, explicitly set forth in the official history of the Medical Department, were generally unknown. No real attempt had been made to utilize this valuable material. The emphasis in thoracic injuries in World War I was, as already noted, overwhelmingly on the septic rather than the traumatic side, but there was still a great deal in the story of chest trauma that would have been of great practical value.

3. Almost no U.S. Army medical officers in the North African theater were familiar with the lessons the British had learned in the 3 years in which they had been at war; during this period, the British had had an extensive experience in this theater. Eventually, untried American thoracic surgeons learned a great deal from British surgeons, but early attempts to capitalize on their experience were only partly successful. When the 77th Evacuation Hospital was in England in 1942, before it was sent to North Africa, the time which its thoracic surgical team finally spent in British chest centers was only a fraction of what had been originally planned (2).

When this and other evacuation hospitals and auxiliary surgical group teams arrived in North Africa, in November 1942, and took over the hospitals in Oran, they found that many patients with chest wounds had received little or no care. Wounds had not been debrided. Sucking wounds had not been closed. Hemothoraces had not been aspirated. Even with the vigorous treatment immediately instituted, including chemotherapy, a great many hemo-


thoraces went on to empyema. Other handicaps existed at this time. Thoracic surgical instruments were in extremely short supply (p. 84), and there were no facilities for intratracheal anesthesia.

In March 1943, Maj. (later Col.) Howard E. Snyder, MC, head of the thoracic surgical team of the 77th Evacuation Hospital, was placed on temporary duty in II Corps headquarters, to evaluate the surgery performed in the early campaigns just concluded in North Africa and to make recommendations for the future care of casualties. His observations, which were reported to the Surgeon, II Corps, 3 April 1943 (2), were based on:

1. Visits to clearing and treatment stations, in some of which organic personnel had been supplemented by general surgical and shock teams from the 2d Auxiliary Surgical Group. Nontransportable casualties were treated at the clearing station of a medical battalion from 5 to 24 hours after wounding, after passing through two installations farther forward.

2. The 48th Surgical Hospital, 50 miles to the rear, to which transportable casualties were sent.

Major Snyder's report stated that, on the whole, triage had been well done, though some deaths that had occurred at the 48th Surgical Hospital might have been avoided if initial wound surgery had been performed at more forward installations. Other lives might have been saved if there had been less speedy evacuation of casualties operated on in forward installations; a number of these patients had been evacuated before they had even reacted from anesthesia. The selection of cases for surgery by teams of the 2d Auxiliary Surgical Group showed excellent judgment, and the surgery performed was generally commendable.

Major Snyder's recommendations were generally applicable to chest injuries:

1. Provision should be made for a more convenient method of blood transfusion, as well as for a source of blood other than clearing station personnel.

2. Provision should be made for oxygen therapy.

3. A shock team from an auxiliary surgical group should be assigned to every clearing station set up to act as a forward surgical hospital.

4. Caution should be exercised in the administration of morphine, to avoid overdosage, particularly in chest and intracranial injuries.

5. Better anesthetic equipment should be provided.

6. Facilities should be provided to hold casualties for a safe period of time in whatever installation they underwent major surgery.

7. More explicit directions should be issued concerning the emergency treatment of head and chest wounds and the disposition of these casualties.

8. Specialty teams for the treatment of these injuries should be assigned nearer the front than in evacuation hospitals, at least as these hospitals were located in North Africa; in some instances, they were as far as 145 miles behind the frontline.


Circular letters-After the Tunisian campaign and before the invasion of Sicily, several circular letters were issued from the Office of the Surgeon, Headquarters, NATOUSA (North African Theater of Operations, U.S. Army), in which there were sections dealing with chest surgery.

Letter No. 13 (3), dated 15 May 1943, gave the following information concerning chest wounds in forward medical installations:

1. A sucking wound of the chest should be closed tightly enough "to prevent to-and-fro blasts of air with respiration but not so tight that air cannot escape from the chest if a pressure pneumothorax builds up from an accompanying wound of a bronchus." A pad of petrolatum-impregnated gauze should be folded to fit the wound; held in position by adhesive tape; and secured with one or two sutures, to prevent its loss into the pleural cavity.

2. Pressure pneumothorax should be promptly corrected by needle aspiration. If it re-forms, a small catheter should be inserted in the second interspace anteriorly.

3. Oxygen therapy may be as important as the administration of plasma. Aspiration of blood and air may make an otherwise nontransportable casualty transportable. Air replacement, is "rarely" advisable. Internal bleeding is usually from the chest wall and requires revision of the wounds of entrance and exit. If the hemorrhage is from a large visceral or mediastinal vessel, thoracotomy is necessary.

4. Definitive surgery for thoracic wounds should be postponed until X-ray examination is possible. It is disastrous to assume that large retained foreign bodies will not promote infection.

Letter No. 16 (4), dated 9 June 1943, dealt with forward surgery with special reference to amphibious operations. In it, the instructions given in Circular Letter No. 13 concerning the closure of sucking wounds and the use of a catheter in pressure pneumothorax were repeated. Extensive surgical emphysema was to be managed by the correction of pressure pneumothorax.

Initial definitive surgery should be limited to debridement and closure of the wound of the chest wall, without complete suture of the superficial layers and skin. Local anesthesia was often satisfactory and eliminated the risk of asphyxia. Transfusions should be given slowly and only when essential.

Thoracic casualties (without specification) should be evacuated by air as "priority" patients, after preliminary aspiration of hemothorax without air replacement.

