History

CHAPTER XI

Long-Term (1943-61) Followup Studies in Combat-IncurredThoracic Wounds

Lyman A. Brewer III, M.D.

Followup information is as notably deficient concerning casualties withcombat-incurred wounds of the chest as it is concerning most other casualties.There are almost no studies of this kind in the medicomilitary literature, whichis extremely unfortunate, for it makes it impossible to determine the true endresults of any given plan of management.

Up to March 1944, chest wounds sustained in the Mediterranean (formerly NorthAfrican) Theater of Operations, U.S. Army, in World War II were treatedaccording to the personal policies of the surgeon who handled the particularpatient. After this date, thoracic casualties were treated by a specific regimenthat differed, in many respects, from the policies employed earlier.

The investigation reported in this chapter was undertaken in an attempt totrace the postwar course of a group of casualties who had sustained chestinjuries in the Mediterranean theater and who had all been treated (1) inforward hospitals, (2) under the direction of a single surgeon and hisassistants, (3) by the specific regimen just mentioned. This group of patientswas followed into the hospitals of the communications zone and the Zone ofInterior, and some of them were followed up for varying periods of time, up toFebruary 1961, after their separation from service.

BACKGROUND OF STUDY

In the summer of 1943, during the Sicilian campaign, studiesat the thoracic surgery center at Bizerte, North Africa, on casualties returningfrom forward areas revealed a high mortality rate and a considerable morbidityamong the group treated by thoracotomy at initial wound surgery. The impressionarose that this operation was being performed on unnecessary indications inforward hospitals and that its promiscuous use was having an adverse effect onthe results of chest injuries.

On the basis of these impressions, Col. Edward D. Churchill, MC, Consultantin Surgery to the theater surgeon, detached Capt. (later Maj.) Lyman A. BrewerIII, MC, from his duties at the Bizerte chest center and assigned him to theforward hospitals supporting the landings at Salerno in September

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1943. His mission was to study the problems of forward surgery in thoracicinjuries and to continue the investigation as the troops advanced into Italy.

Two facts promptly became apparent to Captain Brewer:

1. Thoracotomies were indeed being performed unnecessarily in forwardhospitals as part of initial wound surgery.

2. In spite of this fact, the indications for thoracotomy in forwardhospitals could be very sharply defined.

At a conference of thoracic surgeons called, and presided over, by ColonelChurchill in March 1944, at Marcianese (vol. I), the results of Captain Brewer'sinvestigations were reported. At this meeting, the indications for primarythoracotomy in forward hospitals were defined, and the so-called limitedapproach to this operation thereafter became the prescribed policy in theMediterranean theater.

This followup study had its genesis during the war, when Captain Brewer tookupon himself the task of keeping duplicate individual records for all casualtieswith thoracic injuries treated by him as head of Thoracic Surgical Team No. 4,2d Auxiliary Surgical Group. The team consisted of Captain Brewer; Capt. CharlesA. Schiff, MC; Capt. Werner F. A. Hoeflich, MC; and 1st Lt. Catherine V.Elliott, ANC.

Team No. 4 served first with the Fifth U.S. Army in Italy and then with theSeventh U.S. Army in France, Germany, and Austria. This army originated in theMediterranean theater and remained under its operational control for thelandings in southern France in August 1944 and during the first part of thecampaign in France. In December 1944, it passed to the logistic control of theEuropean theater.

The team served in forward hospitals during the landings at Salerno inSeptember 1943 and the campaign in Italy, the landings at Saint-Rapha?l and thecampaign in southern France, and then during the campaigns in Germany andAustria until V-E Day in May 1945. It was variously attached to the 94thEvacuation Hospital (Salerno to Cassino), the 11th Field Hospital (Cassino), the11th Evacuation Hospital (Anzio to Civitavecchia), the 11th Field Hospital (fromthe D-day landings at Saint-Rapha?l into eastern France), the 66th FieldHospital (Vosges Mountains), and the 80th Field Hospital (Germany and Austria).

The casualties were thus encountered, and the surgeonsworked, under a wide variety of conditions of climate and terrain, in Italy,France, Germany, and Austria, at all seasons, and from beachheads to mountains.

MATERIALS AND METHODS

Although Major Brewer and his team had personally treatedmore than 1,000 casualties with combat-incurred wounds, only 822 had wounds ofthe chest, and only 372 of these were treated in forward hospitals. Of the 210patients

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whose histories were reviewed when this analysis wasundertaken, only 167 had sufficiently detailed records to make followupinvestigation of any real value.

There are numerous problems connected with such an investigation. Thetracking down of a large number of former soldiers for varying periods of time(from 3 to 17 years) after the termination of hostilities and their return tocivilian life was not simple. It was impossible, in fact, to follow the majoritybecause of the general movement of the population that now seems part of the wayof life in the United States. Had all of these men reported for furthertreatment to VA (Veterans' Administration) clinics and hospitals, there wouldhave been no problem. Most of them did not. As will be pointed out later, theirfailure to seek medical advice is probably a reflection of the fact that most ofthem did not think that they needed it.

The Veterans' Administration, however, is the most obvious source of help inan undertaking of this kind, and with few exceptions, the men followed up inthis series after separation from service are those who reported to VA hospitalsand clinics, either because they were disturbed over their status or becausethey were actually in need of treatment.

Whatever success was achieved in this investigation is attributed to threeagencies:

The project was initiated with the complete cooperation, andhad the assistance throughout, of The Historical Unit, U.S. Army MedicalService, a class II activity of The Surgeon General, Department of the Army,under whose direction the volumes in this historical series are being prepared.

It also had the complete cooperation of the Veterans'Administration and of the Federal Records Center, General ServicesAdministration, St. Louis, Mo. (formerly the Army Records Center). Through thepainstaking efforts of the personnel of these two agencies, records werecollected from numerous sources and were forwarded to the study center in the VARegional Office in Los Angeles, Calif.¹

In some instances, these records were well over an inch thick. A great dealof the material included in them consisted of correspondence concerningdisability claims, pensions, and similar matters, but when it was winnowed, itcontained sufficient medical evidence to make good followup studies possible in167 patients.

In a number of cases, additional followup material wasobtained by direct correspondence with the veterans themselves. This method madeit possible to obtain firsthand, personal reports of their current status andalso to secure current roentgenograms.

¹Itshould be added that this truly unique investigation was the concept of Dr.Lyman A. Brewer III, and that it was through his vigorous personal efforts thatit was brought to a successful conclusion.-F. B. B.

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FIGURE 195.-Punchcard designedto secure data in long-term followup of veterans with combat-incurred wounds ofchest. Top, front. Bottom, back.

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BASIC DATA

The data were collected on punchcards especially made up for the project(fig. 195).

The age range of the 167 casualties was from 18 to 39 years.Of this number, 16 were in the 18- to 19-year group, 118 in the 20- to 29-year group,and the remainder (33) in the 30- to 39-year group.

In 131 instances, the wounding agents were shell fragments and in 36,gunshot.

Both in age distribution and in wounding agents, therefore,the patients in this series are representative of all types of combat casualtiesin World War II.

THERAPEUTIC CLASSIFICATION

The 167 patients were studied in two groups, according to their management inforward hospitals, as follows:

1. In 86 cases, wound debridement was carried out in forward hospitals, butthoracotomy was not performed.

2. In the remaining 81 cases, in 25 of which the wound wasthoracoabdominal, either thoracotomy or a combined thoracic and abdominaloperation was carried out.

This classification is based on the point, alreadyemphasized, that careful definition of the indications for, andcontraindications to, thoracotomy in forward hospitals was one of the majorcontributions made by thoracic surgeons who treated chest wounds in theMediterranean theater in World War II. One of the most important objectives ofthis study was to determine whether any casualty in the group in whichthoracotomy was omitted had died later from complications or had suffereddelayed morbidity referable to his wound. Only a long-term followup couldsettle this point.

The components of both resuscitation and initial wound surgery have beendescribed in detail in the first volume of this thoracic surgery) subseries.

INITIAL WOUND SURGERY

In the group of patients in whom thoracotomy was notconsidered necessary at initial wound surgery, the penetrating wound produced bythe missile was of such limited dimensions that the wound did not suck (blow)originally or after adequate debridement. In this type of wound, as in allothers, important considerations, in addition to the size of the missile,included its angle of penetration, its velocity, the damage to the bonycage, and the thickness of the original protecting musculature. The location ofthe wound was obviously a matter of great importance. A wound up to 2 cm. in diameter, if it was located in the interiorthoracic cage, might result in a traumatic thoracotomy, while a wound up to 14cm. in diameter, if it was located in the scapularregion pos-

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teriorly, might not result in traumatic thoracotomy, evenafter extensive debridement. It was also generally true that smaller externalwounds were likely to produce less damage within the chest than would largerwounds. In 3 of the 86 cases in which primary thoracotomy was omitted, blastinjuries were associated with powder and dirt burns of the chest, but neitherthe injury nor the possibility of internal damage was considered an indicationfor immediate thoracotomy.

In the remaining 81 cases, the initial wound was so extensive that itconstituted, in itself, a traumatic thoracotomy; or the necessary debridementwas so extensive as to produce a traumatic thoracotomy; or intrathoracic orintra-abdominal damage required entrance into these cavities to controlhemorrhage or repair damaged organs.

The indication for thoracotomy in 56 of these 81 cases was serious damage tothe chest wall or the intrathoracic contents. In six cases in this group, thediaphragm was lacerated, but the abdomen was not penetrated. In three othercases, the diaphragm was lacerated and the liver was penetrated by smallforeign bodies, 2 mm. in diameter in eachinstance. In none of the three cases was the injury sufficient to cause eitherhemorrhage or extravasation of bile, and thoracolaparotomy did not provenecessary at the base section later. Small foreign bodies in the liver areusually well tolerated. Had the injuries been more serious, exploration of theabdomen would have been necessary.

In the remaining 25 cases, the wounds were thoracoabdominal, andintra-abdominal procedures were necessary. The number of casualties in this groupwould have been larger except for the fact that patients with abdominal injuriesassociated with chest injuries were considered within the province of generalsurgeons. These casualties were always classified as nontransportable at triage,and they were treated in forward installations, very often by general ratherthan thoracic surgeons.

Since thoracotomy was done in over half of the 167 cases in this series, theemphasis on limited thoracotomy may seem somewhat misplaced. There are at leasttwo valid reasons for the high proportion:

1. All the patients who were treated by primary thoracotomy werefirst-priority, nontransportable casualties. The data (tables 20-23) show thatboth intrathoracic and extrathoracic damage were frequently extremely severe.

2. The concentration of so many serious injuries in such a small series isexplained by the fact that frequently in forward areas in which there were fewor no thoracic surgeons, thoracic casualties were referred to Thoracic SurgicalTeam No. 4, which served as a sort of unofficial forward thoracic surgerycenter.

Another index of the severity of the injuries in this series is thelength of hospitalization in forward hospitals. The 86 patients in whom primarythoracotomy was not done were held from 7 to 14 days, on the average, while the81 who required thoracotomy were held, on the average, from 4 to 7 days longer.An occasional patient in both groups had to be evacuated before the optimum timebecause of the tactical situation.

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TABLE 20.-Thoracicdamage in 167 followed-up thoracic casualties according to surgical proceduresin forward hospitals

Thoracic damage	Surgical procedure			Total
	Thoracotomy		Thoracoabdominal surgery
	Yes	No	Thoracoabdominal surgery
Chest wall:
Soft tissue	56	86	25	167
Bony cage	69	23	19	111
Persistent pneumothorax	10	13	5	28
Persistent hemothorax	45	29	17	91
Foreign bodies:
Chest wall	8	18	9	35
Pleura	14	4	3	21
Lung	18	15	3	36
Mediastinum	6	1	3	10
Pulmonary laceration	38	12	11	61
Pulmonary hematoma	27	53	9	89
Mediastinal injury	7	4	2	13
Diaphragmatic injury	9	1	25	35

TABLE 21.-Associated injuries in 167followed-up thoracic casualties according to surgical procedure

Region	Surgical procedure			Total
	Thoracotomy		Thoracoabdominal surgery
	Yes	No	Thoracoabdominal surgery
Head	5	5	1	11
Neck	5	9	1	15
Pelvis	7	6	3	16
Extremities:
Upper	23	22	7	52
Lower	12	21	5	38
Spine	1	---	1	2
Blast	9	6	6	21

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TABLE 22.-Intra-abdominal damage in81 followed-up thoracic casualties according to surgical procedure

Viscera and structures injured	Surgical procedure		Total
Viscera and structures injured	Thoracotomy	Thoracoabdominal surgery	Total
Diaphragm	10	21	31
Stomach	3	4	7
Small intestine	---	5	5
Large intestine	---	5	5
Liver	2	11	13
Spleen	---	6	6
Kidney	---	5	5
Pancreas	---	1	1
Vessels	3	3	6
Retroperitoneum	---	4	4

TABLE 23.- Complications in forwardand fixed hospitals in 167 followed-up thoracic casualties according to surgicalprocedures in forward hospitals

Complications	Surgical procedures in forward hospitals				Surgical procedures in fixed hospitals				Grand total
	Thoracotomy		Thoraco- abdominal surgery	Total	Thoracotomy		Thoraco- abdominal surgery	Total
	Yes	No	Thoraco- abdominal surgery	Total	Yes	No	Thoraco- abdominal surgery	Total
Shock¹	8	---	4	12	---	---	---	---	12
Coma	1	---	1	2	---	---	---	---	2
Wet lung	37	22	6	65	---	---	---	---	65
Hemothorax	18	5	3	26	---	---	---	---	26
Wound infection	---	---	---	---	5	2	3	10	10
Empyema	1	---	2	3	4	3	2	9	12
Pneumonitis	1	2	2	5	---	---	---	---	5
Lung abscess	2	---	---	2	---	---	---	---	2
Chronic hemothorax	2	4	5	11	---	---	---	---	11
Bronchial fistula	2	---	---	2	---	---	---	---	2
Abdominal²	---	---	1	1	4	---	6	10	11
Other³	5	7	4	16	1	3	3	7	23

¹Severe only.
²Subphrenic and peritonealabscesses, et cetera.
³Hepatitis, amputations,toxic psychoses, et cetera.

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SUBSEQUENT SURGERY

In oversea hospitals-By the time the Italian campaign began, excellentfacilities had been provided in the thoracic surgery centers in base sections ofthe North African theater for handling thoracic and thoracoabdominal casualties. The principles of treatment were becoming standardized. Well-trained andexperienced personnel were available. Also, it was possible to keep the patientsin these hospitals, when necessary, for periods up to 150 days.

Delayed primary wound closure, with or without redebridement, accounted forthe largest number of operations (59) necessary in base section hospitals (table24). No undue morbidity followed the removal of retained foreign bodies in 13 cases; in fact, the patients were then in much better conditionto withstand the procedure than they were immediately after wounding.

Most of the drainage operations for infections of the chest wall and forempyema (seven each) were required because of the extent of the original woundand the serious contamination that had occurred.

Seven decortications were carried out for empyema and two for organizinghemothorax. Most of the patients in the empyema group had been treated only bydebridement and thoracentesis in forward hospitals.

Colostomies were closed twice, both in patients in particularly goodcondition. It was always desirable to perform this operation overseas if itcould be done.

As these data show, most surgery in base section hospitals,aside from delayed primary wound closure, was necessary for infections of thechest wall and pleural cavity. Persistent pneumonitis was not seen in any ofthese patients.

TABLE 24.- Surgeryrequired in fixed hospitals according to surgery performed in forward hospitals

Surgery in fixed hospitals	Previous surgery in forward hospitals			Total
	Thoracotomy		Thoracolaparotomy
	Yes	No	Thoracolaparotomy
Drainage of chest wall	2	3	2	7
Drainage for empyema	5	1	1	7
Removal of foreign body	5	7	1	13
Decortication	4	4	1	9
Abdominal surgery	2	---	4	6
Delayed primary wound closure	26	31	2	59
Other	8	12	6	26

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In Zone of Interior hospitals.-Only a small amountof surgery was necessary in these casualties in Zone of Interior chest centers:

Two patients required drainage for empyema 5 and 6 months,respectively, after wounding. One had had a traumatic thoracotomy and the othera thoracoabdominal wound.

