APPENDIX
Special Reports and Statistical Data
B. Noland Carter, M.D., and Michael E. DeBakey, M.D.
Throughout this volume, statistical and othermaterial has been cited from the clinical experiences in World War II of variousorganizations and individuals. This appendix summarizes the clinical-statisticaldata on thoracic surgery of the activities of:
1. The 2d Auxiliary Surgical Group in the Mediterranean(formerly North African) Theater of Operations, U.S. Army, from the final reportmade by Maj. (later Lt. Col.) Reeve H. Betts, MC; Maj. (later Lt. Col.) Paul C.Samson, MC; Maj. Lyman A. Brewer III, MC; Maj. (later Lt. Col.) Lawrence M.Shefts, MC; and Maj. Thomas H. Burford, MC.
2. The 5th Auxiliary Surgical Group in the European Theater ofOperations, U.S. Army, from the final reports on 1,068 war wounds of the thoraxand abdomen, made by Maj. William H. Falor, MC; Maj. Charles B. Burbank, MC; andMaj. (later Lt. Col.) Elmer D. Gay, MC.
3. The Kennedy General Hospital thoracic surgery center,Memphis, Tenn. The material used is an analysis of the first 500 thoraciccasualties received in the center after it became fully operational. The reportwas prepared by Maj. Earle B. Kay, MC, and Lt. Col. Richard H. Meade, MC.
The original detailed reports are on file in The HistoricalUnit, U.S. Army Medical Service.
2D AUXILIARY SURGICAL GROUP
Basic Data
Between the Tunisian landings in November 1942 and the end ofthe war in Italy in May 1945, the 27 general surgical and 5 thoracic surgicalteams of the 2d Auxiliary Surgical Group1cared for approximately 22,000 battle casualties in North Africa, Sicily,Italy, southern France, and Germany. The 3,154 abdominal injuries included inthis material are analyzed in another volume of this series.2
During the specified period, surgeons of the2d Auxiliary Surgical Group cared for 1,364 casualties with thoracic wounds, 135of whom (9.89 percent) died, and 903 casualties with thoracoabdominal wounds,247 of whom (27.35 percent) died. This is a total of 2,267 casualties withthoracic and thoracoabdominal wounds and 382 deaths (16.85 percent).
Among the casualties with only chest woundswere 115 civilians and prisoners of war, of whom 19 (16.52 percent) died. Thisleaves 116 deaths in 1,249 U.S. Army personnel with thoracic wounds (9.29percent). The following discussion includes only these 1,249 casualties unlessotherwise specified.
The figures include all penetrating and perforating woundsencountered by the group surgeons during this period. They do not includeinjuries limited to the thoracic cage,
1The extensive experience of the teams of the 2d Auxiliary Surgical Group with thoracoabdominal injuries is summarized under that heading (p. 136).
2Medical Department, United States Army, Surgery in World War II. General Surgery. Volume II. Washington: U.S. Government Printing Office, 1955, pp. 79-333.
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without pleural penetration, even though pleural damagesometimes occurred under these circumstances.
In the early days of the Tunisian campaign, asmall number of these casualties were operated on in clearing stations. A fewwere also operated on in beach installations, during the first few days ofamphibious landings. With these exceptions, all the casualties received theirinitial wound surgery in field and evacuation hospitals.
All the deaths occurred in these forward hospitals, for whichthe figures can be assumed to be complete. On the other hand, casualties wereheld in forward hospitals only for limited periods, seldom more than 14 days. Itmust therefore be assumed that a certain number of deaths occurred later, infixed hospitals and thoracic surgery centers in the base. There is noinformation on this point, for the attempts at followup that were occasionallymade were not successful.
Deficiencies of records-Manyerrors and imponderables enter into any records prepared by medical officersunder field conditions. There are errors and omissions in these. Yet they aresurprisingly complete when one considers the circumstances in which the materialwas compiled. It was necessary for each team to prepare from four to sevenofficial records on each patient, all in longhand, all without secretarial orstenographic help, and all containing much duplicated material. All post mortemexaminations were made by members of the teams, and all protocols were writtenby them in longhand. During rush periods, when surgeons were working long hoursunder extremely adverse conditions, their zeal in the preparation of additionalrecords for some future study was naturally limited. The most amazing thingabout the records is that they were kept at all.
These statistics and conclusions are based onthe overall experience of the surgeons of the 2d Auxiliary Surgical Group. Theyrepresent not only individual experiences but the aggregate experiences of allthe surgeons. The number of injuries is large enough to warrant conclusions. Thecasualties were treated over a sufficiently long time, in sufficiently variedclimates and terrains, under sufficiently varied conditions, to compensate forsome of the variables and to cancel out some of the inevitable errors. The chiefjustification for the presentation of this clinical-statistical material indetail is that, so far as is known, this is the most extensive study ofcombat-incurred thoracic and thoracoabdominal wounds that has ever been made.
Chronologic division of cases-Thereare a number of reasons for analyzing certain of these data according to whetherthe casualties were treated before or after 1 May 1944. The date, which isarbitrarily selected, represents a turning point in clinical policies, to whichthe improved results (a drop in the case fatality rate from 11.27 percent to 8.3percent) bear witness. Among the factors responsible for this improvement were:
1. Better triage, based on a clarified definition oftransportability (vol. I).
2. More rapid evacuation of casualties from the battlefield tothe division clearing station.
3. A more correct appreciation of the physiologic componentsof resuscitation, including the importance of wet lung (p. 207).
4. A clarification of the indications for thoracotomy inforward hospitals and of the limitations of this operation.
5. Improvements in postoperative care.
6. The provision of liberal amounts of blood by a theaterblood bank, so that every casualty could be given all he needed.
7. Improvements in anesthesia, as a result of both moreadequate equipment and the increased experience of anesthesiologists.
8. The universal availability of penicillin, which after 1 May1944 could be used in adequate amounts whenever it was indicated.
9. The increased experience of both thoracicsurgeons and general surgeons who were called upon to care for thoraciccasualties, which is discussed elsewhere as the so-called learning curve (p.139).
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It was the opinion of many surgeons of the 2dAuxiliary Surgical Group that casualties cared for after 1 May 1944 were,generally speaking, more severely wounded than those treated before that date.This is not a matter which lends itself to statistical proof. If the opinionwere correct, and if other factors had remained equal, a higher case fatalityrate might have been anticipated after that date. Instead, as just pointed out,the rate fell, probably for the reasons just specified.
Wounding Agents and Location of Injuries
In the 1,203 injuries in which this information is available,the wounding agent was a shell fragment in 830 cases, a gunshot wound in 371cases, and a stab wound in 2 cases.
In 1,240 stated injuries, the right side was involved 602times (48.55 percent) and the left side 603 times (48.63 percent); both sideswere involved 35 times (2.82 percent).
In 1,238 injuries, 719 of the wounds were penetrating (58.08percent), 478 perforating (38.61 percent), and 41 lacerating (3.31 percent).
Shock and Resuscitation
Shock-Of the 400thoracic casualties treated before 1 May 1944 (hereafter referred to as Group I)for whom this information was recorded, 149 were not in shock, 67 were in mildshock, 83 were in moderate shock, and 44 were in severe shock. The correspondingdata for the 849 casualties treated after 1 May 1944 (hereafter referred to asGroup II) indicate that 314 were not in shock, 162 were in mild shock, 190 werein moderate shock and 110 were in severe shock.