Letter No. 20 (5), dated 22 June 1943, contained the comments by hospitals in the communications zone on the treatment of battle casualties in forward areas during the Tunisian campaign. Generally speaking, these patients had been well treated and were received in good condition, but there were two adverse comments:

1. Some patients with chest wounds who had undergone exploration and removal of foreign bodies had been received with hemopneumothoraces and


collapse of the affected lung. Measures should have been taken to maintain an expanded lung.

2. Several patients were received with large, untreated hemopneumothoraces after being held in forward hospitals for as long as 10 days. Although X-ray facilities were available, they had not always been used. One patient with a large foreign body in the chest had a fulminating hemothoracic infection, but there was no mention of any examination of the chest, although the wound of entrance was obvious.


In Sicily, as described elsewhere, there were two important advances in surgical management, both of which directly influenced the results obtained in all serious injuries. The first was the establishment of platoons of field hospitals directly adjacent to clearing stations, for surgery on nontransportable casualties (p. 91). The second was the effective use of auxiliary surgical group teams to augment the intrinsic personnel of field hospitals (p. 92).

Circular letter-Circular Letter No. 3 (6), dated 7 August 1943 and issued in the field to all unit surgeons, dealt with the care of the wounded in Sicily. The section on wounds of the chest covered the following points:

1. The management of nontransportable casualties with wounds of the chest in field hospitals. Their number would be limited, the majority of such casualties being cared for in evacuation hospitals. Indications for transfer to a field hospital included dyspnea, sucking wounds, continuing hemorrhage, imminent shock, and thoracoabdominal wounds.

2. Indications for first aid measures in battalion aid stations, collecting stations, or clearing stations. These included:

a. Shock. The patient with a chest wound must not be placed in the Trendelenburg position. The amount of blood and plasma used should be only what was absolutely necessary, and it should be administered slowly.

b. Continuing hemorrhage from the chest wall, which should be controlled by ligature, hemostatic suture, or a mushroom pack.

c. Tension pneumothorax, which should be relieved as early as possible by the insertion of a large-bore needle in the second interspace anteriorly. For evacuation, a small catheter should be substituted for the needle, or a flutter valve should be used.

d. Open or sucking wounds, to be closed by the technique already described.

3. Initial wound surgery at a field hospital. This should be limited to debridement except in the occasional case of continued severe bleeding from the lungs, mediastinum, or heart; then thoracotomy should be done. Thoracoabdominal wounds required emergency surgery, which could sometimes be performed in toto through the thoracic approach.

4. Chemotherapy. Sulfanilamide should be dusted into the pleural cavity before closure, and an adequate sulfadiazine blood level should be maintained for from 7 to 10 days after admission.


5. Postoperative care, which was extremely important, whether or not thoracotomy had been done. Hemothoraces were to be aspirated daily if necessary. If drainage had been instituted, the catheter or tube was to be removed within 48 hours.


When Col. Edward D. Churchill, MC, arrived in the North African theater in March 1943 and assumed his duties as Consultant in Surgery to the Surgeon, NATOUSA, then Brig. Gen. Frederick A. Blessé, it was the beginning of a fruitful association that was reflected in the care of all wounded, and not least in the care of thoracic casualties. Up to this time, in the absence of official directives, each chest surgeon had been proceeding according to his own training, experience, and personal preferences. There was no uniformity of opinion or practice concerning the indications for thoracotomy, its timing, the management of foreign bodies, or any other problem related to combat-incurred chest injuries. For all practical purposes, the chest surgeons at hospitals in the theater and those on the teams of auxiliary surgical groups were establishing their own policies.

Almost as soon as he arrived in the theater, Colonel Churchill began to emphasize the division of wound management into the initial phase, the reparative phase, and the reconstructive phase. The division proved increasingly sound because it made for more precise thinking and more logical management. The concept was particularly adaptable to the problems of thoracic trauma.

In spite of the obvious need for standardization in the management of chest injuries, Colonel Churchill issued no immediate directions for their management but set up, instead, what amounted to a number of clinical research problems in the hospitals in which thoracic surgeons were working, particularly the 9th, 11th, 38th, and 77th Evacuation Hospitals. The observations in these hospitals, and the policies developed from them, represented one of the truly significant advances in military surgery in World War II.

With careful observation of large numbers of chest wounds, it became clear that the reaction to them fell into two phases:

1. An immediate, urgent phase, characterized by disturbances of cardiorespiratory physiology that were often profound and that could be fatal if they were not corrected immediately, though not necessarily by surgery.

2. A delayed, nonurgent phase, characterized by infection. Infection was not an inevitable result of chest injuries, and, if it did develop, it was not an immediate complication.

The division of the bodily reaction to wounds of the chest into these two phases made it clear that their management also fell into two phases:

1. The immediate application of procedures that would result, expeditiously and uniformly, in the correction of acute cardiorespiratory abnormalities of traumatic origin. These measures, to be carried out in the most forward installations in which the proper facilities existed and competent personnel


were available, formed an essential part of resuscitation. As already indicated, they were not necessarily surgical. When they were effective, as they usually were, major surgery could safely be deferred until an evacuation hospital was reached.

2. The later performance, in the evacuation hospital, of debridement and such other surgery as might be indicated.

This routine frequently prevented infection. If infection developed in spite of these measures, it could be cared for in a fixed hospital in the communications zone.

It is important to note the shift of therapeutic emphasis in the management of chest wounds in World War II. In the First World War, the focus of attention was on the pleural space. In the Second World War, the focus of attention was on the cardiorespiratory apparatus. In the earlier war, the casualty was thought to be progressing satisfactorily as long as no pleural infection was evident. The same concept prevailed in the first few months of fighting in the Mediterranean theater in World War II. Then the emphasis shifted from the management of posttraumatic pleural infections to the preservation and restoration of pulmonary function, which frequently prevented the development of these infections or at least minimized their seriousness. What this amounted to was a complete reversal of the World War I concept that a casualty was in good condition if he did not develop empyema and the substitution for it of the concept that, unless pulmonary function was satisfactory, progress was not satisfactory.