In three instances, removal of foreign bodies was necessary. In the first case,the missile was removed from the lung of a patient who had had debridementwithout thoracotomy in a field hospital. In the second, the missile was removedfrom the abdomen when a colostomy was closed. In the third case, the object wasremoved from the liver.

The only other thoracic surgery required was excision of an arteriovenousfistula involving the internal mammary artery.

Chest pain and dyspnea were the principal complaints of casualties who werenot returned to duty from Zone of Interior chest centers. In practically all ofthese cases, as will be pointed out later (p. 523), physical and roentgenologicexaminations showed excellent lung expansion and minimal pleural reaction.

MORTALITY AND DISPOSITION

Deaths-Four deathsoccurred in base section hospitals, all in casualties with multiple wounds, allof whom had been serious problems from the moment they were carried into theshock tent of the field hospital until they died in a fixed hospital in thebase. Three had thoracoabdominal wounds; hepatic infection and jaundice werefactors in each fatality, and one patient also had peritonitis. The remainingcasualty had a traumatic thoracotomy and a spinal cord injury with paraplegia.He died of pulmonary complications and secondary hemorrhage soon afterevacuation from the field hospital.

Disposition-Two casualties, both of whom had small wounds limited to thechest, were discharged from forward hospitals directly to their units.

In viewof the multiplicity and severity of the wounds sustained by most of theremaining patients in this series, it is surprising to learn that about half ofthem could be returned to duty in the theater, most to limited duty but a few toactive frontline combat. The larger number of casualties returned to duty, 50,were in the group in which primary thoracotomy was not necessary, but 38patients who required thoracotomy and 5 who required thoracoabdominal surgerywere also returned to duty. This was, of course, a sound policy in an overseatheater, in that it conserved manpower in the theater and reduced the need forreplacement from the Zone of Interior. One reason that it was possible was thatthe holding time in base section hospitals, sometimes up to 5 months, wassufficient for small wounds to close by secondary intention,² for wounds closedby delayed primary suture to heal solidly, for pleural effusions to be absorbed,and for hematomas of the lung to resolve.

²Two kinds of wounds wereallowed to heal by secondary intention: (1) those in which infection was justenough of a possibility to make surgeons in the base hospitals hesitant toperform delayed primary closure, and (2) large clean wounds which for one reasonor another were not suitable for delayed primary closure.

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In the Zone of Interior, only 17 patientswere returned to duty, most of them to limited duty. The group was about equallydivided between those who had undergone primary thoracotomy and those whohad not. The number was necessarily small, in view of the policy in theMediterranean theater of not evacuating casualties to the Zone of Interior,unless there was a shortage of beds, until it was reasonably clear that theycould not return to duty in the oversea theater.

When the group of patients returned to duty overseas is addedto the group returned to duty in the Zone of Interior, it is seen that more thantwo-thirds (112) ofthe 163 patientswho survived surgery in forward and base hospitals could be returned to someform of useful army service. Had the war continued and this same trendcontinued, there would have been an enormous saving in manpower. As it was, itis impossible to estimate the morale factor inherent in the return to duty ofsuch a large number of seriously wounded men.

The postwar status of these casualties will be discussed later.

The case histories which follow have been selected from thehistories of the 167 patientsfollowed up after forward surgery to illustrate special conditions andcomplications and the methods of treatment employed for them. They aredeliberately presented in some detail.

WOUNDS OF THE CHEST WALL

Although the chest wall was, of course, involved in allpenetrating wounds of the chest, in 22 casesin this series, these wounds were small. They were sometimes associated withserious intrathoracic problems, but in all cases, the wounds themselves werereadily managed by simple debridement.

In the remaining 145 cases, trauma to muscle masses and the bony cage wasextensive enough to create challenging clinical problems. Foreign bodies werepresent in 35 cases,and there were 88 sucking wounds and 4 thoracoabdominal wounds in the series.The bony case was involved 101 times, the ribs 77 times,the scapula 13 times,the sternum 6 times,and the spine 5 times.

Wound infection was not a serious problem in any field hospital, but in 10 ofthese 145 cases, drainage of the wound was necessary for this reason in basesection hospitals. In all 10 cases, the relation between the development ofinfection and the time at which debridement was performed seemed clear cut; in afew cases, initial wound surgery had been delayed up to 72 hours. Empyema developed in 9cases at the base section and in 2 othersin the Zone of Interior, but in only 2 ofthese 11 cases did a severe wound infection exist.

Case 1

Management overseas-This 31-year-old infantryman was wounded in thechest at 1130 hours on 14 October 1944, near Hupelmont, France. Three hourslater, he received a plasma transfusion of 1,000 cc. in a battalion aidstation, where the sucking wound of the anterior chest wall was closed by skin

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FIGURE 196 (case 1).-Schematic showing of large defects of chest wall. A. Wound: Large sucking wound of exit in right anterior chest wall, with destruction of portions of fourth, fifth, and sixth ribs and the corresponding costal cartilages (a), wound of entrance in left chest (b), and through-and-through wound of left upper arm (c). B. Closure of large chest wall defect by suture of mobilized pectoralis major (a) and rectus abdominis (b). C. Closure of central portion of wound with wounds of entrance (a) and exit (b) left open down to fascia, and closed drainage tube in situ (c).

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FIGURE196b (case 1).-Schematic showing of large defects of chest wall. A. Wound: Large sucking wound of exit in right anterior chest wall, with destruction of portions of fourth, fifth, and sixth ribs and the corresponding costal cartilages (a), wound of entrance in left chest (b), and through-and-through wound of left upper arm (c). B. Closure of large chest wall defect by suture of mobilized pectoralis major (a) and rectus abdominis (b). C. Closure of central portion of wound with wounds of entrance (a) and exit (b) left open down to fascia, and closed drainage tube in situ (c).

sutures and a sulfonamide powder was placed in it. He was given morphine gr.? and, because of wet breathing, atropine gr. ¹/50.

When he was received at the 11th Field Hospital at Eloyes,France, at 1545 hours, he was dyspneic and cyanotic, and his breathing was stillwet. A large wound in the anterior chest wall (fig. 196A) extended from theanterior axillary line on the right at the sixth interspace across to the fourthrib in the anterior axillary line on the left. Breath sounds were heardbilaterally distant on the right, and there were numerous rales and rhonchithroughout both lung fields.

The resuscitative regimen included oxygen by nasal catheter; penicillinintramuscularly; thoracentesis, with removal of 300 cc. of bloody serous mucusfrom the right chest; intercostal nerve block, including the fifth through theeighth nerves; and catheter aspiration, which produced bloody serous mucus.

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FIGURE 197 (case 1).-Serial roentgenograms in large defect of chest wall. A.Posteroanterior roentgenogram, 14 October 1944, immediately after wounding,showing fluid in lower half of right chest, with mottled infiltration above andon the left. Note air in anterior mediastinum outlining left mediastinalpleura. B. Lateral roentgenogram showing hazy lung fields and displacement ofheart posteriorly by air in anterior mediastinum. C. Posteroanteriorroentgenogram, 21 October 1944, showing closed drainage tube in right chest(reinserted to control pulmonary air leak), right hydropneumothorax, andsubcutaneous and mediastinal emphysema. D. Posteroanterior roentgenogram, 25October 1944, showing clearing of both lungs.

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FIGURE 197.-Continued. E. Posteroanterior roentgenogram, 19 November 1960, 16 years after wounding, showing irregularity of fifth and sixth ribs anteriorly, slight blunting of right costophrenic angle, prominent bronchovascular markings, and fibrosis of right paracardiac region above diaphragm. F. Lateral roentgenogram on same date, showing pleural shadow anteriorly and fairly flat diaphragms.

Roentgenologic examination (fig. 197A and B) showed fluid occupying the lowerhalf of the right chest, with a mottled infiltration above and to the left, andair in the mediastinum displacing the heart posteriorly.

When the patient was first observed, his pulse was intermittently irregular,and there were dropped beats at the radial pulse. There were also prematurecardiac contractions. After 4 hours of the intensive resuscitation justdescribed, his condition improved, and his lungs seemed entirely dry.

The sucking wound of the right chest was thoroughly debrided, and portions ofthe fourth, fifth, and sixth ribs, with the corresponding costal cartilages,were resected. The laceration of the right lung was repaired with interruptedsutures of fine catgut, and a drainage tube was introduced into the lower rightpleural cavity and connected with a closed system.

To effect closure, it was necessary to mobilize a large pectoral flap and arectus flap. These were sutured together and attached to the chest wall, to fillin the huge defect left by resection of the three ribs (fig. 196B). The centralportion of the chest wall was closed (fig. 196C), and the wounds of entrance andexit were left open and packed with gauze down to the muscle layers.

A wound inthe left upper arm was debrided.

The patient's condition was satisfactory throughout the operation, but anhour after it was concluded, his respirations became very wet. Bronchoscopy,which was performed at once, yielded a moderate amount of bloody mucus from bothbronchi. At this point, cardiac arrest occurred. The catheter was at oncewithdrawn and the bronchoscope was removed. Oxygen was administered by

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face mask, with intermittent positive pressure on theanesthetic bag. In less than 2 minutes, the heartbeat returned, the respirationsalso returned, and within 10 minutes, the patient regained consciousness.

Late on the second postoperative day, subcutaneous emphysema in the neck andthe chest wall became quite marked. Pneumothorax, which was evident on theright, was controlled by a catheter inserted into the pleural space and fixed toa closed drainage system (fig. 197C). The inferior drainage tube ceased tofunction within 48 hours and was removed at this time.

The temperature was elevated to 101^? F. for the first week afteroperation, but when the patient was evacuated to the base section on the 12thpostoperative day, the emphysema had disappeared (fig. 197D), the lung wasexpanded, and the wound was clean.

Contrary to the usual practice, it was necessary in this case to use a tightbinder during the postoperative period, because of the mobility of the chestwall. It was discarded as the wound healed and the wall became firm.

Management in the Zone of Interior-Thepatient required no activetreatment in the Zone of Interior and was given a disability discharge.

Followup.-This patient has been well since he was finally discharged from the VAoutpatient clinics 5 years ago except for dyspnea on manual exertion and somepain. He has held a variety of jobs.

Roentgenologic examination on 19 November 1960, 16 years after wounding (fig.197E and F) showed prominent bronchovascular markings, and slight fibrosis ofthe right paracardiac region above the diaphragm. The lateral view was clearexcept for blunting of the right cardiophrenic angle.

Comment-This patient presented a number of problems: A large anteriorsucking wound of the right chest; fractures of the fourth through the sixth ribsand their cartilages; some evidence of blast injury to the heart, with cardiacirregularity; a moderately severe wet lung syndrome; and mediastinal emphysema.Satisfactory closure of the large defect in the chest wall was effected withflaps of pectoral and rectus muscles. Although the patient had had atropine (gr.¹/200)90minutes earlier, cardiac standstill occurred whenbronchoscopy was performed after operation. Positive pressure oxygen waseffective, and there were no further difficulties in this regard. Accumulationof air in the affected hemithorax required the insertion of a second closedthoracostomy tube. The explanation of the cardiac standstill was probably acombination of hypoxia., so-called cardiac blast, and vagovagal trachealstimulation. The use of atropine before operation may have been helpful inproducing the prompt recovery.

Case 2

Management overseas-This technical sergeant, attached to a tankdestroyer battalion, was wounded in the left chest by a high explosive shellfragment at 0845 hours on 3 December 1943, near Cassino, Italy. At the battalionaid station, a sucking wound of the left chest anteriorly (fig. 198A) was packed

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FIGURE 198 (case 2).-Schematic showing of sucking wound with defect of chestwall. A. Wound in anterior aspect of chest, with sucking wound of secondintercostal space packed with petrolatum-impregnated gauze. B. Schema ofpathologic findings, anterior view: Foreign body in lung and pleura (a),hematoma of left upper lobe (b), wet lung (c), mucus and blood in trachea (d),and engorged superior vena cava (e).

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FIGURE 198.-Continued. C.Findings at thoracotomy, lateral view: Sucking wound (a), laceration of leftupper lobe (b), hematoma of left upper lobe (c), foreign body in pleura (d),left hemothorax (e), and wet lung (f).

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FIGURE 198.-Continued. D. Anterior aspect of chest at conclusion of operation: Debrided pectoralis major muscle sewn together to close sucking wound (a), with fine-mesh gauze packed into wound (b), and closed intercostal drainage tube (c).

with a dressing sprinkled with powdered sulfanilamide, and morphine (gr. ?) was given.

The patient was received at the 94th Evacuation Hospital at1100 hours the same day. Here he gave a history of having had a severerespiratory infection for the previous 4 or 5 days. At this time, he was inshock, with blood pressure of 80/60 mm. Hg, pulse of 130, and wet and laboredrespirations. He was extremely dyspneic. Signs of fluid were present over theentire left chest, and rales were heard over the right chest.

The chest wound was fairly clean. It was cleansed down to thepleural opening, which was 2 by 3 cm., and a fresh petrolatum-impregnated packwas inserted. Resuscitative measures included tracheal aspiration, which yieldeda large amount of bloody fluid; intercostal nerve block, from the second throughthe eighth nerves on the left; thoracentesis, which yielded 700 cc. of bloodyfluid; and a transfusion of 500 cubic centimeters.

The patient's condition improved with these measures, butrespirations were wet over both lung fields, and it was obvious that he had beenwounded at a time when he had a severe bronchopulmonary infection. Therefore,since

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the wound was fairly clean, it was decided that the risk ofimmediate surgery was greater, under the circumstances, than the development ofinfection of the chest wall.

Roentgenograms on the day of wounding, taken after aspiration of the chest(fig. 199A), showed a large foreign body in the left upper lobe and a hematomain the same location.

The patient was given 4 gm. of sulfadiazine daily until 7 December 1943.During this period, he ran a low-grade temperature.

Operation was performed on 7 December 1943, under light nitrous-oxideanesthesia. The hematoma shown in the roentgenogram 4 days earlier was stillpresent, but the foreign body was not readily accessible, and no search was madefor it (fig. 198B and C). Lateral pleural drainage was instituted. Thepectoralis muscle was closed (fig. 198D) and the rest of the wound was left wideopen and packed.

The postoperative course was satisfactory, and the patient was evacuated tothe 24th General Hospital at Bizerte, 10 days after operation. Here, 3 weekslater, elective thoracotomy was done, and a large foreign body was removed fromthe left pleural space and left upper lobe. Satisfactory healing followeddelayed primary wound closure.

Four months after wounding, the patient was released for limited duty in thecommunications zone. At the end of the war, he was sent to the Zone of Interiorby rotation and discharged there.

Followup-A communication from this patient on 22November 1960 stated that he had done outside construction work since the war.His only complaints were mild dyspnea when he had chest colds and some pain inthe left shoulder associated with overwork. He was married and had children.

Roentgenograms made on 21 November 1960 (fig. 199B and C) showed the leftlung completely expanded and no abnormalities of consequence.

Comment.-Theinteresting feature in this case is the admission of the patient to aforward hospital with a sucking wound superimposed upon a severebronchopulmonary infection. It was decided to repack the wound daily and allowthe respiratory infection to subside before surgical closure of wound wasundertaken. Removal of the foreign body in the left pleura and upper lobe wasperformed at the base section. Recovery from this operation, as from thedeferred initial wound surgery, with closure of the pectoralis muscle, in theforward hospital, was uncomplicated, and there was no residual disability.

This is the only case of the kind in this particular series, though therewere a number of similar instances in the cases in this series not followed upafter the war. The lesson to be learned from it is that, while generalprinciples must be followed in wartime, they must be flexible enough to permiteach case to be managed on its own merits.