Blood and plasma-Duringthe early fighting in North Africa, plasma was used liberally and bloodinfrequently. Blood was used in increasing amounts and on broadening indicationsin the fighting in Sicily and in the first months of fighting in Italy, but thesupply was limited, and it was often difficult to obtain until a theater bloodbank was established in Naples in February 1944. That circumstance is part ofthe explanation for the more limited use of blood and the more liberal use ofplasma in Group I injuries in this series. On the other hand, there must also betaken into consideration that in the early months of the war, it was believedthat plasma was an acceptable substitute for whole blood and that in somequarters, at least, this belief died slowly. The amount of blood and plasmaadministered to these two groups of casualties therefore depended not only upontheir special necessities but upon the availability of whole blood and theoriginal impression of the value of plasma.
It is not thought that the statistics that follow arecomplete, though they are based on all the specific information recorded on theemergency medical tag and on the records of the hospital in which initial woundsurgery was performed. Entries on some additional charts suggested thatreplacement therapy might have been employed, but the data were not specific andwere discarded.
The composite recorded figures for replacement therapy are asfollows:
In Group I, 196 or 400 patients (49.00percent) received plasma in the total amount of 138,200 cc., the average amountper patient being 705 cc. The largest amount given was 2,500 cc.
In Group II, 569 of the 849 casualties (67.02 percent)received a total amount of 351,200 cc. of plasma, the average amount per patientbeing 617 cc. The largest amount given was 2,750 cc. The drop in Group II ofalmost 100 cc. in the average per case probably reflected the increasedavailability of blood at this time and the restriction of plasma to its properuses.
In Group I, 172 of the 400 patients (43.00 percent) received atotal of 179,900 cc. of blood, the average per patient being 1,046 cc. Thelargest amount given was 3,600 cc.
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In Group II, 633 of the 849 casualties (74.56 percent)received a total amount of 753,850 cc., the average amount per patient being1,189 cc. The largest amount given to a single patient was 7,500 cc.
Autotransfusion was used in 29 patients in Group I, in thetotal amount of 23,400. The average per patient was 807 cc., and the largestamount thus given was 2,700 cc.
In Group II, 42 patients were treated by autotransfusion, inthe total amount of 28,950 cc. The average per patient was 689 cc., and thelargest amount given was 2,000 cc. The figures for Group II probably reflect theincreased availability of blood; autotransfusion is not a desirable technique ifblood can be secured elsewhere.
Other resuscitative measures-In GroupI, 8 of the 400 patients were treated by intercostal nerve block, 53 bythoracentesis (in 1 case via intercostal catheter), and 4 by tracheal aspirationper catheter. Preoperative bronchoscopy to clear the airway was not used in anyinstance in Group I.
In Group II, 69 of the 849 casualties were treated byintercostal nerve block, 218 by thoracentesis (in 9 cases by intercostalcatheter), 25 by tracheal aspiration per catheter, and 8 by bronchoscopy. Onemust be impressed by the more active measures used in Group II to facilitatedeep breathing and coughing and to keep the airway clear. In spite of the timeconsumed by these additional measures, the average timelag fell from 15.7 hoursin Group I to 14.0 hours in Group II.
Measures to control pressure pneumothorax were seldomnecessary. This complication was encountered only once in Group I and only 10times in Group II.
Surgical Procedures
In Group I, 234 of the 400 patients (58.50 percent) weretreated only by debridement. In Group II, 534 of the 849 patients (62.90percent) were thus treated.
In Group I, 67 thoracotomies were performed by generalsurgical teams in the 243 cases which they handled (27.57 percent). There were11 deaths (16.42 percent). In this same group, over the same period, 72thoracotomies were performed in 157 cases (45.86 percent) by thoracic surgicalteams, with 10 deaths (13.89 percent).
In Group II, 224 thoracotomies were performed in 623 cases bygeneral surgical teams (35.95 percent), with 27 deaths (12.05 percent). In thissame group, 72 thoracotomies were performed in 226 cases by thoracic surgicalteams (31.86 percent), with 6 deaths (8.33 percent). The casualties in thisgroup were all cared for after strict limitations had been put upon the use ofthoracotomy. This fact is reflected in the much smaller proportion of cases inwhich the operation was used, as well as in the reduced case fatality rates.
Thoracotomy was performed through the wound in 368 cases, in156 of which it was necessary to enlarge the traumatic thoracotomy, and by aseparate elective incision in 67 cases.
The indications for the operation, according to the 144 chartson which this information was available, were as follows:
Combined thoracic and abdominal wounds (as contrasted tothoracoabdominal wounds) in 63 cases, with 13 deaths.
Bleeding in 36 cases, with 6 deaths.
Injuries to the mediastinum, heart or both in 20 cases, with 2 deaths.
Retained foreign bodies in 11 cases.
Retained bone fragments in 3 cases, with 1 death.
Pulmonary lacerations in 2 cases, with 1 death.
Bronchial injuries in 3 cases, with 1 death.
Injuries of the esophagus in 3 cases, with 3 deaths.
Possible injury of a hilar vessel, pressure pneumothorax, andfailure of the lung to expand in 1 case each. The casualty with the vascularinjury did not survive.
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Analysis of Fatalities
The breakdown of the 116 deaths in 1,249 wounds of the chestin U.S. Army personnel (9.29 percent ) was as follows:
53 deaths in 768 debridements (6.90 percent).
19 deaths in 234 debridements in Group I (8.12 percent).
34 deaths in 534 debridements in Group II (6.37 percent).
54 deaths in 435 thoracotomies (12.41 percent).
21 deaths in 139 thoracotomies in Group I (15.11 percent).
33 deaths in 296 thoracotomies in Group II (11.15 percent).
9 deaths before, or in the course of, operation.
There were 19 deaths in the 115 wounds in civilians andprisoners of war not included in this analysis (16.52 percent).
Among the 1,249 casualties with chest injurieswere 200 who also had associated wounds of major importance, including 63 woundsof the abdomen, 42 severe compound fractures, 39 spinal cord injuries, 15 severesoft tissue wounds, 7 traumatic amputations, and 4 contralateralthoracoabdominal wounds.
There were 46 deaths in these 200 cases (23.0percent), as compared to 70 deaths in the 1,049 U.S. Army casualties (6.67percent) whose wounds were limited to the chest or who had associated wounds notof major importance. In all combat injuries, the risk was always greater whenthe wounds were multiple, and it increased in proportion to the severity of theprincipal and associated injuries. In many of the cases just listed, the chestwound was obviously of lesser importance than the associated injury.
Causes of Death
In 16 of the 116 deaths in U.S. Armypersonnel, the cause was not recorded and it was impossible to gather from thescanty notes to what they should be attributed. The 41 separate causes listedfor the remaining 100 deaths can be conveniently grouped as follows:
Pulmonary and respiratory causes-Of the100 deaths, 28 were due to pulmonary or respiratory conditions. This was thelargest single group of deaths, and, from the clinical standpoint, the groupmost amenable to treatment. In the opinion of the surgeons who cared for thesecasualties, some of these deaths, at least, must be regarded as preventable.
Seven deaths from pulmonary edema occurred between the first and fourthpostoperative days. In every instance, the pulmonary damage was severe. It isnot known whether positive pressure oxygen therapy was employed in any of thesepatients, but in several cases, it was thought that injudicious replacementtherapy played a part in the fatality.
In 15 cases, the cause of death was listed aspneumonia. In some instances, exposure on the battlefield, preexisting upperrespiratory infection, and the virulence of the organism in relation to theresistance of the host explained both the complication and the fatal outcome.
