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Chapter VIII




Lyman A. Brewer III, M.D.


Refinements of diagnosis in thoracic injuries (and all others) were deferred, as a practical matter, until the patient had reached the field or evacuation hospital in which initial wound surgery was to be carried out. Up to that point, all that was necessary for the care of the patient was the general information that he had a wound of the chest which was or was not sucking and in which hemorrhage was or was not a factor.

When the casualty arrived in a field hospital, a preliminary appraisal was made of his wounds and of his general status. His pulse, respiration, and blood pressure were determined immediately and recorded. If he was in shock, or seemed to be verging on shock, resuscitative measures were instituted at once, to prepare him for surgery or to make him safely transportable farther to the rear.

The dressing was checked, to make certain that the wound was not sucking and bleeding was not active. Then, if the patient was in shock or was thought to be verging on shock, diagnostic measures were discontinued and resuscitative measures (p. 241) were instituted at once. The manner in which he reacted to these measures often aided considerably in the determination of his disposition. Many times, after pain had been relieved and vital capacity improved, it became evident that transportation farther to the rear could be safely undertaken. In other instances, when no improvement occurred or when a period of temporary improvement was followed by regression, it became equally evident that operation was an essential part of resuscitation and must be undertaken without delay.

Aside from the fact that resuscitation, from the lifesaving standpoint, was frequently imperative, anything but a tentative diagnosis was often difficult, if not actually impossible, until the casualty had been brought out of shock and his impaired cardiorespiratory balance had been improved or entirely corrected. A soldier admitted to a shock tent groaning with pain, dyspneic, cyanotic, and hypotensive, did not lend himself to examination or appraisal. An experienced chest surgeon, however, or even a considerably less experienced medical officer on a shock team, usually had little difficulty in arriving at a precise diagnosis and making a decision as to the urgency of surgery after such resuscitative measures had been employed as forced coughing, endo-


tracheal catheterization or bronchoscopy, replacement therapy, thoracentesis, and intercostal nerve block.

There were five main points to be considered in the diagnosis of a thoracic wound:

1. The course of the missile and the probable direct damage that it had done.

2. The possible blast effect of the missile.

3. The presence or absence of signs of a completely or partially obstructed airway.

4. The presence of a sucking wound.

5. The presence and degree of pulmonary compression caused by air (pneumothorax) or blood (hemothorax) in the pleural cavity.

While it was frequently impossible, it was always desirable that casualties with thoracic injuries, both before and after operation, should be kept away from the noise of gunfire. The apprehension created by it increased dyspnea and had other bad effects.



History-taking in the manner in which it was usually practiced in civilian medicine was not possible in military medicine, partly because there was no time for such a detailed inquiry and partly because the casualties were, for the most part, in no condition to endure it. It was an invariable rule not to question any patient who was seriously wounded or who was in shock or verging on it until he had been sufficiently resuscitated for the questioning to impose no additional strain on him. If it was possible, however, it was important to learn the position of the patient when he was wounded, for this information helped to clarify the probable course of the missile through the body and its final resting place. It was also important to learn how near the patient was to the actual site of a shell explosion, so that its blast effects could be estimated.

Multiplicity of Wounds

Careful examination of the entire body was a matter of the greatest importance. Serious diagnostic errors, and consequent errors of management, could result if the attention were concentrated on a single wound, however obvious it might be. The associated wound was sometimes more serious than the chest wound and might require more radical surgery (fig. 21).

Wounds of the abdomen were sometimes a part of the thoracic wound and sometimes independent of it. Spinal cord injuries were frequently associated with chest injuries (vol. II, ch. I). Associated wounds of the arm and shoulder


were also frequent, and some chest wounds were sometimes overlooked because of the more conspicuous perforating wounds of the upper arm. It was particularly important in injuries of the arm and shoulder that complete chest roentgenograms be made.

FIGURE 21.-Chest casualty with multiple other wounds, including an injury of the buttock for which colostomy was necessary. The pictures were taken in a base hospital, after closure of the wound of the chest wall. A. Patient recumbent. B. Patient in left lateral position.

Multiplicity, in short, was a factor which influenced every phase of chest injuries, from battlefield management to disposition, and it accounted for a certain rather sizable proportion of the fatalities in such injuries. Multiple wounds, as might be expected, were particularly notable in battlefield deaths (figs. 22, 23, 24, 25, 26, and 27). In the study of a thousand such deaths made by Capt. William W. Tribby, MC, in Italy in 1944 (1), there were only 312 cases in which the wounds were not multiple. In the 572 wounds of the chest included in the series, the wounds were limited to the chest in only 84.