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FIGURE 199 (case 2).-Serial roentgenograms in sucking wound with defect ofchest wall complicated by severe bronchopulmonary infection. A. Posteroanteriorroentgenogram, 3 December 1943, shortly after wounding, showing large foreignbody and hematoma in left upper lung field, with haziness of both lung fields.Although the chest has been aspirated, a small amount of pleural fluid is stillpresent on the left. B. Posteroanterior roentgenogram, 21 November 1960, 17years after wounding, showing clear lung fields, prominent bronchovascularmarkings, and sharp costophrenic angles. Note healed fracture of left sixth rib,apparently the result of elective thoracotomy performed in base hospital in1943. C. Lateral roentgenogram on same date showing clear lung fields and deep,clear costophrenic angles.

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LACERATIONS OF THE LUNG

Lacerations of the lung of sufficient magnitude to present clinical problemswere present in 61 of these 167 cases. Neither blunt trauma nor spontaneouspneumothorax was an etiologic factor in any case. In each instance, the lung wastorn by a penetrating missile or by fractured ribs.

Intrapleural decompression was required in all 61 cases, butthoracotomy to repair the rent was employed only selectively. The laceration,per se, was not regarded as an indication for this procedure.

In 13 cases, continuing leakage of air was treated conservatively, byaspiration or catheter drainage, and in each instance, the laceration closedspontaneously. In a number of cases not included in the group followed up, smalllacerations of the lung were closed when thoracotomy was done, but whether allthese repairs were necessary is another matter.

In the 48 cases in this series in which thoracotomy was done on theindication of pulmonary lacerations, direct repair of the laceration wasnecessary in 38 cases, in 6 of which the tear was so extensive that musclegrafting was required to effect closure. This technique proved highlysuccessful; neither bronchopleural fistula nor empyema developed in anyinstance.

In only one instance in the series was pulmonary resection carried out in aforward hospital. In this case, a laceration of the lung and damage to the bloodsupply and the bronchus of the posterior basal segment of the right lower lobeserved as a valid indication for segmental resection because the damaged area ofthe lung was no longer viable.

Pulmonary resection was not necessary at any hospital in thecommunications zone, nor was it necessary in a Zone of Interior hospital. Onepatient among the 61 with pulmonary lacerations developed a pneumothorax in theZone of Interior, 3 months after wounding, and thoracotomy was necessary toremove the foreign body causing the difficulty. No other patient in the seriesrequired surgery in the Zone of Interior, and this was the only thoracotomyperformed for this reason in this series in any Army general hospital in theUnited States.

One other point should be emphasized in connection withlacerations of the lung: Patients in this group with progressive or tensionpneumothorax were not evacuated to the rear until the condition was undercontrol unless tactical circumstances demanded movement of the installation. In2 of these 61 cases, evacuation was necessary for this reason before the airleak was controlled, but in each instance, a trained medical technician rode inthe ambulance with the patient to insure that the decompression catheterfunctioned properly en route. This conservative evacuation policy undoubtedlyexplains why recurrent pneumothorax was not a problem in base section hospitalsin the Mediterranean theater.

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Case 3

Management overseas-This 19-year-old infantryman waswounded in the left chest posteriorly, the left upper arm, and the left hip at 0800hours on 28 November 1943, in themountains near Cassino, by an artillery shell fragment. Emergency treatment consisted of the application of anocclusive dressing sprinkled with a sulfonamide powder, sulfadiazine by mouth,and morphine. At the collecting station, a unit of plasma was given. Because oftransportation difficulties, the patient did not reach a clearing station untilthe following day.

When he arrived at the 94th Evacuation Hospital at LePezze,he was found to have a sucking wound (fig. 200A), satisfactorilyoccluded, of the left posterior chest in the region of the sixth, seventh, andeighth ribs, and smaller wounds of the left arm and left chest. He wasextremely short of breath. The temperature was 101? F., the pulse 90, therespirations 48, and the bloodpressure 130/80. Breath sounds were absent over the left chest; the right chestwas fairly clear. Roentgenograms made on 30 October 1960 (fig. 201A and B) showed almost completecollapse of the left lung; fractures of the sixth, seventh, and eighth ribs;and a foreign body apparently within the cardiac shadow. Some fluid was presentin the left chest; the right lung was fairly clear.

The routine of resuscitation included bronchial aspiration per catheter,after which respirations became more satisfactory.

Operation was performed on 30 November 1943, at 0040 hours.The posterior sucking wound, which was found to be infected (fig. 200A), wasvery carefully debrided down to clean muscle tissue. The instruments, gloves,and drapes were changed before the remainder of the operation was proceeded with.

Fractures of the sixth, seventh, and eighth ribs were exposed and thefragments were removed. The pleural cavity was entered by extending thewound of the sixth intercostal space (fig. 200B). A metallic foreign body, 2 by 1.5 cm., was removed from the left upper lobe, along with some ribfragments. A hematoma was present in this lobe, as well as a foreign body whichdid not penetrate the heart. Rib fragments were also removed from the left lowerlobe (fig. 200C). Lacerations in both lobes, from which air wasbubbling, were easily repaired with catgut (plain O) mattress sutures. About500 cc. of blood was aspirated from the pleural space, after which extremelythorough pleural lavage was carried out.

The chest wall was closed (fig. 200D) by suturing the trapezius andlatissimus dorsi muscles over the pleural defect in the sixth intercostalspace. The serratus was closed more anteriorly. The fascia and subcutaneoustissues were left wide open. Closed intercostal drainage was instituted in theeighth intercostal space.

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FIGURE 200 (case 3).-Sucking wound of left posteriorchest with earlyinfection. A. Wound. Posterior aspect of thorax showing infected sucking woundof sixth intercostal space on left, packed with gauze. B. Diagram of findings atthoracotomy showing: Collapsed lung with foreign body (a), pulmonary laceration(b), hemothorax (c), bone fragments in left lower lobe (d), and hematoma insame location (e).

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FIGURE 200.-Continued. Appearance ofwound after repair of laceration of left upper lobe with removal of foreignbody, leaving hematoma undisturbed (a). Closed pleural drainage has beeninstituted (b).

The immediate postoperative course was stormy, with the temperature rangingdaily from 100? to 102? F. Roentgenologic examination on 7 December 1943showed diffuse haziness of the left chest, and thoracentesis yielded purulentexudate.

In spite of the fever and the infection, the patient's general condition wasgood, and he was therefore evacuated to the base when an inordinate number offresh casualties required that the hospital be emptied.

The left empyema was drained at the 33d General Hospital, at Bizerte, byresection of a portion of the ninth rib.

Management in the Zone of Interior-InFebruary 1944, the patient wasevacuated to the Zone of Interior. By this time, the chest wound was healed, theempyema had been controlled, and the lung was fully expanded, the onlyabnormality being some pleural thickening on the left. Neurolysis of the leftmedian nerve was carried out at Walter Reed General Hospital, Wash-

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FIGURE 200.-Continued.D. Airtight closure of deep muscles of chest wall: Packing of superficial woundabove closure (a), and closed pleural drainage (b).

ington, D.C. After a period of limited duty, the patient was discharged fromthe Army on 14 March 1946.

Followup-A communication from thepatient in November 1960 statedthat he had worked in the post office as a mail clerk since his discharge fromthe Army. He was married and had two children. He had no symptoms referable tothe chest. Roentgenograms made on 21 November 1960 (fig. 201C and D) showed an essentially clear left lungfield. The only abnormality was regeneration and fusion of the sixth, seventh,eighth, and ninth ribs.

Comment-This casualty was in serious condition when hewas first seen, with an infected sucking wound of the left chest posteriorly, analmost complete collapse of the lung, some fluid in the left chest, and aforeign body at first thought to lie within the cardiac shadow. A hematoma waspresent in the left upper lobe, and there were fragments of fractured ribs inthis lobe and in the left lower lobe. Conservative management included bronchialaspiration per catheter as part of the resuscitative regimen, debridement,removal of the

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FIGURE 201 (case 3).-Serial roentgenograms of sucking wound with earlyinfection. A. Posteroanterior roentgenogram, 30 October 1943, shortly afterwounding, showing collapse of left lung and fracture of sixth, seventh, andeighth ribs. Note that in this view a foreign body appears to be within thecardiac outline. B. Left lateral roentgenogram, showing foreign body within lungand not penetrating heart. C. Posteroanterior roentgenogram of chest, 21November 1960, 17 years after wounding, showing regeneration and bridging ofsixth, seventh, eighth, and ninth ribs; slight blunting of left costophrenicangle; and slight pleural reaction on left. Otherwise, the lung fields areclear. D. Lateral roentgenogram on same date, showing clear lung fields andsharp posterior costophrenic sulci.

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foreign body and the rib fragments, repair of lacerations in the involvedpulmonary lobes, closure of the chest wall, and closed intercostal drainage.

Although the patient developed an empyema, it was readily controlled by correctrib-resection drainage, and the damaged lung was fully expanded when he wasreceived in a Zone of Interior hospital. At the present time, 17 years afterwounding, he is leading an active life, with no residua from his chest injuryand no significant roentgenologic abnormalities.

This case is another illustration of the excellent resultsachieved by strict adherence to the principles and practices of thoracic surgerydeveloped in the Mediterranean theater during World War II.

MEDIASTINAL INJURIES

Injuries to the mediastinum were recorded only 13times in these 167 cases. This might be expected. As pointed out several timesearlier in this history, because the heart, great vessels, esophagus, trachea,and bronchi are located in this area, most casualties with severepenetrating mediastinal wounds do not survive to reach any hospital.

The casualties in this series who survived mediastinal injuries all hadwounds produced by small foreign bodies, whose driving force was spent.Bleeding into the mediastinum sufficient to produce a widened mediastinal shadowwas present in five instances, but in all, the blood was absorbed withoutsequelae.

Although this is a small group and the mediastinal injury was not always themost important lesion, six of the casualties had traumatic thoracotomies, andothers had considerable trauma to the thoracic cage and the lungs. Small foreignbodies were removed in four instances and allowed to remain in the others.

At the base section, five patients were returned to limitedduty. The other five were evacuated to the Zone of Interior, where all receiveddisability discharges, in one instance on the basis of psychoneurosis.

The problems encountered in the treatment of mediastinal injuries areillustrated in the following case history:

Case 4

Management overseas-This 19-year-old Japanese-American infantrymanreceived a high explosive shell-fragment wound of the left chest (fig.202A) at 1100 hours on 8 November 1944, at Biffontaine, France. He received twounits of plasma at the battalion aid station, where the wound was packed with adressing sprinkled with sulfanilamide.

When the casualty was received at the 11th Field Hospital at1345 hours, he was in deep shock. The blood pressure was 80/70 mm. Hg, thepulse 128, and the respirations 40. The massive sucking wound of the leftanterior chest was occluded by an airtight packing.

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FIGURE 202 (case 4).-Anterolateralsucking wound of left chest. A. Anterolateral aspect of left chest after removalof petrolatum-impregnated gauze pack: Large, dirty wound, 5 by 8 inches,involving pectoralis major and serratus magnus (a), stump of fifth rib (b),defect in pleura 2.5 by 3 inches (c), and stump of fifth costal cartilage (d).B. Findings at thoracotomy: Tense hemopericardium (a), nonopaque foreign bodies(dirt, bone, cloth) in pericardium (b), hematoma of pericardium (c), hematoma ofentire left lower lobe (d), laceration and hematoma of lingula of left upperlobe (e), accessory lobe (f) and hemothorax (3,000 cc.) (g).

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FIGURE 202.-Continued. C. First stepin wound closure: Residual defect in pleura, 1 by 1.5 inches, impossible toclose (a), closure of intercostal muscles (b), and anterior stump of fifthcartilage (c). D. Closure of muscles of anterior chest wall over pleural defect:Upper portion of pectoralis major (a), lower portion (b), serratus magnus (c),and pleural defect (d). E. Wound closure: Anterior reinforcement of closure byskin suture (a), skin wound left open posteriorly (b), posterior inferior closedintercostal drainage tube (c), and anterior intercostal closed drainage tube(d).

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After 200 cc. of plasma had been given, pulmonary edema occurred, and no moreplasma was given. Tracheal suction, repeated several times, produced quantitiesof thin, pinkish fluid. When only 20 cc. of fluid could be obtained bythoracentesis, the pack in the wound was temporarily loosened, whereupon a largeamount of bloody fluid escaped. An attempt at blood transfusion precipitatedpulmonary edema, and endotracheal suction was again applied, with positivepressure oxygen therapy, the anesthetic bag being squeezed with eachinspiration.

Roentgenologic examination (fig. 203A and B) showed hazinessof the entire left lung field, a shift of the heart to the right, andsubcutaneous emphysema. The right lung was fairly clear.

At the end of 8 hours of the regimen described, the patient's condition wasstill precarious. Blood transfusion was again attempted, while at the same time,measures were carried out to combat wet lung. The blood pressure wasimperceptible at times, but eventually, after intercostal nerve block and theadministration of atropine gr. ¹/150, itrose to 96/60 mm. Hg.

After the patient's condition had improved sufficiently andhis lungs had been dry for several hours, operation was undertaken at 0130 hourson 9 November, on the indications of continued intrathoracic hemorrhage; thenecessity of closing the sucking wound; and the possibility of bothdiaphragmatic and cardiac injury. The operation began with debridement of thechest wall. The pectoralis and serratus muscles were extensively involved (fig.202A), the defect measuring 5 by 8 inches. The fifth rib was shattered, and hadto be removed down to the cartilage. There was an opening 2.5 by 3 inches in thefourth and fifth intercostal spaces.

Excellent exposure of the pleural cavity (fig. 202B) was obtained by openingthe fifth intercostal space posteriorly. A massive hematoma occupied the lowerlobe of the left lung and the lingula of the upper lobe, but the accessory lobewas not involved. About 90 cc. of bloody fluid was aspirated from thepericardium, which was extremely tense. After dirt, cloth, and fragments of ribwere removed from the pericardium, it was seen to contain a large hematoma. Awindow was made in the pericardial sac, to permit drainage into the pleuralcavity, which contained about 3,000 cc. of blood. After the blood had beenremoved, the cavity was thoroughly washed out with physiologic salt solution. Alaceration in the upper lobe of the left lung had almost completely sealed over.

Pleural drainage was effected in the second intercostal space anteriorly andin the base posteriorly and was connected with a closed-drainage system.

By this time, the lung had expanded satisfactorily and there was no furtherevidence of bleeding. The chest wall was closed (fig. 202C and D) by partialclosure of the intercostal bundles of the fifth interspace. The pectoralis majorwas mobilized from above and brought down over the pleural defect, and theserratus magnus was brought up behind. Since the muscles were abnormally thin,it was necessary to close the skin and subcutaneous tissues with mattress

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FIGURE 203 (case 4).-Serial roentgenograms in mediastinal injury withintrapericardial foreign bodies and hematoma. A. Posteroanterior roentgenogram,7 November 1944, immediately after wounding, showing massive left hemothorax,with slight shift of mediastinum to right, and extensive emphysema of left chestwall. Right lung is fairly clear. B. Lateral roentgenogram on same date showingdiffuse haziness. No radiopague foreign body is seen. C. Posteroanteriorroentgenogram, 22 November 1960, 16 years after wounding, showing clear lungfields and normal heart shadow. Note muscular defect of left anterior chestwall, with resection of anterior portion of fifth rib, and tenting of leftdiaphragm. D. Lateral roentgenogram on same date showing defect of left anteriorchest wall with pleural reaction posterior to it and high anterior tenting ofleft diaphragm. Otherwise, the findings are within the normal range.

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sutures anteriorly; both posterior limbs of the wound were left open (fig. 202E).

The wound in the left arm was then debrided. The ulnar nerve had beentraumatized but not completely lacerated. The brachial artery, however, had beenlacerated. After the clot which occluded it had been milked out and a free flowof blood had been reestablished, repair was accomplished with No. 00000 silksutures. The pulse, which had not previously been present in the left wrist,could now be felt.