One temptation had to be overcome: The sweep of technical advances in chest surgery between the World Wars was not a criterion of their applicability to the types of chest trauma encountered in wartime. The limitations of these procedures and their correct timing, as well as the echelon of medical care in which they were to be instituted, had to be defined by trial and error, in the hard school of medicomilitary experience.


As described elsewhere (p. 82), the first medical meeting of any Army on the European mainland during World War II was held in the King's Palace, Caserta, Italy, on 11 November 1943. The meeting was an outgrowth of the great interest in wound surgery on the part of the military surgeons who were doing the work and, particularly, on the part of the Surgeon, Fifth U.S. Army, and his administrative and consultant staffs. At this meeting, which was devoted entirely to chest wounds, there were laid down many of the principles of the rational approach to chest trauma which was later to become theater policy.

By this time, it had become clear to many of the thoracic surgeons in the Fifth U.S. Army that a conservative approach accomplished better results than a more radical approach; that is, the limited use of thoracotomy in forward hospitals. At this meeting, Capt. (later Maj.) Lyman A. Brewer III, MC,


presented an analysis of 90 penetrating wounds of the chest that he had personally handled by conservative measures.

The keystone of the conservative policy was the use of thoracotomy in forward hospitals only on strictly limited indications. Captain Brewer's personal experience to date, as well as the general experience in the chest center at the 53d Station Hospital at Bizerte, also showed that foreign bodies, whether metallic objects or bone fragments, even when they were of considerable size, did not, in themselves, constitute valid indications for either traumatic or formal thoracotomy in these hospitals. There was, of course, no objection to their removal if they were accessible through the wound used for debridement. In the course of the discussion, it was pointed out that the time required to stabilize these patients and transport them to hospitals in the base was so brief that the risk of infection supervening before the necessary surgery could be done was very slight indeed. The composite experience to date at the Bizerte thoracic surgery center showed that the case fatality rate in chest wounds was reduced by half when thoracotomy was performed only on limited indications and that the morbidity record was also greatly improved.

In March 1944, Colonel Churchill met at Marcianise, Italy, with Major Snyder, Consultant in Surgery, Office of the Surgeon, Fifth U.S. Army; Lt. Col. (later Col.) Frank B. Berry, MC, later Consultant in Surgery, Office of the Surgeon, Seventh U.S. Army; and a number of thoracic surgeons from the 2d Auxiliary Surgical Group, including Captain Brewer; Maj. Thomas H. Burford, MC; Maj. (later Lt. Col.) Lawrence M. Shefts, MC; Maj. (later Lt. Col.) Paul C. Samson, MC; and Maj. (later Lt. Col.) Reeve H. Betts, MC. Critical review of the experience with chest wounds in the theater showed the same pattern as at the November 1943 conference; that is, results were increasingly good when thoracotomy was performed in forward hospitals on strictly limited indications and were much less good when it was used on ill-defined indications. At the 24th General Hospital chest center, near Bizerte, for instance, Major Samson had found that 30 percent of all casualties with intrathoracic injuries had been submitted to major initial wound surgery at forward hospitals, and that half of this group had poor results. Maj. William M. Tuttle, MC, and his associates at the chest center at the 36th General Hospital, Naples, had had a similar experience: 39 percent of the patients admitted had already been subjected to major thoracotomy, and in 37.8 percent of this group the results were poor.

Basic Principles

The discussion at this meeting made it clear that considerable uncertainty still existed in the minds of many forward surgeons as to what constituted valid indications for thoracotomy as part of the initial wound surgery of chest injuries. It was agreed that the accrued experience of the theater was now sufficient to permit crystallization of the indications for major chest surgery in forward hospitals and for the establishment of a uniform, mandatory, theater-wide policy for the management of chest injuries.


As a result of the extended, detailed discussion at this meeting, it was decided that hereafter the policy for the management of these injuries should be based on the following principles:

1. The prime concern in the management of penetrating wounds of the chest is the timing of surgical intervention, and the proper spacing of surgical procedures, in forward and rear hospitals. In the forward area, the goal of therapy is the restoration of physiologic equilibrium. The complications of infection are usually delayed and, if they occur, they can, as a rule, be adequately managed at the base.

2. The physiologic disturbances that attend wounds of the chest are serious and urgent, but thoracotomy is not the way to control them. Appropriate measures include needle aspiration of air and blood from the chest, aspiration of blood and mucus from the tracheobronchial tree, control of pain by injection of the intercostal spaces with procaine hydrochloride, control of pressure pneumothorax by insertion of a catheter with a flutter valve, oxygen therapy, blood replacement, and debridement of sucking wounds (with hemostasis of bleeding vessels and approximation of deep structures of the chest wall to close the pleural opening).

3. Thoracotomy should be performed only on strict indications.

4. Closed drainage of the pleural space should be instituted after thoracotomy or after extensive surgery for a wound of the chest wall with involvement of the parietal pleura unless there are definite contradications to its institution. The catheter should be removed as soon as the clinical course permits, which is usually within 48 hours.

5. A patient with an injured lung should be kept slightly dehydrated and depleted, since pulmonary edema can be invited by the too-liberal use of intravenous infusions or excessive transfusion.

6. The preferred thoracotomy incision or the extension of a missile track should be in the posterolateral area of the thoracic cage. Anterior incisions should be avoided, as they frequently break down after closure.