FIGURE 22.-Diagrammatic showing of multiple wounds of head, neck, chest, and both upper extremities caused by shell fragments (mortar). Many small penetrating wounds are present in the face, neck, chest, and both arms. The largest wound, 2 by 3 cm., is in the left anterior axillary line near the shoulder; its track perforates the thoracic wall. (Redrawn from Tribby, case No. 17.)


FIGURE 23.-Multiple wounds, head, chest, and upper extremities, caused by shell fragments. Penetrating wounds, one above right ear and one in right cheek, 1 by 1.5 and 2 by 6 cm. Right side of chest shows a crushing injury with partial evisceration of lung and fractures of ribs and sternum. Right axillary region mutilated, with a compound comminuted fracture of upper end of humerus. Through-and-through wound in right forearm, with a compound comminuted fracture of ulna; lateral point of entry, 1 by 2 cm.; posterior point of exit, 2 by 5 cm. Wound of left hand, 3.5 by 6 cm., shows a compound comminuted fracture of second metacarpal bone. (From Tribby, case No. 58.)


FIGURE 24.-Multiple wounds, head, chest, and both upper extremities caused by high explosive; penetrating wound, 1.7 cm. in diameter, located below left eye; two penetrating wounds, 1 cm. and 1.5 cm. in diameter, in right cheek; anterior wound enters cranial cavity. Four penetrating wounds in anterior chest vary from 1 cm. to 3 by 6 cm.; all four wounds enter thoracic cavity, largest in left upper chest. Left shoulder is mutilated, with compound comminuted fracture of proximal end of humerus; severe mutilation of left hand; penetrating wound, 1.5 cm. in diameter, in right arm in middle of biceps muscle. (From Tribby, case No. 105.)


FIGURE 25.-Multiple wounds, chest and abdomen, caused by high explosive. Wound, 1 cm. in diameter, perforates thoracic wall in anterior left side, in anterior axillary margin at level of first rib. Wound, 1 cm. in diameter, enters thorax in anterior right side at margin of sternum through third intercostal space. Wound, 1.5 by 2 cm., enters thorax in anterior right side in anterior axillary line, level of eighth intercostal space; penetrating wound, 7 mm. in diameter, lateral right side of chest, posterior axillary line, level of eighth intercostal space. Wound 1.2 cm. in diameter, perforates abdominal wall in midline of epigastrium near tip, xiphoid process. (From Tribby, case No. 513.)


FIGURE 26.-Diagrammatic showing of multiple wounds of head, neck, chest, abdomen, right upper extremity, and both lower extremities caused by shell fragments. There is a penetrating lacerated wound, 4 by 10 cm., in the right posterior side of the skull in the region of the squamous suture; both perietal bones, the occipital bone and the right mastoid bone, are extensively crushed. A penetrating wound, 2 cm. in diameter, enters the base of the neck in the right lateral side. A penetrating wound, 2 by 3 cm., in the right mid chest area through a transverse fracture of the fourth rib. A through-and-through wound is present in the lower abdomen; the point of entry, 2 cm. in diameter, is in the left lower quadrant, and the point of exit, 4 cm. in diameter, is in the right side near the umbilicus. A wound, 4 by 6 cm., penetrates the right anterior shoulder without a palpable fracture. A through-and-through wound in the proximal third of the right mid arm reveals a compound comminuted fracture of the humerus; the point of entry is located laterally and measures 10 cm. in diameter; the point of exit is located medially and measures 12 cm. in diameter. A penetrating wound, 5 cm. in diameter, in the right distal arm, exposes a compound comminuted fracture of the lateral epicondyle of the humerus. There are several large lacerated, penetrating wounds in both anterior thighs, in the knees, and in the right mid leg. The largest wound is in the distal anterior right thigh and measures 20 cm. in diameter; there is a compound comminuted fracture of the femur in this latter wound. (Redrawn from Tribby, case No. 465.)