The patient made a satisfactory recovery.

Management in the Zone of Interior-When the patientreached the Zone of Interior, no further surgery on the chest was necessary.Repair of the ulnar nerve was carried out at DeWitt General Hospital, Auburn,Calif. He was discharged from the Army on 17 August 1946.

Followup-A communication from thispatient on 23 November 1960 revealed thathe was working 40 hoursa week as a building materials salesman. He had no difficulty in breathing andno other complaints. Roentgenograms made on 22 November 1960 (fig. 203C and D) showed the left lung to be completely expanded andthe lung fields clear. The chest wall defect was apparent on the film, bothlaterally and anteriorly, and the left diaphragm was tented, but there were noother abnormalities.

Comment-This patient was observed at a field hospital ineastern France with a large sucking wound of the anterior chest wall, whichundoubtedly involved both the lung and the heart. Stabilization was extremelydifficult and occupied some 10 hours. Although surgery was taxing, he withstoodit well; it included removal of foreign bodies from the pericardium,pericardial drainage, and the structural problem inherent in the reconstructionof the anterior chest wall. The pectoralis and serratus muscles were used tocover the defect, and the weakest portion of the repair was reinforced byclosure of the skin over it. The associated wound in the arm, which involvedboth the ulnar nerve and the brachial artery, also required a taxing repair.

The fact that this patient is well and working withoutcomplaints referable to the chest 16 years after wounding is heartening when oneconsiders the severity of the original wound and the complex problems involvedin both resuscitation and initial surgery. The presence of clear lung fields,except for diaphragmatic tenting, at the end of this period of time also speakswell for the staged management employed in this case.

BLAST INJURIES

Generalized blast injury, caused by a wave of generalized positive pressurefollowed by a wave of negative pressure, was a factor in 21 cases in this series. In three instances, there was noexternal wound except for powder and dirt burns of the skin. Perforated eardrumswere present in four cases,

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and transient cardiac irregularities and evidences of cerebral anoxia werecharacteristic of the early stages in practically all cases.

All 21 patients were evacuated to the base section, where 3 patients died ofwounds not directly due to the blast injury. After periods of up to 5 months,six patients were returned to limited duty in the communications zone. The other12 patients were returned to the Zone of Interior. None of them was released foractive duty, and all of them eventually received disability discharges, two withthe diagnosis of psychoneurosis as the principal cause. Followup studies showedslight pulmonary emphysema, but no instance of clinical dyspnea was reported.

Localized blast effect, due to the impact force of high explosive shellfragments upon the chest wall and thoracic organs, was a factor in practicallyevery patient in the series who had a severe injury of the chest wall.

The following case history illustrates the problems of blast injuries and thetypical followup status of those who sustained them:

Case 5

Management overseas-This 21-year-old infantryman was 20 feet away froman aerial bomb blast which occurred at 1330 hours on 10 November 1943, nearVenafro, Italy. He was unconscious for a short period of time. When he regainedconsciousness, he found that he had been sprayed with dirt and had sufferedfacial burns. He was picked up by a corpsman shortly after the blast and takento a battalion aid station, where he was given 250 cc. of plasma and morphinegr. ?.

When he was admitted to the 94th Evacuation Hospital atLePezze at 1530 hours, he complained of severe dyspnea, orthopnea, wheezing,choking, slight dysphagia, and severe chest pains. Coughing produced bloodysputum.

Examination showed a second degree burn of the face,involving the left cornea and conjunctiva, but no other external wounds. Theveins in the neck were full. The patient was cyanotic, and his breathing wasextremely difficult. Breath sounds were decreased, and in some areas almostabsent, over the right chest, and scattered rales were also heard on the left. Theheart sounds were distant and slightly irregular.

The left tympanic membrane was ruptured. Hearing was impaired on this side,and later there was slight drainage from the ear.

Roentgenologic examination on 11 November 1943, the day after injury (fig.204A), showed diffuse bilateral haziness and infiltration, which were taken toindicate petechial pulmonary hemorrhage and edema.

Treatment consisted of oxygen administration by nasal catheter, repeatedcatheter bronchial aspiration, restriction of fluids by mouth, and control ofthe chest pain by small doses of morphine. The patient was not digitalized, andhe was not given intravenous fluids.

The lungs gradually cleared (fig. 204B), and 14 days after wounding, he wasevacuated to a base hospital.

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FIGURE 204 (case 5).-Serialroentgenograms in blast injury. A. Posteroanterior roentgenogram, 11 November 1943,24 hours after injury, showingdiffuse bilateral haziness and infiltration indicative of petechial pulmonaryhemorrhage and edema. B. Posteroanterior roentgenogram, 17 November 1943, showing clearing of lung field.C. Posteroanterior roentgenogram, 7 January 1960, 16 years after severe blastinjury. The only abnormality is slight emphysema of upper lobes. The diaphragmsare at level of the eleventh ribs; their contours are rounded. Heart is alsonormal.

Management in the Zone of Interior-In the Zone ofInterior, the patient required no treatment for the blast injury. Theconsiderable facial scarring left by the powder burns was treated by plasticsurgery at Valley Forge General Hospital, Phoenixville, Pa., in March 1944. On28 November, he was returned to limited duty and served without difficulty untilhis discharge on 1 September 1945.

Followup-Since his discharge from the Army, the patient has beenfollowed up in the Veterans' Administration. His only complaint is brief, mildheadaches, about three times a week, relieved by simple medication. They are

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thought by the neurologist to be evidence of an early, mild, chronic brainsyndrome as a result of the blast injury.

Roentgenologic examination on 7 January 1960, 16 yearsafter the blast injury (fig. 204C), showed no abnormality except mild pulmonaryemphysema of the upper lobes.

Comment-This case history illustrates a typical blastinjury, produced by a powerful wave of positive, followed by a wave of negative,air pressure, from a bomb apparently of considerable size. The infantryman wasabout 20 feet from the bomb, his nearness to it being shown by the superficialburns and dirt wounds of the skin of the face. The symptoms and signs were thoseusually observed in serious blast injuries. They included unconsciousness,severe dyspnea, hypoxia, severe chest pain, and rupture of an eardrum. Thedilatation of the veins of the neck indicated increased venous pressure, and thewet lung syndrome was characterized by the presence of persistent rales andrhonchi.

Treatment included maintenance of a clear airway by repeated catheteraspirations; the administration of oxygen, to provide adequate oxygenation ofthe blood while the lung was healing; restriction of fluids by mouth; and avoidance of administration of fluids by vein. With these measures, digitalizationwas not necessary.

This casualty could be returned to active duty, and 16 years after the blast injury, he is in good health and isleading an active life. He has no pulmonary symptoms and there are nosignificant roentgenologic findings. The only (minimal) evidence of the injurytakes the form of occasional mild headaches.

THORACOABDOMINAL WOUNDS

Thoracoabdominal wounds, which occurred 25 times in these 167thoracic wounds, represented the combined problemsencountered when two major serous cavities were involved. The seriousness ofthese problems is evident in certain facts:

1. Three casualties, as already mentioned (p. 450), died of latecomplications in base hospitals.

2. No patient in this group was returned to duty from theforward area, although four performed limited duty in base sections of theMediterranean or European theaters within 2 months after wounding.

3. Secondary surgery was required in six cases, three timesfor drainage or empyema, twice for drainage of subphrenic infections, and oncefor removal of a foreign body which was left in situ in the forward area because of the urgency of the abdominal wounds.

4. All patients who returned to the Zone of Interior eventually receiveddisability discharges, in one instance almost 10 years after wounding.

The following case histories illustrate the course of, and the problemsinvolved in, thoracoabdominal wounds:

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Case 6

Management overseas-This 22-year-old infantryman was wounded in the leftlower chest anteriorly (fig. 205A) at 1200 hours on 28 September 1944, atFaucompierre, France. He was standing about 100 feet from an 88-mm. shellexplosion. He was knocked down but did not lose consciousness. Within 15minutes, he was taken to a battalion aid station, wherehe was given eight sulfonamide tablets by mouth and a unit of plasmaintravenously. The wound was sprinkled with a sulfonamide powder and dressed.

When he was admitted to the 11th Field Hospital at Eloyes, France, the woundwas bleeding moderately. He complained of moderate pain in the chest and severepain in the left upper quadrant of the abdomen. The blood pressure was 120/78mm. Hg, the pulse 80, and the respirations 20.

The wound in the lower left chest was close to the costal margin in theeighth intercostal space. It was packed because movement of the chest wallcaused sucking. Breath sounds on the left were decreased, but the right lungshowed no abnormalities.

The patient complained of increased pain in the abdomen immediately afteradmission to the field hospital. Examination revealed tenderness in the leftupper quadrant; pressure on any portion of the abdomen produced pain in thisarea.

Roentgenologic examination (fig. 206A) showed a large metallic foreign bodybelow the left diaphragm, at the level of the eleventh rib. The lung fields werehazy.

The patient had eaten a K-ration 5 hoursbefore wounding, and gastric lavage produced undigested food along with bloodyfluid.

Obviously, peritoneal contamination had occurred from a wound of thegastrointestinal tract, and operation was urgent. At 1530 hours, when theanesthesiologist began induction, the blood pressure fell to 40/0 mm. Hg. Aftera transfusion of 500 cc. was given, the systolic pressure rose to 90 mm. Hg,and operation was restarted at 1630 hours.

The wound at the eighth intercostal space was debrided and the incision wasextended along this interpace (fig. 205A), to expose the pleural cavity. The diaphragm was foundwidely torn. The omentum had herniated into the left pleural cavity, which alsocontained gastric contents. When the diaphragm was opened posteriorly, providingexcellent exposure of the upper abdomen (fig. 205B and C), an 8-cm. tear was found in the stomach. Both thespleen and the pancreas were lacerated. The foreign body responsible for these wounds, which was 4 by 1 by 2 cm.,had dropped back into the stomach. It was removed, after which the gastriclaceration was repaired and the spleen was removed. Blood in the amount of 1,000cc. was aspirated from the peritoneal cavity, which also contained a smallamount of gastric contents. The rent in the gastrocolic omentum was repaired.The diaphragm was closed with a double layer of interrupted silk sutures. Thechest wall was closed in layers with similar suture material. Closedintrapleural drainage was instituted.

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FIGURE 205 (case 6).-Schematic showing ofthoracoabdominal wound. A. Woundof entrance: Shell fragment wound in anterior eighth intercostal space (a),metallic foreign body (b), and incision in eighth intercostal space (c). B.Diagram of course of missile: Wound of chest wall (a), laceration of diaphragmand stomach (b), foreign body (c), and laceration of spleen and pancreas (d).

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FIGURE 205.-Continued. C. Excellent exposure of left upper abdomen at operation, with diaphragm opened and rib spreaders in place: Anterior wound in stomach (a), posterior wound in stomach (b), foreign body (c) responsible for lacerations of pancreas (d), spleen (e), and left lower lobe of lung (f).

The immediate postoperative recovery was satisfactory, but on the followingmorning, the patient was dyspneic and cyanotic, and diffuse rales were heardover both lungs. Thoracentesis produced 500 cc. of bloody fluid. Because the hematocrit showedhemoconcentration, an intravenous infusion of glucose and physiologic salt solution was given, together with 250 cc. of plasma. Bilateral intercostal nerve block wascarried out from the sixth through the twelfth nerves. The penicillin therapybegun before operation was continued. Thereafter, the patient coughed and raisedsputum, and the lungs cleared.

On the eighth postoperative day, peristalsis was active, and fluids werepermitted by mouth. On the 10th postoperative day, signs of consolidation weredemonstrable in the right lower lobe, and some fluid was present. Bronchoscopyproduced thick mucus from the right lower, middle, and upper lobes, and a smallamount from the left side. The temperature ranged from 100? to 101? F.

Roentgenologic examination on the 13th day (fig. 206B) revealed fluid and infiltration in the lowertwo-fifths ofthe right lung field and fluid in the left costophrenic angle. Because of thepneumonitis and fluid on the right side, subphrenic abscess was considered aparamount diagnostic possibility. On the 19th postoperative day, thoracentesisproduced 700 cc. of clear fluid from the right pleural cavity. Roentgenologicexamination (fig. 206C) after this procedure still showed pleural fluidbilaterally, especially on the right.

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FIGURE 206(case 6).-Serial roentgenograms in thoracoabdominal wound. A. Posteroanteriorroentgenogram, 28 September 1944, immediately after wounding, showing largemetallic foreign body below left diaphragm, at level of eleventh rib, withhaziness of both lung fields. B. Posteroanterior roentgenogram, 11 October 1944,showing fluid in left costophrenic angle and fluid and infiltrative process inlower two-fifths of right lung field. C. Posteroanterior roentgenogram, 19October 1944, showing fluid in both pleural cavities, more marked on right.

On the following day, the patient was evacuated to the 36th General Hospitalat Dijon, France. Here the pleural effusion on the right gradually resolved. Onthe left side, the fluid became purulent and rib-resection drainage was required. A subphrenic infection did not develop.

Management in the Zone of Interior-At Fitzsimons GeneralHospital, Denver, Colo., to which the patient was evacuated, the empyema pocketon the left side gradually became obliterated without further surgery. Thepatient was considered for limited duty, but with the end of the war in Europeand the reduced necessity for manpower, he was given a disability discharge on28 May 1945.

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FIGURE 206. Continued. D.Posteroanterior roentgenogram, 19 November 1960, 16 years after wounding,showing lung fields clear except for pleural shadow above diaphragm anddeformity of rib in lower left costophrenic angle as result of rib resection forempyema. E. Lateral roentgenogram on same date, showing blunting of anteriorcardiophrenic sulcus. Posterior sulci are sharp, and lungs are clear.

Followup.-Following his discharge, the patient returned to an active civilianlife. At this time (November 1960), he is still working hard as a maintenance worker in alarge city. The work at times involves manual labor, but he wrote that he had"no ill effectsfrom his injury" and considered himself perfectly well.

Roentgenologic examination on 19 November 1960,16 years after wounding (fig. 206D and E), showed clear lung fields except for blunting ofthe lower left costophrenic angle as a result of rib resection for empyema, withsome blunting of the anterior cardiophrenic sulcus.

Comment-This casualty had serious injuries, including asucking wound of the chest; a tear of the diaphragm; and lacerations of thestomach, spleen, and pancreas. Severe blood loss and early contamination of thepleura and peritoneal cavities with gastric contents made resuscitationdifficult. The spleen was removed, and the stomach, pancreas, and diaphragm wererepaired. The course after operation was stormy, as a result of bilateralpleural effusion and pneumonitis. The right side cleared under penicillin andsulfonamide therapy, combined with aspiration of the chest. Empyema developedon the left side, as a result of early soiling of the pleura with gastrictcontents. Recovery followed drainage of the left empyema, with a completereturn to health. At the end of 16 years, this man has no residual symptoms and is hardatwork.

Case 7

Management overseas-This 23-year-old sergeant in a chemical warfarebattalion sustained bilateral shell-fragment wounds of the posterior chest at2130 hours on 10 December 1944, at Enchenberg, France. He was given four

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FIGURE 207 (case 7) .-Schematic showing of thoracoabdominal wound. A. Wounds: Sucking wound over left eleventh rib posteriorly (a), fracture of eleventh rib (b), and nonsucking wound in right chest posteriorly (c).

units of plasma and two injections of morphine at a battalion aid station.The sucking wound in the left chest was packed.

When he was admitted to the 54th Field Hospital at 0200 hours on 11 December,he was comatose, apparently from shock and from the two injections of morphine.The blood pressure was 90/60 mm. Hg, the pulse 130, and the respirations 36. Hisrespirations were wet and labored.

Examination revealed shell-fragment wounds of the right and left chestposteriorly. The wound on the left side was sucking (fig. 207A). Roentgenologicexamination (fig. 208A) revealed massive opacity of the left chest, haziness of the right lung, and a large amount of gas in thestomach. After gastric decompression, another examination (fig. 208B) showed aforeign body in the upper part of the left upper lobe.