Indications and Contraindications for Thoracotomy

Indications for primary thoracotomy, either by extension of the wound or by separate incision at a site of election, were to be limited to:

1. Continuing intrapleural hemorrhage not controlled by hemostasis in the course of debridement of the chest wall, which was uncommon.

2. Anatomic or clinical evidence of penetration of the diaphragm, which was common.

3. Large intrapleural foreign bodies or other debris readily accessible by simple extension of the wound.

4. Wounds of large bronchi or of the intrathoracic portion of the trachea, which were uncommon.

5. Passage of a missile through, or its lodgment in, the mediastinum, with reason to suspect visceral damage, particularly injury to the esophagus.


The following conditions were not, in themselves, to be regarded as indications for thoracotomy either by extension of the wound or by a separate incision:

1. Foreign bodies, whether metallic objects or fragments of bone, whether they were in the lung or the pleural space.

2. Hemothorax. Evacuation of blood from the pleural cavity by suction at the time of debridement of the chest wall wound was not considered a thoracotomy.

3. Laceration or contusion of the lung in the absence of definite evidence of continuing hemorrhage.

Traumatic thoracotomy-A considerable part of the meeting at Marcianise was taken up with a discussion of the advantages and disadvantages of traumatic thoracotomy; that is, thoracotomy performed through an extension of the traumatic wound or through the wound itself. As Colonel Churchill pointed out, it permitted such procedures as removal of accessible foreign bodies from the pleural space and of indriven bone fragments from the lung; control of bleeding from the chest wall remote from the wound of entrance; suture of presenting lung lacerations; evacuation of clotted blood; and visualization, appraisal, and sometimes suture, of diaphragmatic perforations.

It was dangerous, Colonel Churchill continued, to attempt to extend the utilization of this procedure beyond these definite limits. Its wise use depended upon a number of variables, including: The condition of the patient, the experience of the surgeon, the tactical situation with respect to evacuation and hospitalization, the anatomic location and the size of the wound, and the presence or absence of retained foreign bodies.

Traumatic thoracotomy thus occupied an intermediate position between simple debridement and formal thoracotomy. When the defect in the chest wall was large, little additional exposure was needed. When it was small, it could be enlarged by intercostal extension or rib resection. When it was properly employed, it could save life, prevent infection, and obviate the necessity for a second operation at the base.

Traumatic thoracotomy, however, had all the risks of any operation undertaken without a precise and predetermined goal and performed through an incision determined by the missile and not chosen by the surgeon. Intrapleural surgery in the presence of a traumatized and partially collapsed lung, instead of being beneficial, could delay pulmonary reexpansion and invite pleural complications or, if they already existed, make them more serious. Unwisely used, therefore, traumatic thoracotomy could unnecessarily delay the casualty's evacuation to the rear and even endanger his life.

Dissemination of Information

The policies just outlined were formally set forth in Circular Letter No. 46 (7), issued in NATOUSA on 29 August 1944. These policies were also incorporated in War Department Technical Bulletin (TB MED) 147 (8),


issued from the Office of The Surgeon General and dealing with the care of battle casualties. The same information was repeated in Circular Letter No. 8 (9), Office of the Surgeon, Headquarters, MTOUSA, in March 1945.



Some years after World War II ended, Colonel Churchill, Consultant in Surgery, Office of the Surgeon, Fifth U.S. Army, stated one of the eternal truths of military surgery (10): "* * * The biologic processes of wound infection and wound healing will not compromise with faulty medical administration * * * and are beyond the reach of command decision."

It was in the light of this truth that the evacuation of all wounded casualties was conducted. Evacuation was a selective process, determined by triage, which meant the sorting or selection of patients from the basic standpoint of whether or not they could withstand transportation farther to the rear. A number of other considerations also played a part. The degree of selection that was practical was profoundly influenced by the military situation. The number of available beds might be limited. There might be restrictions, imposed by the terrain or the tactical situation, on the movement or on the placement of hospitals. Transport might be in short supply. The patient might be able to withstand evacuation if it were not unduly extended but entirely unable to withstand it for any long period. Triage required a high degree of clinical ability, but it also had to be a completely objective process, in which humanitarian considerations could not be permitted to take precedence over medicomilitary necessities.

The closer to actual combat the casualty was seen, the less the element of selection determined his evacuation and the more weight was given to the single factor of his transportability. At the battalion aid station, the only selection possible was the separation of casualties rendered noneffective by their wounds from those who could be returned to their combat duties almost immediately. The same policies prevailed at the collecting station. At the clearing station, evacuation first became really selective, for both surgical and military reasons. It was militarily undesirable to perform major surgery in a forward area on any casualty who could be moved out of the combat zone without detriment to his condition. It was essential to move any casualty whose need for surgery was urgent to the field hospital adjacent to the clearing station.

Triage was always an individual matter. Only when a general retrograde movement was in progress did evacuation ever become a mass movement of all casualties away from the combat zone. Even then, certain nontransportable patients could be left to the care of an enemy known to respect the Geneva Convention. In all theaters, U.S. Army surgeons cared for many enemy wounded who had been left behind as their armies retreated.


Triage was also a continuous function. In the clearing station, the decision was made as to what casualties should go to the field hospital. In the field hospital, reevaluation after resuscitation often showed that the casualty who was originally nontransportable had become transportable and could safely be evacuated farther to the rear. On the other hand, no chances were taken. If there was any doubt at all as to his transportability, the casualty was kept in the field hospital and operated on there. Particular care was necessary in the group of patients just mentioned, those who seemed to become transportable after resuscitation. In some of them, recovery was more apparent than real, and fatalities occurred among them both during transportation and after they were received in evacuation hospitals.