FIGURE 27.-Diagrammatic showing of multiple wounds of neck, chest, abdomen, and left upper and right lower extremities caused by high explosive. A penetrating wound, 2 cm. in diameter, is found in the tip of the left shoulder. The track extends downward and medially and enters the left side of the thorax. There are comminuted fractures in the head of the left humerus and in the lateral end of the clavicle, in the acromion process of the scapula, and in the first rib. Four lacerated penetrating wounds are present in the posterior right side of the neck and chest between the levels of C7 and T4. The largest wound, 4.5 by 8 cm., is near the inferior angle of the right scapula. There are compound comminuted fractures in the first four ribs, in the right scapula and in the body of T2. A superficial lacerated wound, 3 by 5 cm., is present in the lower posterior left side of the chest. A wound, 1 by .5 cm., enters the abdominal cavity above the posterior left crest of the ilium. A penetrating wound, 2.5 cm. in diameter, enters the abdomen in the right flank near the tip of the eleventh rib. There is a through-and-through wound in the proximal end of the right leg adjacent to the knee joint. The medial opening measures 3 by 4 cm., the lateral opening, 3 by 5 cm. The proximal ends of the tibia and fibula are severely comminuted. (Redrawn from Tribby, case No. 580.)


Methods of Physical Examination

Physical examination was carried out after the clothing had been cut away and removed, to avoid the possibility of overlooking associated wounds. Wounds that were adequately dressed when the casualty was received in the field hospital were not disturbed until it was possible for both the chest surgeon and the shock officer to examine them together. Multiple inspections were avoided. They invited infection and, if a sucking wound was present, permitted the further entrance of air into the pleural cavity. Examination included the head, neck, and extremities, as well as the chest, back, lumbar area, and abdomen, to insure that a small wound of entrance or any source of hemorrhage was not overlooked.

Experience showed that in the circumstances that prevailed in a field hospital, a gross physical examination offered more useful information than could be obtained from more refined methods applicable in civilian practice. For example, a check of the position of the trachea in the suprasternal notch or of the position of the apex cardiac impulse gave as much evidence, and sometimes more evidence, of the presence of a clinically significant hemopneumothorax than did time-consuming percussion and auscultation, measures that were often difficult to carry out in a busy, noisy resuscitation ward. Minor deviations from the normal, such as would have been found by more refined methods of diagnosis, were seldom of particular significance in the plan of management.

Projection of the Course of the Missile

Physical examination was carried out by the usual routine, supplemented by accurate localization of the external thoracic wound or wounds and by projection of the probable course of the missile, beginning with the information provided by roentgenologic examination. It was necessary to take into consideration the location of the external wound or wounds, to identify fractures of the ribs, and to visualize any metallic fragments which might be present. It was also necessary, when possible, to determine the patient's position at the time of wounding.

As a general rule, missiles traveled in a fairly straight line, but if they struck the bony thoracic cage, deflections were to be expected. The voluminous literature on the erratic course of missiles within the body has always tended to put too much emphasis on the exceptional case in which the missile, because it struck a rib or some other bony structure and was reflected from it, failed to take the usual straight course.

Foreign bodies lying free in the pleural cavity could be quite misleading. In one such case, no wound of entrance could be found, and the only associated wound was over the deltoid tubercle. When the patient was asked about his position at wounding, he said that he was lying on the ground, with his arm extended upward alongside his head, when he was injured (fig. 28). This was


only one of many cases in which, when the facts were secured, the course of the missile ceased to be mysterious.

If the patient's condition permitted, it was always best to move him to a clean litter before roentgenologic examination. In more than one case, a foreign body which lay free on the litter was sometimes erroneously thought to be in the body.

Details concerning the localization of retained foreign bodies appear under that heading (vol. II, ch. VII).

FIGURE 28.-Diagrammatic showing of apparently bizarre course of missile, with only wound of entrance over deltoid tubercle. A. Course of bullet at wounding, when patient was lying with left arm extended above his head. B. Course with arm at side.



Among the points on which the casualty with a chest wound was questioned when time and circumstances, including his own status, permitted were the following:

1. His chief complaint. This was not always related to the obvious wound or wounds, and such an inquiry sometimes directed attention to a wound which had not been entered on the emergency medical tag.

2. Pain, including its type, location, and relation to respiration. Pain of some degree was the rule in thoracic wounds, although its intensity was frequently dulled by morphine before the patient was received in the field hospital. It was often located in the chest wall, but pleural pain was a definite


entity. Even if the wound was limited to the thorax, it was frequently associated with abdominal pain and tenderness.