Resuscitation was begun immediately and continued for 14 hours. It included,in addition to gastric decompression, catheter suction of the tracheobronchialtree, intratracheal oxygen administration under positive pressure, and the slowtransfusion of 1,000 cc. of blood.

At the end of this period, the lungs were clear and the bloodpressure had stabilized at 112/72 mg. Hg. The patient was therefore taken to theoperating room and, under endotracheal anesthesia, the pack was removed from thesucking wound of the left lower posterior chest. The wound was debrided down tothe pleura, after which it was extended upward and laterally along the eleventhintercostal space. The eleventh rib was divided to improve exposure (fig. 207B).The kidney capsule was torn, and there was a rent 3 by

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FIGURE 207.-Continued. B. Diagram of course of shellfragment in abdomen and thorax: Sucking wound of entrance (a), laceration ofupper pole of kidney (b), severe laceration of spleen (c), laceration ofdiaphragm (d), laceration and hematoma of left lower lobe (e), laceration ofleft upper lobe (f), shell fragment in lung (g), and massive hemothorax (h).

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FIGURE 207.-Continued. C. Posterior view of chest: Central portion of woundpacked down to sutured muscle layers (a), closure of skin at both ends ofincision (b), wound in right posterior chest wall after debridement and packingwith fine-mesh gauze (c), Penrose drain to left kidney (d), and closedthoracostomy drainage tube (e).

1 cm. in the posterior lateral portion of the upper pole. A catheterized specimen hadshown blood. Bleeding was controlled with catgut sutures, so that it was notnecessary to remove the kidney. The spleen, which was badly torn and bleeding,was removed; the artery and vein were controlled with mattress sutures of No. 00silk. The diaphragm, which was torn near the dome, was opened anteriorly, toprovide adequate exposure of the inferior pleural cavity. The lower leftpulmonary lobe, which was lacerated and the site of a hematoma, was oozingmoderately; it was repaired with fine catgut sutures. About 800 cc. of blood wasaspirated from the pleural cavity.

Since the upper pulmonary lobe expanded fairly well at this point, it wasdecided to remove the foreign body. It was left in situ, however, when exposureproved inadequate and there was no evidence of leakage of air or bleeding fromthe affected area. Closed catheter drainage was instituted in the eighthintercostal space.

The diaphragm was debrided and closed with interrupted sutures of No. 00silk. Sulfanilamide (3 gm.) and penicillin (100,000 units) were left in theupper abdominal cavity. The kidney was drained with a Penrose sheath drainthrough a stab wound in the flank.

The latissimus dorsi was closed over the defect in the eleventh intercostalspace in the central portion of the wound, which had been debrided, and thisarea was packed with gauze down to the muscle layer (fig. 207C). The anteriorand posterior extensions of the wound were closed in layers.

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FIGURE 208 (case 7).-Serialroentgenograms in thoracoabdominal wound. A. Posteroanterior roentgenogram, 11December 1944, immediately after wounding, showing massive opacity of leftchest, haziness of right lung, and large amount of gas in stomach. B. Obliqueroentgenogram after gastric decompression, with Levin tube still in stomach. Aforeign body is now visible in left upper lung. Left chest is hazy. C.Posteroanterior roentgenogram on sixth postoperative day, showing expansion ofleft lung but somewhat hazy lung field. Retained shell fragment is clearly seenin left mid lung field.

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FIGURE 208.-Continued. D. Posteroanterior roentgenogram, 19 November 1960, almost 16 years after wounding, showing few adhesions along left diaphragm, healed fracture of eighth rib, and clear lung field. E. Lateral roentgenogram, on same date, showing clear lung fields and sharp costophrenic angles.

The right posterior wound did not extend through the muscle layers and didnot involve the pleura, so it required only debridement. It was packed withfine-mesh gauze.

The patient received 1,000 cc. of blood during the operation, which hetolerated well. His temperature was elevated for the first 6 days, but otherwise his recovery was satisfactory.Roentgenologic examination (fig. 208C) on the sixth postoperative day showed the left lung to bewell expanded.

The patient was evacuated to the 23d General Hospital at Vittel, France, onthe seventh day after operation. Here an elective thoracotomy was performed,with removal of the foreign body in the left upper lobe.

Management in the Zone of Interior-After satisfactory recovery from thisoperation, the patient was evacuated to the Zone of Interior. Afterhospitalization at Kennedy General Hospital, Memphis, Tenn., where he was foundto require no further active treatment, he was sent to a reconditioning centeron 28 July 1945. Hewas discharged shortly after V-J Day.

Followup.-A communication from thepatient on 26 November 1960 statedthat he was working as a carpenter's helper, was married, and had two children.He suffered from occasional attacks of nausea and vomiting, which responded tosimple medication. He had no breathing difficulties except on strenuousexertion, when he became somewhat dyspneic.

Roentgenologic examination (fig. 208D and E) on 19 November 1960 showed the left lung to be well expanded. Two pleuralstreaks were seen at the left base in the posteroanterior view, but thecostophrenic angles were sharp in the lateral film. The lung fields were normalexcept for prominence of the bronchovascular markings.

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Comment-This patient was admitted to a field hospital in seriouscondition, with a severe thoracoabdominal wound. He was in shock, which wascomplicated by both the wet lung syndrome and morphine poisoning, andresuscitation required 14 hours. At operation, it was found possible to save thedamaged kidney. Since the foreign body in the left upper lobe could not bereached through the low thoracoabdominal incision being used, it was left insitu at the original operation and removed later at the base. The hematoma ofthe left lower lobe resolved spontaneously. Only reconditioning was needed in aZone of Interior hospital.

At the present time, the patient is living an essentially normal life, withonly occasional minor gastrointestinal symptoms and some dyspnea on strenuousexertion. His condition immediately after wounding was so precarious that theadditional surgery necessary to remove the foreign body at the originaloperation might well have been fatal. Vigorous resuscitation, staging ofsurgery, and limitation of initial wound surgery were important factors in thesuccessful result and in the patient's excellent state of health 16 years afterwounding.

Case 8

Management overseas-This 21-year-old infantryman sustained shell-fragmentwounds of the left chest (fig. 209A), shoulder, upper arm, and the scalp at 1400hours on 22 September 1944. He was given sulfonamide tablets and two units ofplasma at the battalion aid station.

When he was admitted to the 11th Field Hospital at Plombi?res, France,shortly afterward, he was not in shock. The blood pressure was 130/80 mm. Hg,the pulse 80, and the respirations 36. He complained of severe pain in the chestand the abdomen.

Breath sounds were depressed on the left, apparently chiefly from pain; therewas improvement when intercostal nerve block was done. Tenderness and reboundtenderness in the left upper quadrant, however, persisted, and peritonealcontamination had evidently occurred.

Roentgenologic examination of the chest (fig. 210A and B) showed the lungs tobe comparatively clear. There was a small amount of fluid at the left base, anda small fragment in the left upper quadrant of the abdomen was seen on bothposteroanterior and lateral films.

Resuscitation consisted, in addition to intercostal nerve block, of the slowadministration of 500 cc. of blood and evacuation of the stomach through a Levintube. No food had been taken that day, and there was little gastric content.

When the patient was taken to the operating tent at 1815hours, the blood pressure was 90/50 mm. Hg and the pulse 114. Chest involvementwas found to be minimal. The small 2-cm. wound of the eighth intercostal space(fig. 209A)

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FIGURE 209 (case 8).-Schematicshowing of thoracoabdominal wound. A. Small penetrating wound in left eighthintercostal space in midaxillary line. B. Pathologic findings: Laceration oflung (a), omentum plugging laceration of diaphragm (b), intact stomach (c),laceration of splenic flexure of colon (d), and foreign body (e).

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FIGURE 209.-Continued. C. Anterolateral chest wall at conclusion of operation: Closed thoracotomy incision (a), closed pleural drainage tube (b), and exteriorized loop of colon over glass rod (c).

could have been handled through either the chest or theabdomen, but the location of the foreign body indicated an approach through thethorax. After debridement of the chest wall, the incision was extended along theeighth intercostal space and the pleural cavity was opened. A moderate amount ofbloody fluid was aspirated. The lower lobe of the left lung was lacerated (fig.209B). A plug of omentum had herniated through a perforation in the diaphragmand sealed off the pleural cavity.

Excellent exposure of the upper abdomen (fig. 209B) was secured through ananterolateral incision in the diaphragm. The spleen and the stomach wereintact. A 1-cm. laceration in the antimesenteric border of the transversecolon was repaired with fine silk sutures. Localized peritonitis was present inthis area only. The foreign body seen on the roentgenograms (fig. 210A and B)was about 1 cm. in diameter and was adjacent to the colon. It wasremoved. The colon was exteriorized through a counterincision in the left upperquadrant and brought out over a glass rod. Exploration revealed no other injuredorgans.

The diaphragm was closed with interrupted silk sutures. Closed drainagewas instituted in the ninth intercostal space posteriorly. The chest wall wasclosed tightly in layers (fig. 209C), primary closure being considered safebecause of the small size of the wound.

The wounds of the shoulder, upper arm, and scalp were debrided.

The postoperative course was benign. The highest temperaturewas 100.8?F. The exteriorized loop of colon healed well, and gas waspassed after the glass rod had been removed. The lungs remained clear throughout(fig. 210C).

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FIGURE 210 (case 8).-Serialroentgenograms in thoracoabdominal wound. A. Posteroanterior roentgenogram ofchest, 22 September1944, shortly after wounding, showing relatively clear lung fields, small amountof fluid in left pleural cavity, and small metallic foreign body in left upperquadrant of abdomen. Levin tube in esophagus is shown by arrow. B. Lateralroentgenogram on same date, showing small metallic foreign body in left upperquadrant of abdomen and haziness of lungs. Note that an artifact present inposteroanterior view is not seen in lateral view. C. Posteroanteriorroentgenogram showing expansion of left lung on sixth postoperative day.

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FIGURE 210.-Continued.D. Posteroanterior roentgenogram of chest, 14 February 1961, 16 years and 5months after wounding, showing clear lung fields. Left diaphragm is flat andcostophrenic sinus is blunted laterally. E. Lateral roentgenogram on same date,showing prominent bronchovascular markings, tenting of diaphragm anteriorly, andsharp posterior diaphragmatic sulcus.

The patient was evacuated to the 46th General Hospital on the10th postoperative day. Here the loop colostomy was opened when some distentiondeveloped. It was closed shortly afterward.

Management in the Zone of Interior-Whenthe patient wasevacuated to Battey General Hospital, Rome, Ga., on 29 December 1944, he required only rehabilitation. After a period of serviceon limited duty, he was discharged in August 1945.

Followup-A communication from this patient on 14February 1961 stated that he had worked as a truck driver since the war. He wasmarried and had children. He had no digestive symptoms and no dyspnea and considered himself well except for occasional pain in the left chest.Roentgenograms at this time (fig. 210D and E) showed no abnormalities ofconsequence.

Comment.-This patient had a satisfactory recovery aftersevere thoracoabdominal wounds and multiple other injuries. Several reasons maybe given: He was admitted to a field hospital 75 minutes after wounding. The gastrointestinal tract was almost empty, since he had taken no foodthat day. Minimal contamination occurred because of the prompt handling of thelacerations of the lung, diaphragm, and colon. The pleura was spared seriouscontamination because the omentum partly blocked off the wound of the colon andalso plugged the diaphragmatic wound. Had the war continued, this man couldhave gone back to full duty. He is well at this time, more than 16 yearsafter wounding, and is leading an active civilian life.

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FIGURE 211 (case 9).-Schematic showing ofthoracoabdominal wound. A. Lateral aspect of chest and abdomen showing 8-cm.sucking wound of sixth intercostal space (a) and foreign body in abdominal wall(b). B. Pathologic findings: Laceration of left lower lobe of lung (a),laceration of diaphragm (b), laceration of spleen (c), laceration of stomach(d), laceration of colon (e), and small foreign body in abdomen (f). C.Anterolateral aspect of left chest and abdomen at conclusion of operation:Central portion of chest wound packed with fine-mesh gauze (a), closedintrapleural drainage tube (b), exteriorized colon (c), and counterincision forremoval of foreign body in abdominal wall (d).

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Case 9

Management overseas.-This 21-year-old infantryman sustaineda high explosive shell-fragment wound of the left chest at 1625 hours on 30October 1944 in the mountains of northern France. At the battalion aid station,the sucking wound was packed (fig. 211A), and he was given morphine gr. ?.

When he was admitted to the 11thField Hospital at Eloyes at 1825 hours, he was in shock, with a blood pressureof 80/50 mm. Hg. He complained of severe chest and abdominal pain and wasspitting up blood. Breath sounds were absent on the left. The right chest wasclear. Tenderness, spasm, and rebound tenderness were present in the left upperquadrant of the abdomen. Roentgenograms are shown in figure 212. The rightchest was fairly clear, and the cardiac shadow was not enlarged. A small foreignbody was discerned in the region of the left upper quadrant of the abdomen. Onfurther examination (fig. 212A andB), it was seen that two foreign bodies were present, one deep in the leftupper quadrant and the other apparently in the abdominal wall. Roentgenogram(fig. 212C) showedhaziness over the left chest.

Two units of plasma were given as soon as the patient was admitted,and transfusions of 1,500 cc. of blood were given over the next 3 hours. By theend of this time, the blood pressure was stabilized. Since there was noimprovement in the abdominal symptoms and signs, the patient was taken to theoperating room at 2125 hours.

The sucking wound in the sixth intercostal space was debrided, and theincision was extended in this interspace down to the costal margin. The leftlower lobe of the lung was lacerated (fig. 211B) and was the site of a smallhematoma. The diaphragm, which was torn, was opened at the domeanterolaterally. This provided excellent exposure of the upper abdomen. Thespleen, which was badly torn, was bleeding and was removed. Two perforations inthe stomach were repaired easily, as was a through-and-through wound of thesplenic flexure of the left colon. A small foreign body was found in thisregion, and a larger object, palpated in the anterior abdominal wall, wasremoved through a counterincision. The splenic flexure of the colon wasmobilized, the perforations in it closed, and the involved area brought outthrough a stab wound in the left upper quadrant of the abdomen, over a glassrod.

The diaphragm was repaired with interrupted No. 00 silk sutures. Closedpleural drainage was instituted in the eighth intercostal space; the catheterwas connected to a closed system. After the pleural cavity had been thoroughlylavaged with physiologic salt solution, the chest wall was closed in layers. Thecentral portion of the wound was left open (fig. 211C) and was packed with fine-meshgauze down to the muscle layer.

For the first week after operation, the temperature rose daily to 101? F.Peristalsis was observed on the second day. The colostomy was opened, and fluidsby mouth were permitted. The lung expanded well and there was only a moderatepleural reaction when the patient was evacuated to the 23d General

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FIGURE 212 (case 9).-Serialroentgenograms in thoracoabdominal wound. A. Anteroposterior roentgenogram ofabdomen showing two intra-abdominal foreign bodies. B. Lateral roentgenogram ofchest and abdomen on same date, showing two metallic foreign bodies in leftupper quadrant. C. Posteroanterior roentgenogram of chest, 30 October 1944,immediately after wounding, showing haziness of left hemothorax, diffusepleural fluid, and small metallic foreign body in left upper quadrant. Rightlung is fairly clear.

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FIGURE 212.-Continued.D. Posteroanterior roentgenogram, 29 December 1960, 16 years after wounding,showing flat left diaphragm and relatively clear lung fields. E. Lateralroentgenogram on same date, showing sharp costophrenic angles.

Hospital, Vittel, France, on the 10th day. He had, however,complained of some pain and distention in the left upper quadrant. Later,swelling, tenderness in the left costal margin, and fever indicated thedevelopment of a subphrenic abscess, which was drained successfully on 30November 1944.

