Medical Science Publication No. 4, Volume 1
THURSDAY AFTERNOON SESSION
22 April 1954
MODERATOR
COLONEL JOHN M. SALYER,MC
AN ANALYSIS OF 2,811 CHEST CASUALTIES OF THEKOREAN CONFLICT*
MAJOR A. R. VALLE,MC
In this paper we present an anlaysis of the 2,811 chest casualties ofthe Korean conflict who were treated at Tokyo Army Hospital between thebeginning of the war and March 1953. A previous report covering 1,535 ofthese casualties has been published (21). However, this paper addsmore than 1,000 cases and contains data which were not available at thetime of the previous reports. Some conclusions are reported because additionalexperiences only served to bear out their validity.
Tokyo Army Hospital was the center for treatment of thoracic casualties.Approximately 85 percent of our patients were United States military personneland 15 percent were members of forces contributed to the Korean effortby other United Nations.
During the first few months of the conflict, definitive treatment couldnot be administered overseas because casualties could be hospitalized inthe theater only 30 days. However, as the bed capacity increased, the periodof hospitalization was increased to 120 days, making definitive treatmentpossible.
In this series we have included only those patients who suffered injuriesto the intrathoracic viscera and do not include those with only superficialwounds of the chest. Of these wounds, 1,968 or 70 percent were of the penetratingtype, 787 or 28 percent were of the perforating type and 56 or 2 percentwere results of crushing injuries.
Hemothorax
The most frequent complication of intrathoracic wounds is hemothoraxwith or without associated pneumothorax. This intrapleural blood may remainfluid or may coagulate and begin to organize. In this series 1,744 patientsor 62 percent either had hemothoraces on admission or developed them withinthe first 2 weeks after admission. Of this number 74 percent or 1,291 remainedsterile and 26 percent or 453 became infected.
*Presented 8 December 1953, to the Military Medicine Refresher Course, and 22 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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We treated hemothorax by simple thoracentesis without air replacement.Following removal of the fluid, 300,000 units of crystalline penicillinand 1 gram of streptomycin were instilled. The procedure is repeated every24 hours, or more often if thought indicated, until no fluid can be obtainedand the chest appears normal to physical and x-ray examinations. Specimensof the fluid removed were sent to the laboratory for culture, antibioticsensitivity tests and other studies as indicated. If infection was present,the antibiotic of choice was administered systemically and intrapleurally,depending upon the manner in which the drug could be administered. Penicillin,streptomycin, terramycin, aureomycin and chloromycetin were utilized.
Eighty percent or 1,395 patients completely recovered after being treatedby thoracenteses and antibiotics only. Sixty-eight percent were returnedto duty and the remainder were evacuated to the Zone of Interior becauseof other wounds although they were recovered as far as their chests wereconcerned.
Many patients had clotted hemothoraces on admission to the hospitalor within 2 days of being wounded. From a review of those patients' records,it would seem that the hemothorax clotted within a few hours of wounding,because at no time was any fluid obtained by aspiration. In other patientsthe hemothorax coagulated gradually, taking from 3 to 4 days to 2 weeks.
Decortication is the established method of treatment for those patientswith significant clotted or organized hemothoraces (3-5, 7-13, 15, 16,19). A total of 254 decortications were performed on patients withboth infected and noninfected organized hemothoraces. Of these 76 percentwere infected and 24 percent were noninfected. Ninety-one percent wereconsidered as having good results, 4 percent as having fair results and5 percent as having poor results.
It is noteworthy that 92 percent of the patients who needed decorticationhad closed intercostal drainage tubes inserted in Korea (23). Wefeel that closed intercostal drainage has many disadvantages as an earlytreatment for hemothorax. It increases the hazards of evacuation sincethe tubes were often found improperly clamped off and fluid from the bottleswas sucked back into the chest. Furthermore, in hemothorax, closed drainageusually loses its value within 24 to 36 hours because of occlusion of thetube by fibrin and clots and by pleural adhesions about the intrathoracicportion of the tube (21-23).
After performing decortications at intervals of 1 to 8 weeks followinginjury, it was decided that the optimum time for such operation is within3 to 5 weeks of injury. From a review of the reports published by surgeonswho had experience in treating chest casualties during World War II, itwould seem that there is general agreement
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upon this interval (10-12). In those operations performed early,the bleeding was much more severe, there was more edema and foreign bodies,if present, were more difficult to locate.