Four patients died of atelectasis. One died oftracheal obstruction caused by an excessive production of mucus, and anotherdied of wet lung, on the fifth postoperative day. Attempts to improve drainageof the tracheobronchial tree were always vigorous, once the importance of thewet lung of trauma had been realized (p. 207), but occasionally they werenot successful. Sometimes there was a recurrence of the tracheobronchialobstruction after it had been relieved, and the stage was then set for thedevelopment of atelectasis and pneumonia if prompt, zealous efforts were notmade to overcome it.
Shock.-Ten patients died of shock, eight on the day ofoperation, one on the following day, and one on the second postoperative day.
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Nine patients died of renal failure, which inmost instances seemed related to their previous state of shock. All these deathsoccurred in Group II; earlier in the war, lower nephron nephrosis was notrecognized and, as a matter of fact, much about it remained to be clarified whenthe war ended.
Hemorrhage-Nine patients died of hemorrhage, as follows:
3 from lacerations of the aorta.
2 from massive intrapleural hemorrhage.
2 from massive intrapulmonary hemorrhage.
1 from mediastinal hemorrhage.
1 from laceration of the vena cava.
The small number of deaths from intrapleuraland intrapulmonary hemorrhage (only five when the lacerations of the greatvessels are excluded) is striking in view of the emphasis put upon intrathoracicbleeding as a possible cause of death in the prewar discussion of chestinjuries.
Cardiac deaths-There were fivedeathsfrom cardiac injuries, three of which had been overlooked, and another deathfrom cardiac tamponade. One of these injuries was complicated by atelectasis.Two other deaths were caused by cardiac fibrillation.
Miscellaneous causes of death-Othercausesof death, which cannot be conveniently grouped, were as follows:
6 deaths from blast injuries, which affected the pulmonarytissues in 4 cases, the mediastinal tissues in 1 case, and the cerebral tissuesin 1 case.
4 deaths from clostridial myositis, in 1 instance complicated by pneumonia.
4 deaths from pulmonary embolism.
3 deaths from mediastinitis, in all of which injuries to theesophagus or the esophagus and trachea had been overlooked.
3 deaths from cerebral anoxia.
2 deaths from aspiration pneumonia, both caused by aspirationof vomitus during anesthesia.
1 death from each of the following causes: cerebral malaria,cerebral embolism, cerebral abscess, phosphorous burns, splenomegaly andjaundice, severe lacerations of the lung, the vagovagal reflex, peritonitis,thrombosis of the pulmonary artery, empyema, right heart failure, massiveemphysema, pressure pneumothorax, and multiplicity of wounds.
Post mortem observations.-Post mortem examination was carried out in 78 of the 116fatalities, the most impressive findings being 12 overlooked injuries, including3 perforations of the aorta; 3 cardiac injuries, 1 associated with massivepulmonary collapse; 3 injuries of the esophagus, 1 associated with an injury ofthe trachea; 1 injury of the trachea; and 1 injury of the vena cava. Thoracicsurgical teams cared for only 3 of these 12 cases.
Chronology of deaths-Of the116 deaths, 9 (7.76 percent) occurred before surgery could be undertaken or onthe operating table. Of the remainder, 26 occurred the day of operation, 19 onthe first postoperative day, and 9 on the second postoperative day. In otherwords, something over half (54.3 percent) of the 116 fatalities had occurred bythe end of the second postoperative day. All but 10 of the 116 fatalities (91.4percent) had occurred by the seventh postoperative day.
5TH AUXILIARY SURGICAL GROUP
In the 1,068 combat-incurred wounds of thechest and abdomen treated by surgical teams of the 5th Auxiliary Surgical Groupin the European theater in 1944 and 1945 were 374 penetrating and perforatingwounds of the chest, with 31 deaths (8.29 percent) and 165 thoracoabdominalwounds, with 39 deaths (23.70 percent). A few of these wounds occurred incivilian casualties, but the analysis does not distinguish them from theinjuries in military personnel.
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Thoracic Wounds
Basic data-Of the 374 patients withperforating or penetrating wounds of the chest, 283 were treated in fieldhospitals and 91 in evacuation hospitals. Field hospitals received twice as manycasualties within the first 12 hours after wounding as in the second 12-hourperiod. Evacuation hospitals received about the same number in each 12-hourperiod. The timelag for field hospitals averaged 7 hours and for evacuationhospitals, 10 hours.
Of these wounds of the chest, 180 were on the left and 189on the right; 5 were bilateral. Gunshot caused 193 wounds and shell fragments181. Penetrating wounds caused by shell fragments were twice as frequent asperforating wounds, and sucking wounds were caused by shell fragments twice asfrequently as by gunshot. Sucking wounds were also twice as common inpenetrating as in perforating wounds.
Policies of management-In theEuropean theater, as in the Mediterranean theater, the management of chestwounds progressed through a definite cycle. In the beginning, before surgeonshad had much experience with combat-incurred wounds, the general tendency was tobe somewhat radical, and there were few patients with chest wounds who did notundergo thoracotomy. When casualties became heavy, however, and there was alarge backlog of patients with abdominal and thoracoabdominal wounds, experienceshowed, as it had in the Mediterranean theater, that casualties with thoracicinjuries could be treated satisfactorily by delayed surgery and by less radicalprocedures.
The following indications for thoracotomy then became regulation:
1. Hemothorax due to active bleeding, with rapid refilling ofthe pleural cavity after aspiration. The source of bleeding was usually anintercostal artery or the internal mammary artery; the lung itself; or, lessoften, the heart or some other mediastinal structure. Patients in this groupwere usually in severe shock on admission and did not respond well toresuscitation.
2. Massive clotted hemothorax that did not lend itself toaspiration. These patients often presented dyspnea, cyanosis, and mediastinalshift. Evacuation of clotted blood and control of bleeding were readily effectedthrough an open thoracotomy, and this method of management became the procedureof choice.
3. Retained foreign bodies 2 cm. or larger in the pulmonaryparenchyma or the pleural cavity. The principal indication for removal of theseobjects was risk of an infected hemothorax or lung abscess. Possible futuredamage to the lung or to a blood vessel was also considered an acceptableindication.
4. Shattered rib fragments in the lung or pleural cavity orlarge fragments that had not perforated the pleura. Many surgeons came tobelieve that bone fragments in the lung were of much more serious consequencethan metallic foreign bodies. They were apt to be long and spiky, with irregularedges, and they tended to penetrate the tissues and to forge ahead in them.After a time, bone fragments often became necrotic, and an abscess or aninfected hemothorax was a possible consequence. Laceration of a blood vessel wasalso far more likely from contact with bone fragments than from contact withmetallic foreign bodies. The preferable technique of removal was thoracotomy orextrapleural rib resection.
Sucking wounds. If intrathoracic damage of any consequence wassuspected, thoracotomy was performed. Otherwise, simple debridement and closurewas usually all that was necessary.
6. Tension pneumothorax due to an air leak, as in bronchopleural fistula.
After these indications had been set up, the treatment ofthoracic casualties became considerably more conservative. Toward the end of thewar, however, reports from general hospitals were to the effect that theincidence of infected hemothorax, empyema, and lung abscess was higher whenforeign bodies were left in situ, and as a result, more thoracotomies began tobe performed. In the 374 wounds of the chest cared for by the
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5th Auxiliary Surgical Group, 142 thoracotomies were performed(38.00 percent), with 12 deaths (8.45 percent).