Management in the Zone of Interior-Thepatient wasevacuated to Barnes General Hospital, Vancouver, Wash., on 29 December 1944. Thecolostomy, which functioned well, was closed in April 1945. He received adisability discharge on 11 August 1945.

Followup-On 28 December 1960, the patient reported that he had worked asa printer since his discharge from the army. He was married and had sixchildren. He had no digestive or other complaints and considered himself well.Roentgenograms made on 29 December 1960 (fig. 212D and E) revealed clear lungfields, with prominent bronchovascular markings.

Comment.-This was apatient with an extremely severe thoracoabdominal wound, which was treatedpromptly, though before his admission to the field hospital, spillage ofcontents into the upper abdomen from wounds of the stomach and colon hadproduced severe shock. Prompt surgery was lifesaving in this case. Colostomyprevented further contamination of the upper abdomen. The subphrenic abscesswhich developed was promptly drained at the base section hospital, and healingwas satisfactory. The colostomy was closed without difficulty in a Zone ofInterior hospital. Although the chest trauma in this case was moderatelysevere, the would could perhaps have been handled from below. Exposure,however, would have been more difficult, and it was

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thought better to handle the sucking wound of the chest andthe wound of the diaphragm in a single operation. The excellent health of thepatient 16 years after operation points up the value of the staged treatmentthat he received.

HEMATOMA

The diagnosis of intrapulmonary hemorrhage or hematoma was made in forwardhospitals in 89 cases in this series. When the chest was not opened and only adebridement of the chest wall was done, the diagnosis was made on clinicalgrounds. When pneumonitis and atelectasis could be ruled out, the presence ofhemoptysis and a pulmonary parenchymal shadow, with slow resolution of theshadow, was regarded as confirmation of the diagnosis.

Hematoma of the lung is a pathologic process in which there is extravasation of blood into the alveoli and interalveolar tissue of thepulmonary parenchyma. Observations at base section hospitals in thecommunications zone showed that these lesions resolved slowly within 4 to 6weeks, according to their severity. No mention is made of their persistence inany of the roentgenologic reports in this series at Zone of Interior hospitalsfrom 2 to 5 months or longer after wounding.

In other words, all 89 hematomas resolved spontaneously and withoutmorbidity. No resection of any type was performed for them, nor did lung abscessor other secondary infection develop in any instance, even when a massivehematoma of an entire lobe might liquefy to produce a cystlike shadow on theroentgenogram.

The evidence from these 89 cases thus clearly indicates that there is noreason to perform lobectomy or segmental resection of a lung that at initialwound surgery is tense and boggy and contains large amounts of extravasatedblood. As alarming as such a lung may appear to a surgeon who is viewing hisfirst pulmonary hematoma, there should be no surgical interference. The lung hastremendous recuperative power because of its dual blood supply from thebronchial and pulmonary arteries, and recovery can be expected withoutcomplications when this natural power is supplemented by vigorous measures tokeep the bronchial tree clear of blood and mucus and the pleural cavity dry.

The concept of noninterference in pulmonary hematoma formation is one of theimportant advances in thoracic surgery developed in World War II.

Case 10

Management overseas-This 31-year-old infantryman was wounded by afragment of a 20-mm. missile from a German airplane at 1500 hours on 24 April1945, at Amerbach, Germany. After a delay of 25 minutes, the ensuing suckingwound was packed with petrolatum-impregnated gauze at a battalion aid station,and sulfonamide crystals were placed in the wound.

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FIGURE 213 (case 10).-Schematic showing of thoracic wound with massive hematoma of the right lung. A. Course of missile: Anterolateral wound of entrance in eighth right intercostal space, with resulting sucking wound (a), passage of missile through lung to lodge close to mediastinum posteriorly (b), and high explosive shell fragment (c). Location of the wound introduced the possibility of diaphragmatic laceration.

When he was admitted to the 66th Field Hospital at Gunzenhausen, Germany, at1855 hours, he was cyanotic and dyspneic, and his respirations were wet andlabored and were 40 to the minute. The blood pressure was 150/72 mm. Hg and thepulse 120.

Examination revealed a large anterolateral sucking wound of the eighthintercostal space (fig. 213A), packed with an airtight dressing. There weresigns of fluid and air in the right chest (fig. 214A and B), and numerous wetrales over both lung fields, but no cardiac shift.

Resuscitation occupied 16 hours. It consisted of the administration ofoxygen; the immediate slow administration of 500 cc. of blood and the deferred,very slow, administration of 1,000 cc. of blood; evacuation of the pleuralcavity by loosening the gauze packing and tipping the patient so that the wounddrained about 500 cc. of blood; intercostal nerve block (T₄-T₈);and bronchial

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FIGURE 213-Continued. B. Findings atthoracotomy: Laceration of right lowerlobe of lung (a), with massive hematoma of entire lobe (b), wet lung ofadjacent lobes (c), clots (500 cc.) and blood (300 cc.) in right pleural cavity(d), and foreign body resting in right lower lobe and pleural cavity (e).

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aspiration per catheter. The patient coughed voluntarily after the nerveblock and the catheter aspiration, and the lung gradually cleared of rales.

The wound in the right thoracic wall was thoroughly debrided underendotracheal anesthesia. Fragments of the fractured eighth rib were resected andthe incision was extended in the intercostal space to make a formal thoracotomy(fig. 213B). The diaphragm was found intact. The right lower lobe of the rightlung was lacerated and was the site of a massive hematoma which resembled theliver in appearance. A foreign body free in the posterior pleural cavity (fig.214B) was removed, and 500 cc. of blood clot and 300 cc. of fluid blood wereevacuated.

Although the lung was lacerated, it was not blowing air, and no attempt wasmade to place sutures in the boggy, engorged right lower lobe.

At this point, it is typical of conditions under which much war surgery wasdone in the Mediterranean theater that a small bug flew into the pleural space.It was not seen again, but the cavity was thoroughly lavaged with 1,500 cc. ofphysiologic salt solution.

The muscles were closed in layers with interrupted sutures of fine silk. Theposterior wound of entry was left open and was packed with fine-mesh gauze downto the muscle layer. Closed intrapleural drainage was instituted in the eighthintercostal space posteriorly. Penicillin (500,000 units) was injected into thetube, which was clamped off for 3 hours.

Bronchoscopy immediately after operation produced a large amount of blood andmucus from the right main bronchus and the right lower lobe bronchus.

The patient ran a febrile course (101?-102?F.) for the first 5 days, afterwhich his temperature gradually dropped to 99? F. Intercostal nerve block wasrepeated twice, with relief of pain and effective cough. Roentgenograms on thethird postoperative day (fig. 214C) showeda small cyst with a fluid level, the result of liquefaction of the hematoma inthe right lower lobe of the lung.

The patient was evacuated to a base hospitalon the eighth postoperative day and thence to the Zone of Interior.

Management in the Zone of Interior-Whenthe patient was received atWalter Reed General Hospital 2 monthsafter wounding, his only complaint was pain in the right chest, with intercostalneuritis. Roentgenograms were essentially negative. He was returned to duty inthe Zone of Interior but eventually was discharged for disability.

Followup-The patient now works as a manager of a store, with no apparentdisability.

Roentgenograms 15 years and 10 months after wounding (fig. 214Dand E) showed clear lung fieldsand no evidence of the massive hematoma or the cyst with fluid level seenshortly after wounding.

Comment-The problems in this case were (1) a suckingwound, (2) a massive hematoma of the right lower lobe of the lung, (3) a foreignbody in the pleura, and (4) the wet lung syndrome. Significant factors in thehistory are

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FIGURE 214 (case 10).-Serialroentgenograms of hematoma of right lower lobe of lung. A. Posteroanteriorroentgenogram, 24 April 1945, immediately after wounding, showing fracture ofeighth rib at diaphragm and foreign body in right lower lung close to hilus.Note haziness of right lung field and shift of heart to left. B. Lateralroentgenogram on same date, showing foreign body lying posteriorly in pleuralcavity. C. Posteroanterior roentgenogram on 27 April 1945 (third postoperativeday) showing cyst with fluid level, result of liquefaction of hematoma of rightlower lobe.

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FIGURE 214.-Continued. D.Posteroanterior roentgenogram of chest, 2 February 1961, 15 years and 10 monthsafter wounding, showing complete absorption of massive hematoma of right lowerpulmonary lobe. There is no evidence of cyst with fluid level seen in April1945. The diaphragmatic shadows are flattened laterally. E. Lateralroentgenogram on same date, showing flattened diaphragms anteriorly and fairly deep sulciposteriorly. Lung fields areclear.

the 16-hour preoperative preparation, the delay being causedby the wet lung syndrome; the necessity for traumatic thoracotomy because of thesucking wound, with removal of the readily accessible intrapleural foreign body;and the conservative management of the massive hematoma of the right lower lobe.Although the hematoma eventually liquefied and formed a pseudocyst, there are noapparent residua and the lung fields are essentially clear more than 15 yearsafter injury.

In this case, the performance of lobectomy at initial woundsurgery to correct the hematoma might have been more than this dangerouslywounded casualty could have endured. His course since wounding indicates thatthe surgery was not necessary.

WET LUNG

Since the concepts and management of traumatic wet lung were developed in theMediterranean theater (p. 208), it is important to assess the results of theincidence and management of this complication of thoracic injuries. It wasextremely troublesome in forward hospitals, in which initial surgery wasperformed. It was a major problem in 65 of the 167 cases in this series.

In general, it was the policy to treat these casualties intensively inforward hospitals (p. 217) and not attempt to evacuate them, regardless of thenature of their wounds, until their lungs were comparatively dry. As a matter offact., they withstood transportation very poorly. It was therefore the policy to

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retain them at the primary installation to which they wereadmitted unless, as sometimes happened, the tactical situation required theevacuation of the whole hospital. At the Battle of the Bulge, at Christmas 1944,the Seventh U.S. Army was serving as the southern anchorof the front, and as a precautionary measure, all noncombat personnel wereevacuated from the frontlines. The clearing station which had been supported bya platoon of the 66th Field Hospital was moved 6 miles to the rear, but theplatoon itself could not move for another week because it was holdingnontransportable casualties who had undergone thoracotomy or thoracolaparotomyand who could not be moved because of serious wet lung complications.

When wet lung was properly managed in forward hospitals, few complicationsarising from it were encountered in base hospitals. When the reverse was true,complications were numerous. In this series, only two patients showed a latepneumonitis which might have been connected with the original wet lung syndrome.This low incidence is in sharp contrast to the earlier experience: In three ofthe four deaths in this series, already described (p. 450), the wet lungsyndrome had been a major problem in the resuscitative regimen, and in thepatient with a spinal cord injury, the problem was never completely solved. Thispatient, who had multiple wounds, was, however, the only one in the group inwhom the wet lung factor was an important cause of death.

By the time casualties reached the Zone of Interior, therewas never any clinical problem traced to the original wet lung syndrome if it hadbeen properly handled in the forward hospital. Chronic pneumonitis, bronchitis,and bronchiectasis were seldom recorded-never in this series-nor was themassive atelectasis so frequent in World War I casualties seen in the thoraciccasualties of World War II. This, no doubt, reflects the careful attention paidin forward installations to the correction of the wet lung.

The following case report illustrates various aspects of thiscondition.

Case 11

Management overseas-A 32-year-old infantry major was wounded in the leftchest by a shell fragment on 22 January 1944, while he was crossing the Rapido River during the assaulton Cassino. He took the sulfonamide tablets in his own first aid kit, and thecorpsman applied a pressure dressing and gave him a unit of plasma. Thirtyminutes later, he was given morphine gr. ? in a battalion aidstation, for severe chest pain.

When the casualty arrived at the 11th Field Hospital inMignano Monte Lungo, Italy, at 1615 hours, the wound (fig. 215A) was bleedingexternally and he had been coughing up blood. He was extremely dyspneic andwas disoriented and in shock, with a blood pressure of 55/35 mm. Hg. The pulse,which was difficult to count, was 130, and the respirations 40. Immediate resuscitative measures consisted of theadministration of nasal oxygen; the administration of three units of plasma and500 cc. of blood; repacking of the

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FIGURE 215 (case 11).-Schematic showing of large sucking wound of chest. A.Wound after debridement of chest wall: Wound of entrance in left chest (a),large shell fragment in right pleura and axilla (b), laceration of right upperlobe of lung (c), and open apical segmental bronchus (d). B. Technique ofbronchial closure. Blowing segmental bronchus sutured with fine silk andreinforced with pedicle muscle graft.

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FIGURE 215.-Continued.C. Appearance of wound at end of operation: Gauze pack in chest wall and lung(a), Penrose sheath drain in right axilla (b), closed pleural drainage (c), andclosure of muscles to superficial fascia (d).

wound, which was oozing and sucking, withpetrolatum-impregnated gauze, repeated bronchial suction, with aspiration ofblood and mucus, as bubbly rales continued present over both lungs; and the veryslow administration of another 500 cc. of blood.

Roentgenograms (fig. 216A) showed a large foreign body (4 by 2 cm.) in theright pleura and axilla and haziness of both lung fields, more marked on theright. There was no mediastinal shift.

Traumatic thoracotomy was performed 10 hours after resuscitation had beenbegun. The wound was debrided across the sternum, after which the shatteredsecond and third costal cartilages were resected, with portions of the secondand third ribs on the right (fig. 215B). The wound was thoroughly debrided, andthe foreign body in the pleura and right axilla was removed. The lung was partlyadherent near the apex and badly torn below. Lobectomy would have been necessaryto close it completely. The fistula in the apical segmental bronchus was closedwith silk, and the closure was reinforced with a graft of pectoralis minor.

The wound in the lung, pleura, and chest wall was packedtightly with fine-mesh gauze (fig. 215C) over an area 4 by 6 centimeters. Theremainder of the wound and the muscles were pulled together with interruptedsutures but left open from the fascial layer outward.

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FIGURE 216 (case 11).-Serialroentgenograms of sucking wound of chest with wet lung syndrome. A.Posteroanterior roentgenogram, 22 January1944, immediately after wounding, showing large foreign body in right axilla andpleura, with diffuse haziness of both lungs, more marked on right. B.Posteroanterior roentgenogram first postoperative day, showing severe bilateralpulmonary edema. Note gauze pack in right mid lung field. C. Posteroanteriorroentgenogram, 7 February 1944, showing clearing of lungs. Dotted line outlinessite and extent of gauze pack; 1-cm. right lateral pleural shadow indicates loculatedpleural fluid. D. Posteroanterior roentgenogram, 3 May 1960, 16 years afterwounding, showing essentially clear lung fields. Note anterior stumps of secondand third right ribs.

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A Penrose drain was left in the left axilla, and closed pleural drainage wasinstituted. Bronchoscopy immediately after operation produced a large amount ofbloody mucus, chiefly from the right upper lobe.

The postoperative course was extremely stormy because of pulmonary edema.Roentgenograms made the day after operation (fig. 216B) showed massive edema ofboth lungs, with the pack in the right anterior chest wall and the lung.Treatment consisted of nasal oxygen, supplemented by brief periods of positivepressure oxygen, administered with each voluntary inspiration by means of ananesthetic machine and manual pressure on the bag (fig. 50, p. 162);intercostal nerve block; and repeated bronchial suction. Because of some blowingfrom the wound, which did not end until a week after operation, it was necessaryto repack portions of the chest wall. Thoracentesis was done twice after closeddrainage was terminated; about 1,000 cc. of bloody fluid was aspirated eachtime.

When the patient was evacuated on the 14th postoperative day, the cavity inthe lung had decreased to about the size of an egg and was granulating well, andthe right had expanded (fig. 216C).

At the 36th Evacuation Hospital, which was then operating as a forwardthoracic surgery center, Maj. Thomas H. Burford, MC, performed a fat graft ofthe pulmonary cavity with delayed primary closure of the large anterior wound.