In 18 cases we used streptokinase and streptodornase according to theprocedure described by Tillett and Sherry (14-18). We obtained suchpoor results that their use was discontinued.
Foreign Bodies
It was the policy at Tokyo Army Hospital to remove only those foreignbodies which exceeded 1.5 cm. in greatest diameter, unless, of course,they were in such a location as to be regarded as dangerous to the patient,unless they caused some pathologic changes within the chest, or producedsymptoms. Persistence or development of reaction about the missile indicatedthe need for exploration and removal (1, 2).
Three hundred and twenty-seven patients had retained foreign bodieswhich necessitated removal. Approximately 85 percent of these were shellfragments which varied in size from 1 to 9 cm. in diameter and the remaining15 percent were bullets of various caliber. The incidence of infectionwhen the foreign body was shell fragment was high, from 60 to 70 percent.When the foreign body was a bullet, the incidence of infection was about10 percent.
Among the 327 patients operated upon at Tokyo Army Hospital solely forthe removal of foreign bodies, the postoperative empyema incidence wasonly 2 percent. The majority of these patients returned to duty but a smallnumber had to be returned to Zone of Interior because of other wounds.
We found that delaying operation for removal of foreign bodies for 2to 3 weeks, if possible, decreases the amount of bleeding at operationand makes location of the foreign body easier. Also the patient is usuallyin much better condition to tolerate the thoracotomy procedure. In reviewingthe records, we also found that the empyema incidence among some 150 patientswho were operated upon in forward areas for removal of foreign bodies was25 percent.
Mediastinal Injuries
One hundred and seventeen or slightly more than 4.2 percent of our patientssuffered mediastinal wounds. The majority of these patients also had retainedmetallic foreign bodies. Approximately 65 percent of these patients developedinfections which were drained through the pleural space.
We removed 32 foreign bodies from the mediastinum, 10 from the pericardium,and 16 from the myocardium. Three patients had
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foreign bodies in the intraventricular septum which we did not remove.
Forty-two patients developed pericardial effusions which were treatedwith pericardiocenteses and antibiotics. Pyogenic organisms were obtainedfrom culture of the aspirated fluid in about 40 percent of the cases.
The following table shows the extent to which other structures in themediastinum were injured.
Esophagus | 9 |
Aorta | 8 |
Thoracic duct | 5 |
Vena cava | 3 |
Trachea | 5 |
The majority of these patients, with the exception of those with injuriesto the heart and great vessels, were returned to duty in the theater.
Thoraco-abdominal Wounds
It was our experience that many patients with thoraco-abdominal woundsinvolving the upper abdomen could be handled adequately through the thoracotomy.The exposure is good and it obviates the necessity of an abdominal or thoraco-abdominalincision. It was our impression that those patients who needed extensiveabdominal surgery made better progress when separate thoracotomies andlaparotomies were done than when a thoraco-abdominal incision was made.Also, infection if it develops, is more localized when separate incisionsare made.
Generally those patients who suffered injuries to the diaphragm andspleen in conjunction with their chest wound had these injuries repairedat thoracotomy. We repaired 186 injuries to the diaphragm and performed8 splenectomies. The majority of these patients were returned to duty inthe theater.
Patients with serious liver damage, multiple intestinal perforationswith or without resection, colostomies, nephrectomies, etc., were evacuatedto the Zone of Interior for definitive chest surgery. If necessary, thetemporizing procedure of open drainage with rib resection was carried outso that they could be safely evacuated.
The following list gives the extent to which various abdominal organswere injured:
Liver | 201 |
Spleen | 82 |
Large intestine with colostomy | 52 |
Small intestine | 18 |
Stomach | 48 |
Kidney | 33 |
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Approximately 18 percent of our patients suffered wounds involving boththe chest and abdomen. Four deaths or slightly more than 25 percent ofour mortality were in this group.
Other Injuries
A large number of our patients suffered nerve injuries and/or orthopedicinjuries along with their chest wounds. Those patients whose injuries wereso serious that there was little likelihood of their returning to dutyin the theater usually received only palliative treatment such as thoracentesisor thoracotomy drainage with rib resection and were evacuated to the Zoneof Interior.