Hemothorax-Hemothorax was recordedas present in 296 of the 374 perforating or penetrating wounds (79.14 percent)and was stated to be absent in 24 cases. It was probably present in all thecases in which no statements were made about it. Hemothoraces varied in volumefrom 200 cc. to 2,500 cc. In the absence of other indications for interference, collections upto 300 cc. were left in situ. Larger collections were treated by aspiration,which was repeated as necessary. Air replacement was not employed, and no fluidwas used except for a small amount of distilled water necessary to dissolve thepenicillin (usually 40,000 units) used intrapleurally. If the chest continued torefill with blood after adequate aspiration, operation was considered to beindicated.
Active intrathoracic bleeding was found at thoracotomy in 50wounds, 32 of which were caused by shell fragments. In 32 instances, thebleeding was from the lung (in 1 case from an intercostal vessel also), in 16from an intercostal vessel, and in 2 from the internal mammary artery.
The case fatality rate was apparently relatedto the volume of the hemothorax. There were 2 deaths in the 49 cases in whichthe volume ranged up to 500 cc. and 12 in the 78 cases in which it ranged from2,000 to 2,500 cc.
Tension pneumothorax-Tension pneumothoraxoccurred only 32 times, usually in valvelike sucking wounds. Treatment consistedof sealing the wound and emptying the pleural cavity by aspirations. If thecollection of air was caused by an actual air leak from the lung, a large needleor stiff catheter was introduced into the pleural cavity via the second anteriorinterspace, and water-seal drainage was instituted.
Injuries of the lung-It was thepractice to leave small lacerations of the lung unsutured unless they werebleeding. Larger lacerations were repaired.
In one instance, pneumonectomy had to be done for severelacerations of both the upper and lower lobes. Recovery was uneventful. Inanother instance, massive intrabronchial hemorrhage occurred after suture of alarge laceration and reexpansion of the lung by positive pressure. The patientdied before the bleeding could be controlled. Autopsy showed that it came fromthe laceration and made it clear that a lobectomy should have been done. Boththese injuries, however, are exceptions; valid indications for radical surgeryfor damage to the pulmonary parenchyma were extremely uncommon.
Cardiac wounds-Cardiacinjurieswere encountered 4 times in the 374 wounds. Two patients recovered uneventfully,one after suture of a laceration of the left ventricle and one after suture of alaceration of the right atrium and repair of a perforating wound of the lowerlobe of the left lung. In the third case, autopsy revealed a shell fragment inthe wall of the left ventricle, which had lacerated the descending ramus of theleft coronary artery. Roentgenograms had indicated that the object was in themediastinum. In the fourth case, autopsy revealed a shell fragment 25 by 15 by10 mm. in theright ventricle. It had entered the superior vena cava and been swept down intothe ventricle, lacerating the tricuspid valve in its passage.
Analysis of deaths-Of the 31 deathsin these 374 injuries, 6 occurred in gunshot wounds and 25 in shell-fragmentwounds. Of the fatal wounds, 14 were on the right side and 14 on the left; 3were bilateral. In one of the bilateral injuries, death occurred suddenly, 7days after initial wound surgery, from a secondary hemorrhage from a laceratedazygos vein. Another patient developed bilateral pneumothorax and died of anoxiaon the third postoperative day.
In 16 cases, death occurred on the operating table or duringthe first 12 hours after operation, chiefly from shock. In these 16 deaths were4 caused by blast injuries and 1 caused by a skull fracture.
One fatality represented a serious but quiteunderstandable error in diagnosis. The patient had sustained a penetrating,sucking wound of the left chest. According to the roentgenograms, the stomachseemed to be in the thorax. When, however, the patient
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stated that as a boy he had had a leftphrenicectomy for tuberculosis, the surgeon's assumption was that the diaphragmwas elevated because of the previous operation and that the stomach wasbelow the diaphragm, not above it. Surgery was therefore limited to debridementand closure of the chest wall, without intrathoracic exploration. The patientdid not react well from operation and died on the third postoperative day.Autopsy revealed a congenital diaphragmatic hernia of the stomach, which hadsustained a perforating wound.
Thoracoabdominal Wounds
Of the 165 casualties with thoracoabdominal wounds treated bythe surgeons of the 5th Auxiliary Surgical Group, 4 died before operation couldbe started or were so obviously moribund that surgery was considered futile. Onthe other hand, the high case fatality rate from shock in the first 12-hourperiod after operation shows that surgery was not withheld merely becausecasualties were poor risks.
Basic data-Of the165 thoracoabdominal wounds, 98 were on the left side, of which 27 were fatal;67 were on the right side, of which 12 were fatal. The difference in the casefatality rates reflects the anatomic location and the vulnerability of theabdominal organs on the two sides.
When there were no thoracicinjuries of consequence, the case fatality rates did not differ substantiallyfrom the rates in the total series (11 deaths in 62 injuries on the left, 6deaths in 36 injuries on the right).
In most of the injuries (84 percent), the wound of entrancewas in the thorax. In avulsing wounds and through-and-through wounds caused bysmall arms, it was often impossible to tell whether the course of the missilewas from the thorax into the abdomen, or vice versa. In about a quarter of allcases, the thoracoabdominal wounds were complicated by other injuries.
Resuscitation-Many casualtieswith both thoracic and thoracoabdominal wounds were brilliant illustrations ofwhat resuscitation can accomplish. One patient with a thoracoabdominal wound,whose blood pressure and pulse could not be obtained when he was first seen,received 17 units of plasma and 6 units of blood in the 10 hours beforeoperation. He entered the operating room with a pulse of 110 and a bloodpressure of 115/80 mm. Hg.
On the other hand, shock was sometimes entirelyirreversible. In these 165 patients with thoracoabdominal injuries, 47 neededintensive replacement therapy because of their poor condition and the severityof their wounds. Six of the forty-seven received 22 percent of all the blood and30 percent of all the plasma given to this special group. They were finallydeemed operable, but all six died of shock within the first 24 hours afteroperation.
Pulmonary injuries.-Therewas no active bleeding in any of the68 lacerations of the lung in these thoracoabdominal wounds. Suture repairwas effected in 20 cases in which a bronchopleural fistula already existed or inwhich it was thought that one might develop. The other lacerations were leftalone. The chest injury usually contributed only a small amount of the bloodaspirated from the chest at operation. Most of it came from injuries of thespleen and, in small amounts, from injuries of the stomach and the smallintestines.
Surgical approach.-There is no information as to the surgicalapproach in 25 cases in this series. In 39 wounds, 22 of which were on the leftside, the approach was by the thorax. In 44 wounds, separate thoracotomy andlaparotomy incisions were used, thoracotomy being the initial procedures in 33cases and laparotomy in 11 cases. In the remaining 57 cases, 36 of which were onthe left side, a laparotomy incision was used and no intrathoracic surgery wasdone.
If the wounding agent was a shell fragment, thoracotomy wasthe preferred mode of approach. The reasoning was that because of its largersize and its tumbling, rotating progress, such a missile was likely to create agaping, sucking wound of the chest and diaphragm, whereas a diaphragmaticwound caused by small arms fire was likely to be sealed over. If the woundingagent was a bullet, the thoracic approach was preferred only
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if there was evidence of a cardiac or vascularinjury, a severe laceration of the lung, or herniation of abdominal organsthrough the diaphragm. Otherwise, a laparotomy was thought to be quicker andless shocking than the management of a bullet wound through a transdiaphragmaticincision, which would require enlargement of the diaphragmatic perforation topermit satisfactory exploration and repair.