Triage was of major interest to the individual casualty, but it was also important from the standpoint of other casualties. A platoon of a field hospital, even when supplemented by the personnel and equipment of attached auxiliary surgical group teams, still had a limited capacity. It was commendable to treat all casualties as far forward as possible, but it was impractical, and it was also harmful. Generally speaking, when the census of even an expanded platoon of a field hospital exceeded from 40 to 50 patients, these men could not be properly cared for. If a casualty whose condition permitted his evacuation were operated on in a field hospital, he occupied space, and utilized the time and attention of medical personnel, which might be desperately needed by another, more severely wounded casualty who could not withstand transportation.

Triage was thus a function of the greatest importance. Whenever possible, it was performed by the surgeons assigned to the particular hospital from an auxiliary surgical group. It could be properly carried out only by experienced medical officers.

The importance of triage was not immediately realized. Major Snyder, after an analysis of 80 deaths which had occurred in Fifth U.S. Army evacuation hospitals in January 1944 (2), concluded that some of them could have been prevented by more careful triage in clearing stations. If a larger number of casualties had been directed to field hospitals and cared for there, the results would certainly have been improved. Of 44 patients in deep shock or with first priority (nontransportable) wounds whose case histories Major Snyder studied, 36 were sent directly to evacuation hospitals from clearing stations. The other eight, although they were sent to field hospitals, were merely observed there and then sent to evacuation hospitals for initial wound surgery.

As a result of this survey, a medical circular was issued on 7 April 1944 (11), from the Office of the Surgeon, Headquarters, Fifth U.S. Army, dealing with the disposition of battle casualties in forward echelons. At the same time, an educational program was carried out in the clearing stations. The prompt improvement that occurred in the triage of casualties was reflected in improved results in all injuries and was maintained until the end of the war.


The improvement in triage which occurred in 1944-45 is evident in remarks made by Brig. Gen. (later Maj. Gen.) Joseph I. Martin, then Surgeon, NATOUSA, some years after the war (12):

* * * The conflict that exists between the necessity of clearing the field of wounded and of bringing treatment and hope to those so badly wounded that they could not be moved reached a fine balance in the Fifth Army during the last year of the war in Italy. This efficiency was in great measure due to the professional zeal, devotion to duty, and judgment of the members of the 2d Auxiliary Surgical Group * * *. Their written record speaks for itself. It will constitute an excellent primer for the inexperienced military surgeon who will be faced with this problem at some future time.

Criteria of Transportability

When the general principles just described were fully established and properly followed, about 7 or 8 percent of all casualties passing through clearing stations reached field hospitals. When these principles were applied to thoracic casualties, in the light of the principles agreed upon at the meeting in Marcianise in March 1944 (p. 199), the majority of men with chest wounds, perhaps from 60 to 65 percent, were cared for in evacuation hospitals.

Since thoracic surgery as a specialty was of quite recent development, the criteria of transportability as applied to chest wounds were not clearly established at the beginning of the war and had to be clarified as the fighting proceeded. In some instances, the indications for holding patients in a field hospital were clearcut. A casualty with a thoracoabdominal wound, for instance, was always nontransportable. All decisions, however, were not so evident.

The chief reason for the original confusion was lack of realization of how well thoracic casualties tolerated transportation if cardiorespiratory disturbances were stabilized before evacuation. As a result, early in the war, many patients were operated on in field hospitals who could safely have been transported to the rear, while others were transported to evacuation hospitals before their cardiorespiratory balance was stabilized, and some of them lost their lives because of the error.

At the division clearing station, criteria for diverting casualties to the nearby field hospital included continuing hemorrhage; severe shock; sucking (blowing) wounds; wounds associated with respiratory distress of any degree; cardiac wounds; wounds of the trachea, esophagus, or large bronchi; and thoracoabdominal wounds, whether the diagnosis was established or merely tentative.

These indications, however, were not always absolute. For instance:

1. Continuing hemorrhage was more often from the chest wall and into the pleural cavity than it was external, and even persistent shock, rapid pulse, and low blood pressure were not always indications that bleeding was occurring. The shock might well be on a cardiorespiratory basis. In such cases, the diagnosis had to be established by repeated aspiration and the response to transfusion.


2. Sucking wounds1 were numerous, because of the predominance of high explosive shell fragments as wounding agents, but the wounds were usually small, and the open pneumothorax was not in itself a common cause of respiratory embarrassment. A sufficiently large petrolatum-impregnated dressing served as an adequate corrective measure, accomplishing sufficient occlusion while at the same time providing an escape for air if a bronchial leak existed.

3. Both pressure pneumothorax and subcutaneous emphysema were surprisingly infrequent in the Mediterranean theater. The explanation was the size of the wounds, which were usually either too small to produce the phenomenon of an open pneumothorax or too large to seal off the escape of air under pressure. Another possible explanation was that preexisting pleural adhesions, which play a role in the mechanism of both these conditions, were uncommon in combat troops in World War II. Whatever the reason, these complications, which had been so frequent and so terrifying in the past, seldom furnished an indication for surgery in field hospitals in World War II.

4. Tracheobronchial obstruction was also not an absolute indication for surgery in the field hospital. It could be controlled by the use of a catheter or by bronchoscopic aspiration to clear the respiratory passages of blood and secretions. When these measures were combined with procaine hydrochloride (Novocain) block of the intercostal spaces involved in the wound, relief of pain was accomplished, and the patient was willing to cough frequently and thus achieve evacuation of his own tracheobronchial tree.