Bacteriology
Many kinds of bacteria were isolated on culture of the fluid aspiratedfrom the chests of our patients. In the beginning, the infection was usuallya mixed one, made up of various gram-negative rods and gram-positive cocci.However, as antibiotic treatment continued, the gram-negative bacilli,such as E. coli, E. freundii, Aerobacter aerogenes, Pseudomonas aeruginosa,various Proteus species, etc., were usually destroyed, leaving onlythe gram-positive cocci to be dealt with.
Hemolytic and nonhemolytic Streptococci were isolated in a number ofcases but by far the most common and most persistent organism encounteredwas hemolytic, salt-resistant, mannite-fomenting (coagulase-positive) Staphylococcus.The Streptococci were easily controlled by antibiotics but usually theStaphylococcus became resistant to all antibiotics except chloromycetinin very high concentrations.
We found various types of proteolytic Clostridia in a number of ourcases, which could account for the massive destruction of lung tissue foundin these cases.
Morbidity
The prime factor in the treatment of chest casualties is the restorationof normal cardio-respiratory physiology as soon as practicable (3, 20).All such procedures as thoracentesis, decortication, removal of foreignbodies and irreparably damaged lung tissue, repair of the diaphragm andchest wall help restore normal function and decrease morbidity.
We feel that physiotherapy is an important adjunct in decreasing morbidity(6). If possible, it is started on the third postoperative day.The patients begin with breathing exercises and blow bottles and passiveand active exercise of the shoulder and arm of the side operated upon.
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The period of hospitalization, in most instances, varied from 3 to 6weeks. Following discharge from Tokyo Army Hospital, these patients whowere considered candidates to return to duty in the theater were sent toCamp King. This camp was a convalescent and reconditioning center. It wasoperated under medical supervision and the amount of activity was graduallyincreased to combat peak. Those patients who could not stand the rigorsof combat conditions were weeded out and sent to limited duty.
Approximately 80 percent of the chest casualties who had definitivetreatment at Tokyo Army Hospital returned to duty in the theater. Alsowe know that a considerable number of patients who had to be evacuatedeventually returned to duty but we have no data concerning these.
Mortality
It is assumed that the initial mortality in thoracic wounds must behigh but we have no overall figures about the mortality of chest woundsin the Korean conflict. However, the delayed mortality appears to be lowerthan might be expected. Our overall mortality at Tokyo Army Hospital was0.6 percent and that reported for the Yokasuka Naval Hospital was 1.9 percent(7).
We had 17 deaths in our series of 2,811 cases. Eight of these patientsdied as a result of serious wounding: 4 patients, of thoraco-abdominalwounds, 1 patient of pulmonary embolism, 1 patient of cardiac tamponadeand 2 with serious nerve injuries. Nine of our deaths were due to homologousserum hepatitis. Many other patients, all of whom had received numeroustransfusions of plasma and whole blood, developed jaundice but did notsuccumb.
More than 800 major operations, excluding thoracotomy drainages, wereperformed without a death, as follows:
Decortications | 254 |
Lobectomies and partial resections | 169 |
Pneumonectomies | 5 |
Splenectomies | 8 |
Thoracotomies for removal of foreign bodies, etc. | 435 |
Many factors contributed to this low mortality. We had the benefit ofthe experience of the chest surgeons in the rather recent World War II;we had more and improved antibiotics; there was plasma and whole bloodreadily available for transfusion near the battle lines; the Mobile ArmySurgical Hospitals could do major surgery if necessary just a few milesfrom the front lines; evacuation was very rapid. Lastly, but of great importance,the patients were healthy young men with an average age of 23 years.
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Late in the war protective vests were introduced which helped decreasethe mortality of chest wounds. They are most effective in stopping low-velocitymissiles and many soldiers who would have been instantly killed if notprotected by the vest, are only wounded.
Conclusions
Our experience with 2,811 chest casualties indicates that, in general,the best early treatment for chest wounds is the most conservative one.
Thoracentesis is the most effective treatment for hemothorax. Approximately80 percent of the patients with hemothorax were cured by thoracentesisand antibiotic treatment. We feel that closed intercostal drainage is seldomnecessary and often dangerous. Ninety-two percent of those patients whorequired decortication had intercostal drainage tubes inserted in Korea.
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