As a rule, the transdiaphragmatic approach wasused on the left side for penetrating wounds of the chest at the level of, orbelow, the seventh rib if the wound was caused by a projectile whose course wasin an almost transverse plane. On the right side, the same indications were usedif it was certain that the projectile had not proceeded to the region of theduodenum, right colon, or pancreas, all areas to which approach is blocked bythe right lobe and main bulk of the liver. Wounds of the diaphragm located overthe extraperitoneal surface of the liver could not be repaired by laparotomyalone; thoracotomy was required for adequate exposure.
The type of abdominal incision was governed bythe course of the projectile and, to a lesser extent, by the degree ofangulation of the costal margin at the xiphoid process. A subcostal incision ina patient with a wide costal flare provided excellent exposure for repair of thediaphragm and stomach and for exploration of the spleen and kidney, with splenectomyand nephrectomy if necessary. In the asthenic individual, a rectus incisionprovided good exposure and had the additional advantage of simplifying theplacement of a stab wound for exteriorization of an injured colon.
Complications-In the 75 cases inwhich the liver was injured, there was no recognized instance of eitherhepatopleural fistula or bile empyema. Drainage in wounds of the liver wasproportionate to the severity of the laceration. Volumes up to 1,500 cc. on thefirst day were not uncommon, and some wounds were still draining rather largeamounts when the patients were evacuated.
Drainage from renal injuries was negligible,and it was concluded that a stab wound to provide for either urine or blood wasprobably unnecessary unless a major calyx of the renal pelvis was involved.
The chief complications in the 165 thoracoabdominal wounds were as follows:
Two bronchopleural fistulas developed within 24 hours ofoperation but closed spontaneously after institution of catheter drainagethrough the second interspace.
Two patients with atelectasis weresuccessfully treated by bronchoscopy. Lesser degrees of atelectasis probablyoccurred and went undetected. Two patients had lobar pneumonia, in one caseassociated with an early empyema. This was the only instance of empyema observedbefore evacuation.
Wound infections were uncommon and usually not serious, butthree wound disruptions occurred, one of which was fatal.
Paralytic ileus was present in most cases, sometimes for 4 to6 days, in extensive injuries of the liver, retroperitoneal hematomas, or largehemoperitoneum.
Analysis of fatalities-Autopsies wereperformed in 21 of the 39 deaths in this series. The fatalities were distributedas follows:
Eighteen patients died of shock, fifteen within the first 24hours after wounding.
Eight patients died of acute pulmonary edema, five with aprofuse terminal serohemorrhagic accumulation of fluid in the bronchial tree. Inthe four cases in which autopsy was performed, the fluid was found to originatein the lung, which was grossly enlarged, heavy, firm, and engorged with blood.Microscopic study revealed edema; acute passive congestion; and red blood cellsin the alveoli, as well as areas suggestive of the consolidation ofbronchopneumonia. In three of the four cases, the surgeon had no doubt that thecardiovascular system had been overloaded. One of these patients had received aunit of blood and 3 units of plasma before operation, and 4 units of blood and11 of plasma during the operation. Another had received 1,500 cc. of physiologicsalt solution and 2,000 cc. of blood in Alsever's solution over 2?hours.
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Five patients died of pneumonia.
Three patients died of peritonitis, one with pneumonia.
Two deaths occurred from overlooked injuries.One patient succumbed to a rapidly spreading retroperitoneal infection from amissed perforation of the cecum. The other died on the fifth postoperative day,from hemorrhagic shock, after the clot in a missed perforation of the inferiorvena cava became dislodged.
One patient with extensive laceration of the liver apparentlydied from biliary peritonitis.
One death was caused by the migration of ashell fragment, which was dislodged from the inferior vena cava and traveled tothe right pulmonary artery, where it acted as an embolus.
One patient suffered an evisceration of a perforated stomach,small intestine, and transverse colon through a 7-by-6-cm. avulsed wound of theleft lower chest laterally. After operation, his blood pressure ranged from 80to 90 mm. Hg, and he was irrational and almost uncontrollable. His condition waspresumably due to chronic shock. When renal shutdown was part of thepicture, as it was in this case, no therapy was effective.
Whether fat embolismplayed a part in any of these deaths is not possible to say. None of themicroscopic specimens studied in the 21 autopsied cases werepositive for fat.
KENNEDY GENERAL HOSPITAL THORACIC SURGERYCENTER
General Considerations
The soundness of policies of early managementof combat-incurred chest wounds could be evaluated by a study of the casefatality rates and morbidity rates of the casualties who survived to reachforward hospitals. Similarly, the soundness of policies of management in alloversea hospitals could be evaluated by an analysis of the residual status, andthe necessity for further care, of the casualties received later in hospitals inthe Zone of Interior. An analysis of the first 500 (of an ultimate 2,350)casualties with combat-incurred chest wounds, received in the thoracic surgerycenter at Kennedy General Hospital after it had become fully operational in June1944, provides interesting and useful data of this kind.
Before these data are accepted absolutely, however, twoqualifying statements are necessary:
1. It is only fair to emphasize that in acomparative analysis made retrospectively from field medical records and forwardhospital records, it was not always easy, or indeed possible, to recognize allthe circumstances that confronted surgeons working under combat conditions andthat might have influenced their decisions concerning therapy.
2. The figures are frequently overlapping and,in a number of instances, though the records provided no actual proof, it wasthought that the incidence of certain injuries and complications was probablyhigher than the stated figures indicated.
The material for this analysis was obtained bya careful review in each case of the field medical record, the records ofprevious hospitalizations overseas, the serial roentgenograms taken during thecourse of treatment, and the condition of the patient on his admission to thechest center. The clinical status of each patient was thus surveyed from thepoint of vantage of his latest hospitalization and in the light of his previoustreatment. As a result, it was possible to make an objective evaluation of thecharacter of the original injury, its initial management, the subsequenttherapy, and the complications which followed special wounds and specialtechniques of management. The composite data permitted the comparativeevaluation of surgical versus conservative therapy, forward thoracotomy and therelation of morbidity to its performance or omission, the use or omission ofdrainage in the closure of chest wounds, and similar routines.
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Had a review of the last 500 patients admittedto the center been possible, there is no doubt that, as policies overseas hadbecome stabilized in the light of experience, the outcome of the analysis wouldhave been quite different.
Basic Data
All 500 wounds of the chest included in this survey were penetrating or perforating. Wounds limited to the chest wall very seldom reached thoracic surgery centers in the Zone of Interior. Small arms fire was responsible for only a few injuries, the great majority being caused by bombs and other high explosives.
The original injuries (the figures are sometimes overlapping) included:
211 retained foreign bodies of significant size.
136 sucking wounds.
75 thoracoabdominal wounds or combined thoracic and abdominal wounds.
62 pulmonary lacerations.
45 bronchopleural fistulas.
15 pulmonary contusions.
9 tension pneumothoraces.
8 blast injuries.
4 fractures of the sternum.
3 wounds of the esophagus.
2 wounds of the trachea.
2 wounds of the pericardium.
As far as could be determined from the records, the chestwound was entirely uncomplicated in only 19 cases. Complications which occurredoverseas included:
Hemothorax in 455 cases. In 151 of these cases, the hemothoraxbecame infected, and in another 49, it became organized without infection.
Subphrenic abscess in 12 cases.
Pneumonitis and lung abscess about foreign bodies in 11 cases.The same complications developed in the 4 hematomas of the lung in the series.