Followup-This patient required no active treatment in the Zone ofInterior, where he was eventually given a disability discharge. Since that time,he has been working as a rural mail carrier and has been followed by a privatephysician. Roentgenograms made on 3 May 1960 (fig. 216D) showed the resectedends of the second and third ribs on the right. Vascular markings in the lungfields were prominent, but the fields were essentially clear.

Comment-This patient had a very large sucking wound,complicated by a wet lung syndrome of such severity that he was delirious fromhypoxia for the first 4 days after wounding. The lacerated upper lobe of theright lung was not sacrificed; a muscle graft closed the major bronchialfistula, and packing of the lung and the chest wall was a successfulcomplementary procedure. Right upper lobe lobectomy would never have beenfeasible in this patient until he reached the base hospital, and there, askillfully performed fat graft and delayed primary wound closure made furthersurgery unnecessary. The wet lung syndrome and massive bilateral pulmonary edemamade his early care extremely difficult.

HEMOTHORAX

Hemothorax is the most common complication of thoracic wounds, which might beexpected, since in every penetrating wound of the chest in which the pleuralspace is involved there is some degree of extravasation of blood into thecavity. A small amount of blood is of little clinical significance if infection

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does not occur; it is well tolerated by the pleura, andabsorption is the rule. If larger amounts are present, preoperative aspirationis necessary to expand the lung and increase the vital capacity, as well as tosupply an accurate index of the amount of hemorrhage which has occurred into thepleural space. After operation, the cavity must be kept empty by the use ofintercostal closed drainage and repeated thoracenteses.

In World War II, when these principles were employed, the goal was toevacuate the casualty to the base section with the pleural cavity completelydry. This was not always possible. In spite of diligent aspiration of blood fromthe chest, a lung which has been traumatized and collapsed temporarily loses itselastic recoil and its ability to expand. During the period in which it isregaining its elasticity, a pleural effusion develops and there is a deposit offibrin that forms a pleural membrane. This membrane is often quite inelastic,and in some cases, the process includes massive clotting, which can be handledonly by decortication.

In this series of 167 chest wounds, bleeding into the pleuralcavity was sufficiently persistent and of sufficient magnitude, in 91 instances,to create a considerable clinical problem. In 77 of these patients, repeatedthoracenteses before operation, repeated after operation and supplemented byclosed intercostal drainage, were successful in expanding the lung. Only 14 ofthe casualties were evacuated to the rear with persistent or clotted hemothoraxand pulmonary collapse. These figures would seem to support the policy ofrepeated, prompt aspiration of the pleural cavity in hemothoraces.

At the base, decortication was carried out in nine cases, seven times fororganizing hemothorax and twice for hemothoracic empyema. The other sevencasualties who developed empyema were treated by drainage. This means thatdecortication was necessary in only 10 percent of the patients in this serieswith severe hemothorax and in only about 5.3 percent of the total series. Nopatient who underwent decortication on any indication was returned to dutyoverseas.

In the Zone of Interior, 2 of the 91 patients with persistent hemothoraxdeveloped late empyemas which had to be drained. No additional decorticationswere necessary. There were no deaths in this group of patients and no majordisabilities due either to chronic empyema or to major collapse of a so-calledcaptive lung. No patient had a chronic draining sinus of the chest wall.

These results are in sharp contrast to the results in WorldWar I, after which the thoracic wards in Veterans' Administration hospitals werefull of patients with collapsed lungs, chronic empyemas, and persistent sinusesof the chest wall following hemothorax and hemothoracic empyema. Theexcellent results in the World War II patients, of which the results in thisseries are typical, were attributable not only to adherence to the principlesestablished for forward surgery but also to the proper timing and staging ofsurgery in base hospitals before the casualties were transferred to the Zone ofInterior.

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Case 12

Management overseas-This 23-year-old infantry sergeant received ashell-fragment wound of the posterior left chest at 1400 hourson 21 September 1944, at Remiremont,France. He also received a wound of the scalp. Immediate treatment consisted ofa pressure dressing, on which sulfanilamide powder had been sprinkled, and thesubcutaneous administration of morphine gr. ?. A unit of plasma was given later at a clearing station.

When the patient was admitted to the 11th Field Hospital at Plombi?res at 1710 hours, he was comatose and in shock, with wet respirationsand pinpoint pupils. The blood pressure was 90/40 mm. Hg, the pulse very rapid and difficult to count, and the respirations 14. Although the record did not indicate it, further inquiryproduced the information that another half grain of morphine had beenadministered at the battalion aid station.

The patient was obviously in morphine poisoning. Shortly after he wasadmitted to the hospital, the blood pressure began to drop further, and he wasgiven a unit of plasma and 500 cc. of blood. An intratracheal catheter wasintroduced, and repeated aspirations were carried out; oxygen was administeredthrough the catheter between the aspirations. When the respirations fell to 12,three ampules of Coramine (nikethamide) were administered intravenously. Whenthe sucking wound of the left chest (fig. 217A) was inspected, a small amount ofblood drained from it.

At 1900 hours, the patient coughed out the catheter, after which he coughedup bloody mucus voluntarily. Oxygen was administered by nasal catheter. Whenthoracentesis of the left chest was done posteriorly, only 5 cc. of blood and 20cc. of air were aspirated; there was no evidence of tension pneumothorax.Penicillin was given intramuscularly.

In spite of the active therapy carried out, the lungsremained wet. Over the next 18 hours, however, there was gradual improvement,in spite of evidence, by the results of thoracentesis, of continued hemorrhageinto the left chest. Over this period, treatment consisted of two additionalblood transfusions, intercostal nerve block, and the administration of oxygen bypositive pressure.

At 1400 hours on22 September 1943, the patient wasconsidered sufficiently prepared to withstand surgery, which was performed underendotracheal anesthesia, in the right posterolateral position. The wound of thescalp was debrided, together with the extensive wound of the left chest and theback. The large wound over the left scapula (fig. 217B) was found to connectwith the right shoulder. On the left side, there were extensive lacerations ofthe trapezius, latissimus dorsi, subscapularis, and rhomboid muscles. A largepart of the central portion of the left scapula was destroyed. The involved areawas debrided, which left a portion of the tip in situ, together with the intactupper portion.

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FIGURE 217 (case 12).-Schematic drawings of chest wound with massive chestwall and intrapleural trauma. A. Posterior aspect of chest showing: Wound ofentrance in right shoulder (a), large sucking wound with destruction of inferiorportion of scapula and fifth rib (b), portion of wound bridged by skin (c), andsecond wound in left shoulder, with two small foreign bodies (d).

The pleural cavity was opened by resection of the comminutedfifth rib. Intrapleural bleeding was occurring from the fifth intercostal artery(fig. 217B), which was secured at once; 500 cc. of blood was aspirated fromthe pleural cavity.A huge hematoma occupied the left upper pulmonary lobe. The bone fragments inthe lung were removed, and a small laceration was closed, but no pulmonarytissue was resected.

Closed catheter drainage was instituted posterolaterally in the left eighthintercostal space. The wound and the pleural cavity were lavaged with physiologic salt solution. The pleura was closed by suturing thesubscapularis and posterior serratus, and then closing the trapezius andlatissimus dorsi over this suture line, as a reinforcing layer (fig. 217C). Thetrapezius on the right was debrided and closed. The whole wound was left open down to the musclelayers.

Bronchoscopy was performed at the conclusion of theoperation. A small amount of bloody mucus was aspirated from the trachea, andlarger amounts from both main bronchi.

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FIGURE 217.-Continued.B. Findings at thoracotomy: Massive hemopneumothorax, with hemorrhage fromfifth intercostal vessels (a), rib fragments in left lung (b), laceration ofleft lower lobe of lung (c), hematoma formation (d), wet lung diagramed onright side (e), and superficial wound of left shoulder (f_.).

The patient was given 550 cc. of blood during the operation.Immediately after it was concluded, his pulse was irregular, but thereafter themajor postoperative problem was keeping the tracheobronchial tree clear.

Roentgenograms before operation (fig. 218A) had showed massive lefthemothorax and haziness of the right lung. There was some improvement inexpansion of the left lung after thoracentesis (fig. 218B). On the ninthpostoperative day, the left lung had almost completely expanded, and both lungswere dry.

After operation, there was considerable drainage (about 500 cc. daily) forthe first 2 days; the loss of blood was covered by transfusions.

Delayed primary closure of all wounds was carried out at the 46th GeneralHospital in the base.

Management in the Zone of Interior-When the patient was evacuated to theUnited States on 18 October 1944, the lung had completely expanded, and thehematoma had completely resolved. He was given a disability discharge on 8 May1945, at Madigan General Hospital, Tacoma, Wash., limitation of motion of thescapula being the main problem.

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FIGURE 217.-Continued. C.Diagram depicting types of muscle closure: Right trapezius closure demonstratingsimple interrupted sutures (a), left trapezius closure demonstrating mattresstype sutures (b), left latissimus dorsi (erector spinae group not closed) (c),infraspinatus, skin and superficial fascia left open, wound packed down tomuscle layer (d), closure of superficial left shoulder wound (e), and closedintrapleural drainage tube (f).

Followup-A personalcommunication from this patient on 6 December 1960 stated that he had beenemployed as a truck driver for the past 14 years. He complained of soreness andstiffness around the left scapula, of lack of much grip in the left hand forheavy lifting, and of inability to do work involving raising the hand to thelevel of the shoulder. Although the chief complaint was referable to theshoulder, the patient stated that when he jumped from a truck platform, adistance of 2 or 3 feet, he sometimes spat up blood the following day. He hadtrouble sleeping on the left side, because of pain in the left shoulder, but hehad no difficulty in breathing, and the occasional hemoptysis, the cause ofwhich is not known, was so slight that he had never bothered to seek medicalattention for it.

Comment-This patient had an extensive sucking wound of the chest wall,with continued hemorrhage into the left pleural cavity. The original trauma wascomplicated by the wet lung syndrome, with bilateral pulmonary edema, and wasfurther complicated by morphine poisoning. Resuscitation

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FIGURE 218 (case 12).-Serialroentgenograms in thoracic wound complicated by massive hemothorax. A.Posteroanterior roentgenogram, 21 September 1943, immediately after wounding,showing massive left hemothorax, with slight shift of mediastinum, and hazinessof right lung, due to wet lung syndrome. A defect in left scapula is faintlyseen. B. Posteroanterior roentgenogram, showing some improvement in expansion ofleft lung after aspiration of blood in left pleural cavity. Appearance of rightlung is not materially altered. Two small foreign bodies are now visible in leftshoulder. C. Posteroanterior roentgenogram, 23 November 1960, 17 years afterwounding, showing clear lung fields, except for prominent bronchovascularmarkings. Note bridging of fourth, fifth, and sixth ribs. Heart and mediastinumare normal, and diaphragmatic angle is clear. D. Lateral roentgenogram, 23November 1960, showing sharp costophrenic angles. These findings areapproximately normal and do not explain occasional hemoptyses reported by thispatient.

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covered 21 hours, but the time occupied in stabilizinghimwas well spent, for he tolerated corrective surgery well. It is gratifying thatfor the past 14 years he has been able to work as a truck driver, and that hisresidual disability is only minor. This is the only patient in the 163 survivorsfollowed up who gave a history of occasional blood-streaked sputum.Roentgenograms (fig. 218 C and D) offer no explanation.

RETAINED FOREIGN BODIES

Retained foreign bodies were observed in 102 of these 167 cases. In 35instances, they were in the chest wall, in 21 in the pleura, in 36 in the lung,and in 10 in the mediastinum.

These objects always presented a difficult problem in forward hospitals, forthe decision as to their removal was frequently delicate. Those in the chestwall were most often removed during debridement at the field hospital. They wereusually accessible without a prolonged search, and if they were not in theoriginal wound of entry, they could be removed by a simple counter-incision.

Foreign bodies in the lung and the pleura were not removed as part oftraumatic thoracotomy at field hospitals unless they were readily accessibleor were believed to lie so close to vital thoracic organs as to constitute apotential danger to them.

Only 13 operations were done for the removal of foreign bodies in basesection hospitals, in only 1 instance because of pulmonary hemorrhage. Onepatient, after an uneventful immediate postoperative course, died 2 months laterof hepatitis and jaundice. He had multiple wounds of the head and trunk, and thesucking wound of the chest was complicated by the wet lung syndrome. In thiscase, a foreign body in the pericardium was removed when the sucking wound wasclosed. The pulmonary object was not accessible, and its removal would havemeant an additional incision and undue prolongation of the operation. It ispossible, though highly unlikely, that the retained object was a factor in thefatal outcome.

Only two foreign bodies were removed in this series in Zone of Interiorhospitals. One was removed because of a delayed air leak, and the other wasremoved during closure of a colostomy. Of the 41 patients with retained metallicforeign bodies who were evacuated to the Zone of Interior, only the patient justmentioned, with the delayed air leak, developed symptoms that required itsremoval.

Case 13

Management overseas-This 29-year-old artilleryman was wounded in theleft shoulder by a high explosive shell fragment at 1146 hours on 29 November1943 near Ardo, Italy. The wound was dressed with sulfonamide powder at a battalion aid station, where thepatient was also given morphine (gr. ?)and sulfadiazine (15 gr.) by mouth.

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FIGURE 219 (case 13).-Schematic showing of chest wound with retained foreignbody. A. Wound: Penetrating shell-fragment wound of left shoulder, with fractureof left humerus (a), passage of missile through chest wall and lung withlodgment in left mid thorax (b), and incision for elective thoracotomy (c). B.Findings at thoracotomy: Large hematoma of left upper lobe (a), hematoma andlaceration, left lower chest wall extending down to diaphragm (b), and foreignbody in lung adjacent to heart (c).

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FIGURE 219.-Continued. C.Diagram of left lung at conclusion of operation following removal of shellfragment. Repair of laceration of left lower lobe with two layers of interruptedsutures of fine silk (a), hematoma of upper portion of left upper lobe, whichwas not disturbed (b), and water-seal intrapleural drainage tube (c).

When he was admitted to the 94th Evacuation Hospital at LePezze at 1410hours, examination revealed a 2-cm. penetrating wound of the left deltoid region(fig. 219A) but no other thoracic injuries. He complained of considerable chestpain and was dyspneic, orthopneic, and coughing up blood. The blood pressure was128/60 mm. Hg, the pulse 128, and the respirations 38. Breath sounds were absentover the left chest, and the heart was shifted slightly to the right. The rightlung was clear. Roentgenograms (fig. 220A) showed a left hydropneumothorax, witha foreign body in the left cardiac shadow, fractures of the sixth, seventh, andeighth ribs, and haziness of the right lung. There was also a fracture of theleft humerus.

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FIGURE 220 (case 13).-Serialroentgenograms in wound with intrapulmonary foreign body. A. Posterolateral roentgenogram,29 November 1943, immediately afterwounding, showing foreign body in left cardiac shadow; extensive collapse ofleft lung; fractures of sixth, seventh, and eighth ribs on left; fracture ofleft humerus; and haziness of right lung. B. Posterolateral roentgenogram, 7December 1943, showing expanding left lung and resection of segments of sixth,seventh, and eighth ribs. Right lung and cardiac shadows are normal. C.Posteroanterior roentgenogram, 2 December 1960, 17 years after wounding, showinghealed fractures of sixth, seventh, and eighth ribs on left; tenting of leftdiaphragm and blunting of left costophrenic angle. Note prominentbronchovascular markings. D. Lateral roentgenogram on same date, showing leftpleural shadow anteriorly and deep posterior costophrenic angle. Note clear lungfield.

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After thoracentesis, which yielded 800 cc. of air and 800 cc. of blood, atransfusion of 500 cc. was given. A second thoracentesis, performed because ofsigns indicating a reaccumulation of fluid and air in the left pleural space,yielded 500 cc. of blood.