3. Dyspnea, including its onset in relation to wounding and whether it was increasing or decreasing. True shortness of breath implied deficient oxygenation, and, in the absence of severe blood loss, was usually attributable to decreased function of the pulmonary parenchyma. Among the conditions which could contribute to it were hemothorax, pneumothorax, and hemorrhagic infiltration of the lung. A history of increasing dyspnea suggested increasing pressure on the lung by blood or air.

4. Whether blood had been coughed up, and, if so, when the episode had occurred in relation to wounding and how copious the hemoptysis had been. Hemoptysis of some degree could be expected in almost all penetrating wounds of the chest. It was also common in severe wounds of the thoracic wall, in contusions of the lung, and in blast injuries. Hemoptysis was always a warning sign, though the amount of blood coughed up varied with the particular wound and was not correlated with its severity.

5. Nausea and vomiting, in relation to the time of wounding and the time of the last meal before wounding. Nausea and vomiting were not commonly associated with wounds limited to the thorax, but they occasionally occurred. In at least one instance, they were present in a wound of the heart (vol. II, ch. II). Frequently, however, these manifestations were related to the stress and strain of combat conditions, under which undigested food might remain in the stomach for many hours, to be ejected under the additional stress of wounding.

6. Any period of unconsciousness, and, if it had occurred, how long it had lasted. A short period of unconsciousness was not infrequent in injuries caused by high explosive shells. Longer periods, especially if the casualty had previously been fully conscious and oriented, were more likely to be caused by shock, severe blood loss, cerebral concussion, or cerebral damage from prolonged anoxia. Maniacal manifestations, which were sometimes observed, always indicated severe anoxia.

The clinical picture of severe shock in a thoracic casualty was sometimes the result of loss of blood by the usual routes but was sometimes the result of a rapid decrease in the vital capacity caused by pulmonary collapse from bleeding into the pleural cavity, with mediastinal shift. This picture might also be produced by the reduced respiratory excursion resulting from pleural pain, most often caused by fracture of the ribs.

7. Sucking (blowing) of the wound. A story of sucking or exchange of air through the wound was presumptive evidence that the missile had penetrated the pleura. The same observations were occasionally made in extensive soft-tissue lesions without pleural involvement, especially if the chest wall was flaccid as the result of multiple rib fractures. The presence or absence of sucking had no bearing on the course of the missile or on the damage it might have done.

8. The wounding agent, the patient's position at the time of wounding, and his distance from the high explosive shell or other missile.


9. Whether the time of wounding, as far as the patient knew, corresponded with the time recorded on the emergency medical tag.

A quick runthrough of these questions, which could be asked as the physical examination was proceeded with, often provided a surprising amount of useful information. It also played a part in establishing the physician-patient relation so often necessarily, but always unfortunately, lacking in medicomilitary circumstances.


General considerations-The general appearance of the patient, including his color, was more important than the physical signs elicited in the chest. If cyanosis and dyspnea of any degree were present, it had to be assumed that the cardiorespiratory mechanism was out of balance. Cyanosis was always a sign of comparatively advanced anoxia. Even under these circumstances, however, it was not always present: If there had been severe blood loss, cyanosis might not be detectable because of the lower hemoglobin content of the blood. It could be missed in poor light.

The type and character of the respirations were important. Patients with badly contused lungs from direct injury or from blast often exhibited the signs of wet lung (vol. II, ch. V). Rapid, rattling respirations, with frequent, ineffectual coughing, were clear evidence of difficulty in maintaining a patent airway.

Chest findings-Both cyanosis and dyspnea indicated the necessity for careful examination of the chest for signs of pressure pneumothorax, a large hemopneumothorax, or an incompletely sealed sucking wound. Any perforating or penetrating wound of the chest of any consequence necessarily resulted in the entrance of at least a small amount of blood or air or both into the pleural cavity. Small amounts did not materially influence the cardiorespiratory mechanism, but when either was present in sufficient quantity to restrict lung expansion, adequate oxygenation could not occur. Physical signs could be most misleading in estimating the size of the pleural collection, and the severity of symptoms was often entirely unrelated to the amounts of fluid or air detected on physical examination.

Unilateral rigidity of the chest wall was frequently associated with hemothorax, but its absence was of no diagnostic significance.