Hemoptysis secondary to the presence of a foreign body in 8 cases.
Atelectasis in 9 cases.
Pericarditis with effusion in 8 cases.
Infected costal cartilage in 7 cases.
Bronchopneumonia in 5 cases.
Diaphragmatic hernia in 5 cases.
Pulmonary infarction in 3 cases.
Esophageal fistula and paraesophageal abscess in 3 cases.
Pericardial tamponade in 2 cases.
Suppurative pericarditis in 2 cases.
These complications (again, the figures are sometimesoverlapping) were managed as follows:
Drainage of empyema in 151 cases, in 46 of which secondarydrainage was also necessary.
Thoracentesis in 47 cases.
Decortication in 49 cases.
Drainage of subphrenic abscess in 12 cases.
Pericardial aspiration in 11 cases.
Closure of bronchopleural fistula in 9 cases.
Repair of diaphragmatic hernia in 5 cases.
Resection of ribs for osteochondritis in 4 cases.
Drainage of suppurative pericarditis in 2 cases and drainageto relieve pericardial tamponade in 1 case.
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When these 500 patients were received at Kennedy GeneralHospital, the chest wound was healed in 314 cases (62.8 percent), and no furthertreatment other than rehabilitation was needed. The remaining 186 patientspresented 213 complications, not all of which, as will be pointed out, developedfrom the original wound. Some of them were the result of the therapy employed.These complications included:
Retained foreign bodies in 131 cases.
Chronic empyema in 82 cases.
Bronchopleural fistula in 36 cases.
Draining sinus in 26 cases.
Hemothorax in 21 cases, in 12 of which the process was of theorganized type. These figures should also be evaluated in comparison with the 82cases of chronic empyema present when these casualties were received at KennedyGeneral Hospital.
Diaphragmatic hernia in 4 cases.
Esophageal fistula or paraesophageal abscess in 3 cases.
Pericardial effusion in 2 cases.
Special Types of Injuries
Sucking wounds-The 136 suckingwounds listed in this series were of such a size as to require immediate closurewhen they were first seen in field or evacuation hospitals. A considerablylarger number of patients had similar wounds, but they were so small as to be ofno clinical significance. They responded promptly to packing or to debridementand primary closure. It should be noted, however, that infection developed inalmost 10 percent of the cases in which the wound was closed primarily withoutdrainage.
In larger sucking wounds, it was the practice to occlude thewound temporarily by packing and to close it permanently later, when debridementwas done. Thoracotomy was done at this time in 78 of the 156 cases.
In a number of cases, the chest wound was only partly closedafter debridement, and intercostal water-seal drainage was instituted. Therecords showed that convalescence was smoother in this group of patients than inany other patients with sucking wounds.
In several cases in which a bronchopleural fistula was presentand had not been recognized, tension pneumothorax developed after closure of asucking wound.
Thoracoabdominal wounds.-In this series, 75 of the500patients had sustained injuries of the thorax and abdomen, either from a singlemissile that perforated the diaphragm or from separate perforations of the chestand abdomen. The abdominal organs injured were, in the order of frequency, theliver in 40 cases, the spleen in 16, the stomach in 15, the kidneys in 9, andthe small intestine and colon in 7.
All these patients had been treated by prompt surgery, but theorder of the procedure depended upon the severity of the chest wound. The chestinjury was given first consideration in large sucking wounds, tensionpneumothorax, pericardial tamponade, or rapidly developing hemothorax associatedwith shock and not relieved by conservative therapy. Otherwise, if thecardiorespiratory physiology was not seriously unbalanced, the primary attentionwas devoted to the abdomen.
The diagnosis of concomitant abdominal injury was frequentlydifficult when the missile had entered the chest, because in chest wounds inwhich there was no perforation of the diaphragm, abdominal pain, tenderness,and rigidity were often part of the picture. Urinalysis was always indicated ininjuries of the lower chest, to determine whether or not blood was present.Intravenous pyelograms, which were made later in general hospitals, occasionallydemonstrated defects in the renal pelvis secondary to injuries of the lowerchest.
In the majority of cases in which the injuryresulted from a single missile, exploration and the necessary surgery weresuccessfully carried out through a transthoracic approach. When there was doubtconcerning the extent and location of the abdominal injury, it was
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FIGURE 1.-Posteroanterior roentgenogram showing large foreign body in contact with esophagus.
the general policy to use a separate abdominal approachbecause it permitted more extensive exploration.
The liver apparently tolerated the presence of metallicforeign bodies quite well. At any rate, no abscess resulted from failure toremove them, though biliary drainage followed the injury in a number of cases.When hepatic injuries were explored transpleurally, both the subphrenic spaceand the pleural space were usually drained. When this precaution was omitted,bile empyema, which occurred in 14 cases, and subphrenic abscess were bothpossibilities. The most serious instances of bile empyema occurred when thewound was closed without drainage.3
Intratracheal anesthesia was employed in allthoracoabdominal injuries, regardless of the surgical approach. The reason isobvious: If a tear of the diaphragm was present, atmospheric air entering fromthe abdominal incision could cause collapse of the lung on the affected side oreven tension pneumothorax.
Tracheoesophageal injuries-There wereonly 3 injuries of the cervical esophagus and only 2 injuries of the upper endof the trachea in these 500 patients, but there were 3 similar injuries in thenext 300 patients admitted to the Kennedy General Hospital chest center. Thethoracic esophagus was not injured in any case in the series studied, eventhough, in a number of instances, ragged shell fragments were seen byroentgenograms to be lodged in the posterior mediastinum close to it (fig. 1).The high immediate case fatality rate resulting from the hemorrhage and themediastinal infection commonly associated with injuries of this kind accountsfor the small number of patients seen with them in Zone of Interior hospitals.
Three of the five patients with tracheal and esophagealinjuries were submitted to immediate tracheotomy, and four had gastrostomies forfeeding purposes within 4 to 10 days after wounding. All five developed fistulasof the esophagus associated with abscesses, which had to be drained. When thetracheotomy tubes were removed, from 2 to 3 weeks after operation, none of thepatients had any difficulty in breathing.
Two patients with injuries of the esophagus developedstrictures which required dilatation, and four of the five with combinedinjuries of the esophagus and the trachea developed persistent paralysis of therecurrent laryngeal nerve. Because these are extremely serious injuries, theeventual outcome in these cases was regarded as being as satisfactory aspossible.
3Experience in the Mediterraneantheater indicated that there was a significantly higher incidence of bileempyema when the diaphragm was closed with catgut rather than with silk.
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Bronchopleural fistulas-The recordsindicated that 45 of the 500 patients in this series had clinically significantbronchopleural fistulas immediately after sustaining their chest wounds. Thechances are that fistulas were also present in a number of other cases but wereso small that they required no special treatment and gave rise to nodifficulties.
Thirty-six patients had bronchopleural fistulas when they wereadmitted to the chest center at Kennedy General Hospital, the majority secondaryto their original injuries. Eight, however, followed the removal of foreignbodies, and six became evident only after the development of empyema. In otherwords, not all of these 36 fistulas were part of the original 45 fistulas.