These and other cardiorespiratory disturbances, although they were frequent and urgent, did not require surgery in a field hospital. They could usually be controlled by the measures just outlined plus the ordinary routine of resuscitation.

The nontransportability of the casualty with a thoracic wound was not always caused by the thoracic wound. Multiple wounds were frequent, and it was often the severity of one or another of these, or their cumulative effect, which made it impossible to move him farther to the rear. In such cases, it was the usual rule to care for the thoracic wound before treating the others. Unless defects in the pleura were closed, the pleural cavity was evacuated of both blood and air, and the tracheobronchial tree was free of blood and mucus, the patient would be handicapped during the performance of the other procedures by incompetent respiratory function.

Air Evacuation

A significant part in the improved results of chest injuries was played by the increasing utilization of air evacuation in transporting patients to base hospitals from forward hospitals (p. 79). The comfort and speed of this method of evacuation undoubtedly hastened convalescence.

1Although the term "sucking wound" has the respectability that comes from long usage, actually, it is neither accurate nor descriptive. Any open pleural wound is potentially a sucking wound, but it does not suck in air all the time. What it really does is blow the air in and out, and for that reason, the term "blowing wound" would be more accurate and more truly descriptive. The use of the term "sucking wound" is continued in this volume merely because it is in general use.-T. H. B.


Routine evacuation of thoracic casualties by air was not possible. A high altitude flight in a nonpressurized plane, which involved respiratory strain, might prove harmful, or even fatal, if the chest wound was associated with any degree of preexisting respiratory difficulty. With careful selection, however, most casualties tolerated flights at from 4,000 to 5,000 feet remarkably well.

Numerous theoretical criteria were set up by which to gage the fitness of thoracic casualties for air travel, but experience in receiving, questioning, and evaluating patients showed that the necessary selectivity involved only a few practical points. Casualties with adequate stabilization of the cardiorespiratory mechanism, with a clear airway, without bronchopleural fistulas or sucking wounds, and without dyspnea, traveled well. Small to moderate pneumothoraces and hemothoraces, if static, were not contraindications to air transportation. Patients with empyema, who had been on open drainage for a short time, also traveled well if the mediastinum were stabilized. It was an additional precaution to be sure that no casualty was evacuated by air who had any appreciable degree of anemia.

Special Study of Evacuability

The following study of the evacuability of 113 consecutive casualties with penetrating or perforating thoracic and thoracoabdominal wounds was made by Major Shefts of the 2d Auxiliary Surgical Group (12). These patients were encountered between 15 January and 4 July 1944 and were examined immediately on admission to the 94th Evacuation Hospital. During this period, this hospital was variously located at Riardo, Mignano Monte Lungo, Anzio, Rome, Montalto di Castro, and Montepescali.

The distance which each casualty had been transported was considered to be the shortest distance between the geographic location of wounding, as far as it could be determined, and the location of the hospital at the time he was admitted. For a number of reasons, the distance traversed was often considerably longer than the estimated shortest distance. The average distance these casualties were transported was 22.2 miles, the range being 60 miles at one extreme and 5 miles at the other. The average lapsed time between wounding and arrival at the evacuation hospital was 8 hours, with the range from 34 hours to 30 minutes.

After careful clinical examination, the 113 patients were divided into two categories, the first based on the severity of their wounds and the second on their general status. The following data were obtained:

1. Of the 73 patients with severe wounds, 33 were received in good condition, 28 in fair condition, and 12 in poor condition.

2. Of the 40 patients with moderately severe wounds, 38 were received in good condition, 1 in fair condition, and 1 in poor condition.

3. These combined figures mean that 71 of the 113 patients were received in good condition, 29 in fair condition, and 13 in poor condition.


4. There were 7 deaths among the 113 patients, all after operation. One death occurred in the group classified as in poor condition and three each in the groups in fair condition and in good condition.

5. Five of the deaths occurred in the twenty-four patients with thoracoabdominal wounds, all of whom were classified as severely wounded. Two of the deaths occurred in the thirteen patients who arrived in good condition, and two in the eight who were in fair condition; the remaining death occurred in the three who arrived in poor condition.

On the Anzio Beachhead, where 73 of the 113 casualties were treated, the 94th Evacuation Hospital performed the functions of a field, not of an evacuation, hospital. Although the average mileage and elapsed time were nearly double at locations other than Anzio, the additional distance and lapsed time did not materially alter the condition of the casualties on hospitalization. From the clinical standpoint, those received at Anzio and those received elsewhere represented about the same proportions of good, fair, and poor risks, and substantially the same results were obtained in their management.

In view of these observations, it is not unreasonable to assume that most thoracic wounds can be safely treated in an evacuation hospital.

It is important to emphasize that the figures in this study and the conclusions drawn from them must be interpreted in the light of the criteria for thoracotomy in field hospitals set up at the meeting in Marcianise, in March 1944 (p. 200).


The policies employed for the management of chest wounds during the Tunisian campaign were individualistic and unstandardized. The experience in Sicily was much the same. The establishment of the first chest center in the theater, at the 53d Station Hospital in Bizerte in July 1943, provided opportunities to evaluate the various policies employed to date, particularly the liberal use of thoracotomy. The evaluation left no doubt of the fallacy of this policy and of the far better results with conservative measures. These measures became standard policy after the meeting at Marcianise in March 1944.

For the last year of the war, therefore, there was a well-established, uniform policy for the management of wounds of the chest in the Mediterranean theater. The techniques employed had been known at the beginning of the war. Indications and contraindications had to be learned, however, as did timing and spacing of the necessary procedures. Still another important lesson that had to be learned was that the objective of resuscitation was to improve the casualty's condition to the point at which he could withstand surgery, which in itself was often the ultimate necessary purpose of resuscitation.