Abdominal findings-Careful examination was carried out in all thoracic injuries to determine whether the wound was thoracoabdominal or whether a separate abdominal wound was also present. Abdominal examination in all chest injuries was also required for other reasons:

1. A large number of patients with uncomplicated thoracic injuries developed acute gastric dilatation soon after wounding, though many times it was not apparent until roentgenologic examination was carried out (vol. II, ch. IV). Gastric dilatation increased respiratory difficulties and was an indication for immediate decompression by nasogastric suction.

2. Even a wound limited to the thorax was frequently accompanied by abdominal pain, tenderness and rigidity (the phrenodiaphragmatique rigidity


referred to by French writers). The abdomen might be completely silent. The origin of these symptoms and signs has never been fully explained. Irritation or injury of the intercostal nerves and diaphragm did not seem to cover all cases. The picture was further confused by the fact that in some intraabdominal injuries, especially if only the spleen or the liver was injured, physical findings soon after wounding might be very slight.

Differentiation between thoracic wounds accompanied by abdominal findings and thoracoabdominal wounds was frequently difficult, but it was imperative to lose no time in making it. As a rule, the abdominal spasm which accompanied a thoracic wound tended to be unilateral and to become less evident upon inspiration, while spasm caused by an abdominal injury tended to be bilateral. Anesthetic block of the intercostal nerves in the involved areas sometimes furnished useful diagnostic aid. If pain and cutaneous tenderness disappeared after the block, it could be concluded that the wound was limited to the chest. If some degree of spasm, rigidity, and tenderness on deep pressure persisted in spite of the nerve block, it could be concluded that an abdominal injury was present in addition to the thoracic wound. This was a time-consuming method, which would not be used in patients in poor condition.

The correct interpretation of clinical symptoms and physical signs was most important in patients whose condition was too precarious to permit roentgenologic examinations until extensive resuscitative measures had been employed.

Details of the diagnosis of thoracoabdominal wounds are discussed under that heading (vol. II, ch. III).


X-ray facilities, as already mentioned, were somewhat limited during the North African campaign, and a field hospital had only a single apparatus for its three platoons. This situation was remedied before the invasion of Italy, and thereafter each platoon had its own machine and accessories.

An essential part of the preoperative routine in chest injuries in which pleural penetration was evident or was a possibility was a roentgenologic survey of the chest and upper abdomen. In many cases, it could be determined clinically exactly what the damage was and what procedures were required for its correction. It was better, however, to take unnecessary pictures than to find out, in the midst of an operation, that they should have been secured. All films were developed and dried at once and taken to the operating room with the patient.

Posteroanterior and lateral films of the chest and upper abdomen were taken in the upright or semiupright position whenever the patient's condition permitted. Pictures in this position provided highly accurate information concerning the extent of the trauma and the organs involved and also revealed fluid levels. This routine was never followed in severely shocked patients. If lateral films were not satisfactory, as they rather frequently were not, oblique


FIGURE 29.-Anteroposterior roentgenogram showing track of missile in left lung, with foreign body in left axilla.

films were made, or fluoroscopic examination was resorted to if the information was considered necessary. Neither method was employed routinely as part of the initial examination, though both were extremely useful later.

The usefulness of roentgenologic examinations in thoracoabdominal wounds has already been mentioned, as has their employment to demonstrate gastric dilatation which could not always be established by physical means.

Foreign bodies are discussed in detail elsewhere in this volume (vol. II, ch. VII), but a few words should be said about them at this point. If it was considered important to localize them at this echelon of medical care, additional films were made with the Potter-Bucky grid. The possibility that a foreign body was free in the pleural cavity always existed when roentgenograms showed the missile to be at a considerable distance from the point suggested by physical examination of the injury (fig. 29), especially if it lay low in the thorax. To substantiate the diagnosis, another film was taken with the patient in another position, to allow for a shift in the position of the object.

In cases in which there was no wound of exit on examination and roentgenograms revealed no evidence of a foreign body, there were two possible explanations:

1. The missile might have been of low velocity when it struck the chest and might have fallen back after causing the wound of entrance.


2. The missile might have had sufficient velocity to penetrate the abdomen or neck after passing through the chest. The number of these injuries was so large that in some hospitals it was routine to take films of both the abdomen and the thorax in all chest injuries. The policy was perhaps somewhat wasteful of films, but it saved time and eliminated the annoyance of having to take additional films later.


1. Tribby, William W.: Examination of One Thousand American Casualties Killed in Action in Italy. Report to Surgeon, Fifth U.S. Army, 1944, 6 vols. [Official record.]