All patients with fistulas observed at the chest center werestudied by roentgenograms, after the introduction of iodized oil, to determinethe size of the residual empyema space and the anatomic relation of the fistulato the site at which drainage had been instituted after thoracotomy (fig. 2). Ifthe fistula was shown to be at some distance from the cutaneous wound anddrainage would have been necessary through a long, narrow, empyematous track,healing was accomplished more rapidly if drainage was established directly overthe fistula. When secondary drainage was instituted, exploration often showedthat healing had been prevented by the presence of necrotic spicules of rib,bits of clothing, and other foreign bodies embedded in the pulmonary tissue. Theremoval of these objects and the excision of scar tissue about the fistula wereusually followed by prompt healing, though in an occasional case, these measures did not suffice and closure of the fistula had to be accomplished bymeans of a muscle flap.
Retained Foreign Bodies
As the incidence of immediate and delayedcomplications shows, the major problems in the management of injuries of thechest concerned retained foreign bodies; hemothorax and pneumothorax; empyema;and the use of thoracotomy, with or without drainage, in forward areas.
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Management overseas-Of the 211patients observed with intrathoracic foreign bodies of considerable size whenthey were first examined after wounding, 47 underwent removal of the objects atthe primary operation and 33, after an interval of several weeks. Many otherfragments were noted in other patients when roentgenologic examination wascarried out, but their size and location were such as to make them of noclinical significance.
Throughout the war, differences of opinion continued toexist as to the clinical significance of metallic foreign bodies and theindications for their removal. The chief reason for removing them was thepossible development of hemorrhage or infection, as well as other complications,but the incidence of these manifestations in this series was not great. In the164 cases in this series in which the objects were not removed at initial woundsurgery, hemoptysis occurred later in 8, draining sinuses developed in 8, lungabscesses in 7, and pneumonitis in 6. In other words, there were no untowardmanifestations in 135 of the 164 cases in which the foreign bodies were notremoved at initial wound surgery. Moreover, practically all of thesecomplications developed within 2 to 4 weeks after wounding.
In many cases in this series, the removal of the foreignbodies at the initial operation was part of the procedure of debridement,hemostasis, and repair of lacerated lung tissue. In this group, the removal wasan incidental step in the operation.
In other instances, however, initial wound surgery wasundertaken primarily for the removal of the foreign body. The objects were oftenhard to locate in newly traumatized tissue, and fresh trauma was created.Bronchopleural fistulas were sometimes created and went unrecognized. If theinjury was small, the chest was frequently closed without drainage. As a resultof these various circumstances, the incidence of postoperative infection in thisgroup of patients was almost 30 percent.
Generally speaking, infection was most frequent in the casesin which dirt, particles of clothing, and similar debris entered the chest withthe foreign body. This extraneous
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material was more likely to be the cause ofinfection than the metallic object itself. Foreign bodies unaccompanied by otherdebris were usually found at operation, as previous roentgenologic evidence hadshown, to be associated with surprisingly little reaction and with no infection.Objects in contact with large blood vessels were practically always wellencapsulated in fibrous tissue.
Management in the Zone of Interior-Ofthe131 patients who entered Kennedy General Hospital with roentgenologic evidenceof metallic foreign bodies still in situ, only 49 harbored missiles consideredof clinical significance because of their size, shape, location, or clinicalmanifestations. Only 23 of these 49 objects were removed, on the followingindications:
1. Large, irregular shell fragments lying within the lungparenchyma were removed without hesitation, particularly if there was anassociated pneumonitis or fibrosis (fig. 3).
2. Similarly, no hesitation wasfelt about removing foreign bodies lying in the mediastinum in contact with theesophagus (fig. 1) or with large blood vessels (fig. 4).
3. Foreign bodies associated with lungabscesses (fig. 5) or empyema were removed at the time the necessary drainagewas instituted. Four patients with retained foreign bodies had eitherpneumonitis or lung abscesses when they were admitted to the center. All fourhad draining sinuses, and three complained of hemoptysis.
4. In other cases, foreign bodies causinghemoptysis or intercostal pain were reproved whenever it could be demonstratedthat they were directly responsible for these symptoms (fig. 6). In most suchcases, the onset of symptoms occurred shortly after wounding. There was noevidence of infection or other reaction in any case in this series in whichroentgenologic examination showed no abnormalities for 2 to 3 months afterwounding. This was not, of course, an infallible rule: In one of these casesgross hemoptysis appeared a year after injury.4
5. In an occasional case in which operation was not otherwiseindicated, the object was removed because of the psychologic factors of fear orpain on the part of the patient.
4Attention is called to the patient observed in theMediterranean theater who required pneumonectomy for a retained foreign body 15years after wounding.
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As the war progressed, the policy at theKennedy General Hospital thoracic surgery center became increasinglyconservative, and foreign bodies were removed only on strict indications. Thepostwar experience will have to determine the late possibilities for harm ofretained foreign bodies and thus establish clear-cut criteria for their removal.It is unfortunate that plans for a formal followup of men with retained shellfragments never came to fruition (vol. I).
Tetanus toxoid was always given beforeoperations for the removal of foreign bodies. Otherwise, the preoperative andpostoperative regimen, including the use of penicillin, was the same as forother thoracic operations.
Hemothorax
Management overseas-Hemothoraxwasrecorded after wounding in 455 of the 500 patients in this series, 91 percent.In many cases, it was present in association with other conditions of seriousimport, such as sucking wounds, lacerations of the lung tissue, and retainedforeign bodies.
The most severely injured patients in this group weresubmitted to thoracotomy in frontline hospitals, on entirely justifiableindications. In many other cases, however, casualties whose injuries wereconsiderably less severe were also submitted to thoracotomy, on indications thatwere far from clear cut. The effectiveness of the method of treatment employedin each case is best determined by the presence or absence of infection. Thefigures are as follows:
Of 74 cases treated expectantly, without any positive therapy,30 became infected (40.54 percent). In 34 cases, the hemothoraces were small andspontaneous healing occurred. Infection occurred in 6 of the 12 cases ofbronchopleural fistula.
Of 156 cases treated by thoracotomy, 75 (48.08 percent) becameinfected (figs. 7, 8, and 9).
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548
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Of 225 cases treated by repeated thoracenteses, only 38 (16.89percent) became infected. If the 13 cases are excluded in which aspiration wasinadequate and only the 212 properly treated patients are considered, theproportion of infection falls to 11.8 percent. In 11 cases in this group, thechances of good results were reduced by the associated bronchopleural fistulas.
Of the 49 patients whose hemothoraces became organized, 20had either had no aspiration of the chest or only a single aspiration, and 7 hadbeen aspirated only twice. Nine had been treated by thoracotomy. All of thesepatients underwent decortication overseas.
The comparative figures leave no doubt of the soundness ofthoracentesis as the preferred method of treatment in cases in which immediateoperation is not indicated for some reason other than the presence of ahemothorax. The circumstances of military medicine were always in favor of thesimplest method of treatment, in this instance thoracentesis, as compared tomore complicated methods, in this instance thoracotomy. The necessity forevacuation, the changes of medical personnel from echelon to echelon, and thecomplicated care required in handling thoracotomy drainage all help to explainthe higher incidence of infection when thoracotomy was used in preference tothoracentesis.
Management in the Zone of Interior-Allthecases in which decortication was done at Kennedy General Hospital furtherconfirmed the advantages of this operation (fig. 10). It proved a logical meansof developing an easily obtainable cleavage plane between the fibrous encasementof the lung and the adjacent viscera, pleura, pericardium, diaphragm, and chestwall. When the peel was separated from these structures, reexpansion of the lungoccurred promptly, the lung tissue herniating through the line of incision assoon as separation was completed.