A comparison of the results of chest surgery before and after the new policies went into effect, after March 1944, left no doubt of the soundness of the change. That the results were related to the policies is quite evident, for the proportion of successful results overseas improved as the proportion of thoracotomies decreased.


The improvement in the condition of patients received in Zone of Interior hospitals was equally gratifying. An evaluation of the first 500 patients received at the Kennedy General Hospital chest center, Memphis, Tenn. (vol. II, appendix), was proof of the wisdom of conservatism in the management of thoracic injuries.


Thoracoabdominal Wounds

Military manuals-Thoracoabdominal wounds are not mentioned as such in War Department Field Manual 21-11, First Aid for Soldiers, 7 April 1943, although wounds of the chest and of the abdomen are both briefly mentioned. The material on thoracoabdominal wounds in War Department Technical Manual 8-210, Guides to Therapy for Medical Officers, 20 March 1942, is entirely derived from the manual on thoracic surgery prepared by the National Research Council.

National Research Council manual (1)-The concept of prompt surgery for abdominal wounds was firmly established by the end of World War I, and there was an almost equal realization of the importance of similarly prompt surgery in thoracoabdominal wounds. It is therefore surprising to find that in the manual on thoracic surgery prepared by the Subcommittee on Thoracic Surgery of the Committee on Surgery, Division of Medical Sciences, National Research Council, less than four pages are devoted to these wounds, which are termed "pleuro-abdominal" wounds. It is equally surprising to find the approach unexpectedly casual. Unless the injury is "compounded," the text states, repair "is usually not an emergency operation." There is a later discussion of the management of adhesions, whose presence, in themselves, would indicate that surgery had been deferred.

In substance, the material on thoracoabdominal wounds in the National Research Council manual is as follows:

1. First aid includes the administration of morphine; chemotherapy; the management of shock, including the administration of blood or plasma; and the immediate closure of a sucking chest wound.

2. Definitive treatment includes examination for abdominal injuries (the implication is that there are a large number of missed diagnoses, including rupture of abdominal viscera); excision of the chest wound; suture of the diaphragm; crushing of the phrenic nerve if the diaphragmatic injury is extensive; control of pulmonary hemorrhage by suture or resection; and tight closure of the chest wall, by use of the diaphragm if necessary.

3. Operation is always performed under intratracheal differential pressure anesthesia.

4. If the diagnosis of thoracoabdominal injury is made before operation, access could be transpleural or abdominal, depending upon the circumstances.


The abdominal route offers a satisfactory approach in early cases "without dense adhesions" and is quicker and easier for surgeons more accustomed to working in the abdomen than in the chest. The transpleural route, however, has its own advantages: When it is used, the pressure in the thoracic and abdominal cavities is immediately equalized, and it is thus easier to reduce the prolapsed abdominal viscera. Repair of the diaphragm is facilitated by lightly crushing the phrenic nerve with a hemostat, thus producing temporary paralysis, a maneuver which is simplified by the ready access to the nerve possible through the thoracic incision. Finally, intrathoracic adhesions between the prolapsed viscera and the lung can be divided under direct vision. Since these adhesions are often dense and troublesome, the thoracic approach is the approach of choice when the injury is "of more than a few weeks' standing."

If the preoperative diagnosis is rupture of a viscus, a median incision is likely to be used, prolonged to the xiphoid process. If the correct diagnosis of thoracoabdominal injury is made and a separate abdominal approach is used, the best exposure is provided by a left paramedian incision, extending from the xiphoid process to the umbilicus. If more exposure is required, it can be secured by cutting the left rectus muscle across at one of the transverse lines.

For right-sided injuries with lacerations of the liver, the subdiaphragmatic space is packed and drained. A posterior or lateral incision is used, with rib resection below the diaphragm if necessary. Left-sided injuries involving the stomach or spleen do not require abdominal drainage.

The entire discussion of thoracoabdominal wounds, in addition to being surprisingly casual, is also surprisingly incomplete. One of the notable omissions is the lack of any directions for the management of wounds of the colon, for which exteriorization or colostomy became the required treatment very early in the war.

Official directives-As the war progressed, the thoracic approach to thoracoabdominal wounds became increasingly popular in the management of thoracoabdominal wounds in the Mediterranean theater, but no official policy to that effect was ever published. There is not a great deal, in fact, on the subject of these wounds in any of the official directives.

In an analysis of the management of the wounded in the Tunisian campaign (5), it was mentioned that in thoracoabdominal wounds, thoracotomy should be done in the field or the evacuation hospital, particularly if the wound was on the right. In a commentary on the care of the wounded in Sicily (6), it was stated that initial surgery should be performed in thoracoabdominal wounds in the field hospital. A sucking wound required priority, but otherwise, either the abdomen or the chest might receive first attention. In an occasional case, everything could be done through a thoracic approach. In other circular letters from the Office of the Surgeon, the official directives did not go beyond the instructions, repeated several times, to treat these patients as first priority, to be cared for in field hospitals.


Cardiac Wounds

As related elsewhere (p. 44), cardiac surgery was no longer a clinical curiosity when the United States entered World War II. Nonetheless, the infrequency of wounds of the heart susceptible to surgical treatment-that is, of cardiac wounds not immediately fatal-is implicit in the scant attention paid to them in the instructions for their management issued during World War II.

Cardiac wounds are not mentioned in any of the circular letters published in the Mediterranean theater during the war. Nor are they mentioned in War Department Technical Bulletin (TB MED) 147 (8), dealing with the general care of battle casualties.