The experience at this center also confirmed the generalopinion that the best results were obtained when the operation was donebetween 4 and 6 weeks after wounding. If the lung was allowed to remaincollapsed for 3 months or more, some fibrosis of the parenchyma frequently tookplace, and reexpansion after operation was delayed.
There is no doubt that decortication, as itwas practiced in World War II, was responsible for many of the good resultsobtained in casualties with chest wounds (fig. 11) who, in the past, wouldhave become invalids from chronic fibrothorax.
Empyema
Management overseas-Of the 151 patientswho developed empyema in association with their chest injuries, 82 had chronic empyema when they were admitted to the chest center. In 62 of the 151 cases(41.06 percent), the cause of the empyema could be traced directly to thecircumstances of the original injury, such as its initial severity, theextensive contamination introduced by the missile, an associated laceration ofthe lung, or the presence of a bronchopleural fistula.
In the remaining 89 cases, the development of the empyemacould be traced wholly or in part to two causes, (1) failure to carry outadequate aspiration of a hemothorax when no other surgery was necessary, and(2) failure to provide postoperative water-seal drainage when surgery had beendone.
No patient who had water-seal drainagedeveloped an empyema of any clinical significance, but infection resulted in31.4 percent of the patients who had been submitted to thoracotomy withoutpostoperative drainage and in 18 percent of those who had had inadequatethoracenteses after operations in which surgical drainage was omitted (figs. 7,8, and 9). In another 9.4 percent of the cases, the thoracotomy tube had beenremoved too soon. The analysis of these cases thus suggests that the incidenceof empyema in combat-incurred chest injuries could be appreciably reduced ifthoracentesis were performed adequately after operation and if adequatewater-seal drainage were provided in all cases.
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Drainage was carried out overseas in all 151 cases of empyema,on an average of 3? weeks after the infection was detected.Secondary drainage was necessary in 46 cases. In the first months of the war,there was a decided tendency to perform open thoracotomy for infected hemothorax,early in the illness, and total empyema seems to have followed this mode oftreatment rather frequently (fig. 12). Later, this policy was almost entirelydiscontinued, and drainage was deferred until this risk no longer existed.
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FIGURE 11.-Infected organized hemothorax managed bydecortication. A. Posteroanterior roentgenogram before operation. B. Same,showing results of decortication.
Management in the Zone of Interior-Themajorityof patients admitted to the chest center with chronic empyema had beenadequately drained, and healing was progressing well. If drainage was notadequate, secondary drainage was instituted. Most of the cavities were eithersmall or moderate-size.
Adjunct treatment of chronic empyema usually consisted ofcontinuous suction with 30 to 50 cm. of negative pressure. Breathing exercisesand blow bottles were also employed, but the experience was that reexpansion ofthe lung was more apt to occur, and to occur at a faster rate, when suction wasemployed. Dakinization of the wound was also employed in a few cases. Otherconstituents of therapy included repeated transfusions of blood and plasma,high-vitamin diets supplemented by the administration of vitamins by otherroutes, and general hygienic measures.
As time passed, it was found that empyemasecondary to hemothorax could be treated by decortication with practically thesame degree of success as could be secured in organized hemothorax withoutinfection. When this method of treatment came into use, it was only anoccasional patient with empyema who had to be submitted to thoracoplasty.
Thoracotomy in Forward Hospitals
Many of the cases in this series proved, as has already beenintimated, that the mere presence of a penetrating or a perforating wound of thechest did not, in itself, constitute an indication for thoracotomy in a forwardhospital. Many operations, in fact, designed to stop hemorrhage or to preventinfection were themselves followed by these and other complications,particularly when the chest was closed without drainage.
Of the 500 patients in this series, 156 weresubmitted to debridement, with thoracotomy and repair of injured pulmonarytissue, within 24 to 48 hours after wounding. Of these, 6 percent developedorganized hemothoraces, and 76 (48.7 percent) developed infection. Thesepatients fared much worse than the 225 patients with hemothorax treated bythoracentesis, in only 16.8 percent of whom was additional treatment necessarybecause of infection.
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It must be granted that the surgical group included theseverest injuries, for which prompt surgery was mandatory and in whichcomplications might have developed if operation had not been done. Furthermore,it was not always easy to determine from records alone the circumstances whichled frontline surgeons to follow the courses which they did. Nonetheless, in 66of the 156 cases in which early thoracotomy was done, the field medical recordsshow no clear-cut indications for the procedure. The majority of the patients inthis group presented both hemothoraces and retained foreign bodies, but neithercan be considered a valid indication for thoracotomy, and there seems to be nodoubt, from the subsequent incidence of infection after the operation, that theywould have fared at least as well, and probably better, if they had been treatedconservatively.
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Since chemotherapy and antibiotic therapy were employedroutinely in both the group treated conservatively and the surgical group, acomparison of results from this standpoint would shed no light on the incidenceof infection in the two groups. An analysis of the use or omission of drainagein the surgical group, however, produces some useful data:
In addition to the 156 patients submitted to thoracotomy as aprimary procedure, 33 other patients underwent the same operation at a latertime overseas. In these 189 cases, drainage was instituted in 81 and omitted in108. In 67 of the 81 drained cases (82.7 percent), healing occurred smoothly,and there was no need for secondary surgery. The patients who became infectedwere, for the most part, those with the most severe injuries.
In contrast, in 61of the 108 cases in which drainage was omitted (56.5 percent), secondaryoperations were required. Furthermore, healing in the undrained group covered anaverage of 14 weeks, while the average in the drained group was 10 weeks.
The higher incidence of postoperative infection, the greaternecessity for secondary surgery, and the longer convalescence all make clearthat a thoracotomy closed without drainage achieved desirable results in a muchsmaller proportion of cases than a thoracotomy supplemented by adequatedrainage. The contrast was particularly evident in the 16 patients who werefound at primary thoracotomy to have lacerated lung tissue. When the wounds wereclosed without drainage and operation was not followed by adequate thoracentesis,many of these patients required secondary drainage for infection (fig. 7).
Other considerations also suggested that routine water-sealdrainage after thoracotomy in frontline hospitals was a far safer plan thanclosure without drainage. The conditions under which a surgeon had to care forthe wounded in the combat zone usually did not permit him to supervisepostoperative care except for a brief period. It was therefore not possible forhim to supervise personally the thorough aspiration of a hemothorax, which wasessential in all undrained chest cases. Another practical consideration was thatwaterseal drainage required considerably less time and attention than repeatedthoracenteses. This was an important matter in a busy frontline hospital.
As these cases indicated, transportation wasnot a contraindication to water-seal drainage. While the patient was en route tothe rear, the thoracotomy tube could be clamped and the bottle temporarilydisconnected, or a flapper type of drain could be used, as was done in a numberof these cases in which results were excellent.
Conclusions
An analysis of the first 500 chest injuries received at thethoracic surgery center at Kennedy General Hospital indicated that the overseamanagement of these cases was generally good. In a Zone of Interior chestcenter, as might have been expected, mortality is minimal; there were no deathsin this series. Morbidity, however, is a matter of consequence. This studysuggests that it can be reduced by the following policies:
1. Thoracentesis should be substituted for operation in themanagement of hemothorax unless other indications for early surgery exist.
2. Thoracotomy in forward hospitals should be limited to suchclear-cut indications as sucking chest wounds, tension pneumothorax, andhemorrhage. The mere existence of a chest wound is not an indication for forwardsurgery.
3. Thoracentesis should be performed adequately afteroperation, or adequate waterseal drainage should be instituted.