Apparently the only detailed instructions for the management of cardiac wounds during World War II appeared in the thoracic surgery section of the National Research Council manual published in 1943 (1). These instructions, like the rest of the material in the manual, were repeated in substance in TM 8-210. These instructions are as follows:

1. The usual first aid treatment should be instituted, including the use of blood or plasma in wounds associated with hemothorax, with a communication between the pericardial and pleural cavities. Replacement therapy is not mentioned in the management of cardiac tamponade.

2. Aspiration should be instituted in wounds associated with both hemothorax and cardiac tamponade, whether they have been caused by bullets or shell fragments.

3. Cardiorrhaphy should be performed if bleeding recurs.

4. Prompt open drainage should be instituted if purulent fluid is obtained from the pericardial cavity.

5. The management of foreign bodies in the heart and pericardium depends upon whether the objects have penetrated these structures directly or have been carried to them by venous channels. If they have entered directly, treatment should be directed to the wounds rather than to the foreign bodies. Postural methods should be employed, in an attempt to throw the object into the circulation, if it is in either ventricle, particularly the left ventricle, whose thick walls make palpation and identification quite difficult. If the object has entered the heart chambers via the circulation, postural methods are also employed. If they are contraindicated or are unsuccessful, conservatism is practiced. Whether or not the object is removed later depends upon whether or not it gives rise to symptoms. Then the risk of removal should be weighed against the severity of symptoms. Objects which are first free in the cardiac chambers and later become fixed should not be disturbed.

The technique of cardiorrhaphy is described in detail. The surgeon is warned that double wounds of the heart are not uncommon and that a wound of the anterior surface is an indication for inspection of the posterior surface.



The policies for the management of thoracic (and other) casualties in the Seventh U.S. Army were generally those employed in the Fifth U.S. Army and base sections in the Mediterranean theater, many of whose surgeons were assigned to the Seventh U.S. Army before the invasion of southern France.

The general policies of surgical care of casualties, including thoracic casualties, were stated in Circular Letter No. 2 (13), dated 18 July 1944. These policies were reiterated in Circular Letter No. 17 (14), on 30 December 1944. The material in this letter was the same as the material in Circular Letter No. 46 (7), issued from the Office of the Surgeon, Headquarters, North African theater, in August 1944. This letter stated the policies for the management of chest injuries which had been agreed upon at the Marcianise meeting in March 1944.

The chief difficulty in new units, according to Colonel Berry, Consultant in Surgery, Office of the Surgeon, Headquarters, Seventh U.S. Army, was failure of their surgeons to realize the extreme importance of performing debridement according to fundamental principles. This was as true of chest wounds as of all other wounds. In theory, these new medical officers fully appreciated the necessity for debridement. In practice, they failed to abide by the theory.

In the Seventh U.S. Army, almost all casualties with wounds of the chest were sent first to field hospitals for examination, evaluation of their wounds, and such resuscitation as might be necessary. About 40 percent were then held in these hospitals for treatment.

Early in the Seventh U.S. Army experience, some surgeons believed that formal thoracotomy should be performed rather frequently at the time of initial debridement and that the official policy of conservatism would produce less good results. This was exactly the same state of affairs that had prevailed in the first days of the fighting in North Africa and Italy. As the campaign in southern France progressed, it became clear, just as it had in North Africa and Italy, that results were better and fatalities fewer when the official policy was strictly followed. When these patients were treated conservatively, they were usually well on their way toward regaining normal lung expansion and function by the time they reached evacuation hospitals. The results reported by general hospitals and observed in visits to them showed that these results were permanent and not ephemeral. As late as May 1945, however, it was necessary to issue another warning against the use of formal thoracotomy in forward hospitals, which had resulted in an increase of empyema (15).


1. Neurosurgery and Thoracic Surgery. Prepared and edited by the Subcommittees on Neurosurgery and Thoracic Surgery, Committee on Surgery, Division of Medical Sciences, National Research Council. Philadelphia and London: W. B. Saunders Co., 1943.


2. Snyder, Howard E.: Fifth U.S. Army. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington: U.S. Government Printing Office, 1962, pp. 333-464.

3. Circular Letter No. 13, Office of the Surgeon, Headquarters, NATOUSA, 15 May 1943.

4. Circular Letter No. 16, Office of the Surgeon, Headquarters, NATOUSA, 9 June 1943.

5. Circular Letter No. 20, Office of the Surgeon, Headquarters, NATOUSA, 22 June 1943.

6. Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, 7 Aug. 1943.

7. Circular Letter No. 46, Office of the Surgeon, Headquarters, NATOUSA, 29 Aug. 1944.

8. War Department Technical Bulletin (TB MED) 147, March 1945.

9. Circular Letter No. 8, Office of the Surgeon, Headquarters, MTOUSA, 10 Mar. 1945.

10. Churchill, E. D.: Selective Evacuation Versus Hitchhiking. J.A.M.A. 145: 841, 17 Mar. 1951.

11. Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army, 7 Apr. 1944.

12. Shefts, L. M.: The Evacuability of Patients With Thoracic Wounds With a Foreword by Brigadier General Joseph I. Martin. Bull. U.S. Army M. Dept. 9(5): 357-363, May 1949.

13. Circular Letter No. 2, Office of the Surgeon, Headquarters, Seventh U.S. Army, 18 July 1944.

14. Circular Letter No. 17, Office of the Surgeon, Headquarters, Seventh U.S. Army, 30 Dec. 1944.

15. Circular Letter No. 9, Office of the Surgeon, Headquarters, Seventh U.S. Army, 18 May 1945.