Thoracotomy was carried out through an elective incision 7 hours afteradmission, through a left posterolateral incision over the seventh rib, becauseof the continued reaccumulation of air and blood in the left hemithorax and alsobecause the foreign body was in the region of the cardiac shadow. Fragments ofthe sixth, seventh, and eighth ribs were resected, and the pleural cavity wasopened through the bed of the eighth rib. The sixth intercostal muscles werebleeding and were ligated, and fragments of ribs were removed from the lung. A huge hematoma (fig.219B) occupied the upper portion of the left lower lobe. Thelaceration in the lung extended down to the diaphragm, where the foreign bodywas felt in the pulmonary substance next to the pericardium, which was notinvolved. The foreign body was removed (fig. 219C) and the lung was repairedwith two layers of mattress sutures of fine silk. The hematoma was notdisturbed. The chest wall was closed in layers from the pleura to the skin, andclosed intrapleural catheter drainage was instituted.

The wound in the deltoid was debrided, and a small sequestrum of the lefthumerus was excised. The wound was packed open with fine-mesh gauze.

At the conclusion of the operation, bronchoscopy was performed and a largeamount of bloody mucus was obtained from both bronchial trees.

The postoperative course was uneventful. Roentgenograms 8 days after wounding(fig. 220B) showed satisfactory expansion of the left lung. The patient wasevacuated to the base on the 13th postoperative day. The shoulder wound healedby second intention.

Management in the Zone of Interior-The only activetherapy which the patient required in the Zone of Interior was physiotherapy tothe left arm. He received a disability discharge.

Followup-The patient has worked as a salesman since his discharge from the Army and has nocomplaints referable to the chest wound.

Roentgenograms (fig. 220C and D) madein December 1960, 17 years after wounding, showed no abnormality except for someobliteration of the costophrenic angle and the thickening of the axillarypleura.

Comment-In this case, a wound of the shoulder wasassociated with extensive damage to the chest wall and the leftlung. Thoracotomy through an elective incision was performed on the indicationof continued bleeding, leakage of air into the left pleural cavity, and thepossibility of cardiac damage from a retained foreign body. At operation, theintercostal vessels were found to be the source of the intrapleuralhemorrhage. The intrapulmonary foreign body was removed at operation, but thelarge hematoma was not disturbed, and satisfactory healing of the lung followed.

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FIGURE 221 (case 14).-Schematic showing of chest wound withretained foreign bodies (rib fragments) in lung. A. Wound: Wound of entrance inleft lateral chest wall (a), fracture of left scapula (b), fracture of spine offourth dorsal vertebra (c), and wound of exit (d).

Case 14

Management overseas.-A 20-year-old infantryman received abullet wound of the left chest at 0800 hours on 12 January 1943. A sulfonamide-powdered dressing was applied to the wound at a battalion aid stationat 0830 hours, and he was given a half grain of morphine and a unit of plasma.Two additional units of plasma were given at a collecting station because ofpersisting shock.

When he was admitted to the 94th Evacuation Hospital at 1130 hours, he wasorthopneic and somewhat comatose and was coughing up blood. He complained ofsevere pain in the left chest, neck, and abdomen. The blood pressure was 102/70mm. Hg, the pulse 142, and the respirations 42. There was considerable externalbleeding. There was a 3-cm. sucking wound in the left

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FIGURE 221.-Continued. B. Findings atthoracotomy: Laceration of lung (a) and fragments of fractured rib in hematoma occupyingapex of left lower lobe (b) .

lateral chest wall (fig. 221A) and a 4- by 5-cm. wound at the base of the neckposteriorly on the right. The sucking wound was immediately packed.

Furtherexamination revealed much crepitus over the posterior chest wall, absent breathsounds on the left, and dullness and signs of fluid in the lower half of theleft chest (fig. 222A). Theright lung was fairly clear except for occasional rales.

Oxygen was administered and bronchial catheter suction begun.Aspiration of the left chest produced 500 cc. of air and 800 cc. of blood. Aslow transfusion of 1,000 cc. of blood was given.

At 2020 hours,about 9 hours after the patient's admission, his blood pressure was stable, thepulse had dropped to 110 and the respirations to 28. He was considered fit forsurgery.

The wound of entrance was debrided along the left lateral chest wall, and theincision was extended upward across the chest to the base of the neck on

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FIGURE 221.-Continued. C. Appearance of wound at conclusion of operation:Wound of entrance (a) and wound of exit (b). Wound has been left open down todeep muscle layer and packed with fine-mesh gauze (c). Closed pleural drainagetube is in situ (d).

the right. The muscles were debrided. The spinous process of the fourthdorsal vertebra, which was fractured, was excised, as was the extensivelyfractured lower third of the left scapula. Fragments of the fractured fifth ribwere also excised. The pleura was then opened through the bed and interspace ofthe fifth rib, and three bony fragments were removed from the apex of the leftlower lobe, which was occupied by a large hematoma (fig. 221B). The lung wasslightly debrided, and all air leaks were closed with interrupted sutures offine catgut. The pleural cavity was lavaged with 1,500 cc. of physiologicsaline, after which a catheter was placed in the eighth intercostal space andconnected with a closed system. The deep muscle layers were approximated withinterrupted sutures of fine cotton. The remainder of the wound was left open andwas packed with fine-mesh gauze (fig. 221C).

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FIGURE 222 (case 14).-Serial roentgenograms of thoracicwound with retained foreign bodies (rib fragments) in lung. A. Posteroanteriorroentgenogram of chest, 1 January 1943, immediately after wounding, showingdiffuse haziness and fluid in left chest; shift of heart to right; and fracturesof fifth and sixth ribs and left scapula. B. Posteroanterior roentgenogram ofchest, 12 January1943, after resection of portion of fifth rib and scapula on left. Note hematomastill evident in lower lobe of expanded left lung. C. Posteroanteriorroentgenogram, 18 November 1960, more than 17 years after wounding, showingpartial absence of fifth and sixth ribs; slight blunting of left costophrenicangle; and increased bronchovascular markings in lung, which otherwise is clear.D. Lateralroentgenogram on same date, showing sharp costophrenic angles and prominentbronchovascular markings.

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At the conclusion of the operation, considerable blood and mucus wereaspirated from both major bronchi through the bronchoscope.

The postoperative course was satisfactory. When the intercostal tube wasremoved on the fourth day, after it had ceased to function, the temperature was100^? F., the pulse 90, and the respirations 22. When the patient wasevacuated to the base section on the 12th day, roentgenograms (fig. 222B) showedgood expansion of the left lung.

Management in the Zone of Interior-The patient wasevacuated to the Zone of Interior after delayed primary wound closure in a basesection hospital. He required no active treatment there, and was given adisability discharge.

Followup-This patient reported in November 1960 that hewas working as a diesel railroad engineer and was in good health. He was marriedand had two children. Roentgenograms made at this time (fig. 222 C and D), 17years after wounding, showed essentially negative lung findings.

Comment-In addition to a sucking wound and extensivedamage to the muscles of the posterior chest wall, this patient had extensivefractures of the ribs, scapula, and a spinous process, which resulted innumerous bony foreign bodies. Although this is an area in which anaerobiccellulitis is always a possibility, healing of the lung and the chest walloccurred without pneumonitis, abscess formation, or other infection. Early,careful debridement, with removal of the bony fragments, undoubtedly was themost important factor in the good recovery and subsequent absence of seriousdisability. The role of sulfanilamide, which was applied locally and given bymouth, is much less certain.

POSTDISCHARGE FOLLOWUP

It has been possible to follow the course in civilian life of119 of the 163 survivors in this series of combat casualties with chest woundssince their discharge from the Zone of Interior hospitals in which they werekept until their wounds had healed and their lungs had expanded. When they werereleased, their chest roentgenograms usually showed good healing of the bonycage and clear lung fields except for pleural adhesions and thickening. Thefollowup periods ranged from 3 to 17 years and averaged 5.6 years.

Roentgenologic Observations

Subsequent roentgenograms usually revealed substantially thesame findings as the predischarge films, although there had often been furtherclearing of the pleural shadows. The most frequent abnormal findings in thecurrent roentgenograms consisted of pleural adhesions or tenting of thediaphragm, which occurred in 57 cases. These roentgenologic findings are exactlywhat one would expect to find in civilian patients after thoracotomy forpulmonary, mediastinal, or cardiac surgery.

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Other roentgenologic observations included thickening of thepleura in 20 cases, slightly increased or prominent bronchovascular markings in8 cases, and pulmonary emphysema in 5 cases. The generally inconsequential abnormalities in the roentgenograms described in the 14 case histories just recorded,all of which were taken 16 or 17 years after wounding, are typical of almost allthe cases in this series.

Retained Foreign Bodies

Of the 119 patients followed up in civilian life, 41 harbored retainedforeign bodies, 35 times in the lung, 4 times in the chest wall, and once eachin the liver and in the region of the right diaphragm. All these objects wereless than 1 cm. in diameter, and in no instance was a pleural orpulmonary reaction noted about them on roentgenograms.

All of these patients had been observed in all echelons ofU.S. Army hospitals, from the combat zone to the Zone of Interior, and in everycase it had been predicted that the retained missiles would cause no furtherdifficulties. The prophecy proved correct in all but 1 of the 41 patients. Theexception was a 32-year-old infantryman, who had sustained multiple wounds ofthe arms, legs, and chest at Anzio on 29 May 1944. He was treated at the 11thField Hospital, where the wounds of the extremities were debrided. The twopenetrating wounds of the left chest were also debrided, and a foreign body wasremoved from the chest wall. On 14 July 1944, a drainage operation was performedfor hemothoracic empyema at the 23d General Hospital at Naples, and on 9February 1945, a chest abscess was drained at Walter Reed General Hospital.

The patient remained well until 3 October 1951, when hemoptysisand a recurrent infection of the lung and the pleura required wedge resection ofthe left lower pulmonary lobe, which was the site of the retained foreign body.Both operations in the Zone of Interior were performed by Dr. Brian Blades.

Thiswas the only case in this series in which a retained intrathoracic foreign bodygave rise to delayed difficulties. The patient represents about 0.6 percent ofthe 163 casualties who survived to be evacuated from hospitals in thecommunications zone. From the purely clinical standpoint, therefore, there seemsto be no reason for early removal of small (less than 1-cm.) asymptomaticmissiles. All such objects, of course, should be removed whenever this can beconveniently done in the course of surgery on other indications.

Symptoms Referable to the Chest

Most of the patients followed up in civilian life had no symptoms referableto the chest. The few who had symptoms complained chiefly of pain anddyspnea. The evaluation of any posttraumatic pain is notoriously difficult,particularly when industrial compensation is part of the picture. Since dis-

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ability and pensions were involved in all of these chest injuries, theproblem was much the same as in civilian compensation cases.

Hemoptysis was recorded only twice. In one case, just described, the bleedingcould be attributed to a retained foreign body. In the other, there wasoccasional slight streaking of blood when a driver jumped off his truck (case12, p. 508). The origin of the bleeding in this case is not apparent; theroentgenogram, taken 16 years after wounding, shows no significant findings.

Severe chronic cough, chronic bronchopulmonary infection, bronchiectasis, andchronic lung abscess, the heritage of so many thoracic casualties of World WarI, did not appear in any of these 119 patients.

Psychoneuroses

There is thus a gratifying paucity of physical complaints in these 119patients followed up in civilian life. In another area, however, unhappydividends of battle wounds are apparent. In 18 cases, reports in Veterans' Administration files indicated some form of psychoneurosis. These were probably themost serious posttraumatic sequelae observed. In two instances, the patients hadsustained blast injuries and had had severe cerebral symptoms immediatelyafterward, but all of these symptoms had cleared up before their discharge fromZone of Interior hospitals.

It seems highly likely that the psychoneuroses in these 18cases are far more closely related to the total experience of war and ofwounding than to the chest wound in itself. They are also both a factor in, andan index of, the casualty's postwar adjustment to civilian life.

Development of Thoracic Disease

Whether the postdischarge development of thoracic disease is related to thoracic trauma is a matter still to be settled. This is the present situation in these 117 men:

1. A number were hospitalized at various times for pneumonia and other acuterespiratory infections, but the number was probably no greater proportionatelythan would be expected in the general population.

2. Two patients developed pulmonary tuberculosis, one after reenlistmentduring the Korean War. Both cleared well.

3. One patient, in 1952, developed a bronchogenic carcinoma on the same sideas the penetrating wound of the chest. He died a year after pneumonectomy.

The incidence of posttraumatic thoracic disease was thus very small in these119 patients. Whether the figures can be taken at their face value is anothermatter. The number of patients followed up is small, and the series is notrepresentative in one sense, that it includes only a few patients who were notcared for in the Veterans' Administration hospitals and clinics. Further-

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more, carcinoma of the lung will undoubtedly be seen inother patients, even in this small group, as they pass into the age range inwhich this and other forms of malignancy are more common.

SUMMARY AND CONCLUSIONS

The patients in the series reported in this chapter, like allpatients with chest wounds encountered after March 1944, were treated bypolicies of management developed, for the first time in medicomilitary history,in the Mediterranean theater. In general, these policies were conservative, andit is fair to say that no patient in the series who was treated withoutthoracotomy at initial wound surgery because he was not considered to need thatoperation suffered in any way because his chest was not widely opened.

In summary, these policies and practices were as follows:

1. Careful stabilization of the cardiorespiratory physiologywas the first principle of management and was vital to the success of everyprocedure from simple debridement of the chest wall to extensive intrathoracicsurgery. That is, no matter what the wound, the first attention was directed toits effect on the lung and the heart. The single possible exception to thisgeneralization was thoracoabdominal wounds associated with shock caused byperitoneal contamination.

2. Debridement of the wound was the first procedure in thoracic wounds. Inthose limited to the chest wall, nothing else was required.

3. The indications for primary thoracotomy in forwardechelons were strictly limited. They included traumatic thoracotomy (suckingwound), thoracoabdominal wounds, continued intrathoracic hemorrhage, leakage ofair from the respiratory tract, and injury to vital mediastinal structures(esophagus,trachea, heart, great vessels, and thoracic duct). In retrospect, there seemsto be no valid reason to widen these indications. Their standardization, infact, represented a major contribution to thoracic surgery in World War II.

4. Immediate recognition and intensive treatment of the wet lung syndrome notonly reduced the initial surgical mortality but prevented the late sequelaeofpulmonary atelectasis and bronchopulmonary suppuration. These were frequentsequelae of chest wounds in World War I. There were no complications of thissort in this series.

5. In severe wet lung, in which pain inthe chest wall was an important factor, treatment consisted of intercostal nerveblock, tracheobronchial aspiration, and the administration of oxygen underintermittent positive pressure. All of these techniques have been carried overto civilian thoracic surgery since the war. In fact, intermittent positivepressure oxygen therapy, which was used in the Mediterranean theater for thefirst time in medical history, in the management of severely wounded thoraciccasualties before and after opera-

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tion, is now almost standard in the management of many pulmonary and cardiacconditions for which thoracic surgery is done.

6. Prompt aspiration of hemothoraces increased the vital capacity of the lungand permitted the evaluation of the degree of intrapleural hemorrhage. In someinstances, this measure undoubtedly prevented the deposition of fibrin and thedevelopment of the so-called captive lung. In no instance was there any evidencethat bleeding into the chest was increased by this technique, as many surgeons,before the war, had predicted.

7. Hematomas, even if they involved an entire pulmonary lobe, responded wellto conservative treatment and furnished no indications for resection of theinvolved tissue. These hematomas resolved with almost no pathologic pulmonaryresidua.

8. Pulmonary lacerations usually responded to intercostal decompression bythe closed technique. If they did not, thoracotomy, with simple suture, was theindicated treatment. Neither lobectomy nor resection was required. In fact,these followup studies, as well as other studies, show that such operations hadno place in the initial surgery of war casualties. Even localized (segmental orless) resections were almost never indicated; only one was performed in thisseries. The explanation is the tremendous recuperative powers of the lungtogether with its dual blood supply and elaborate lymph drainage.

9. Sucking wounds of the chest required immediate occlusion of the chest walldefect. After resuscitation of the patient from the cardiorespiratory point ofview, traumatic thoracotomy could be performed with a low mortality andgenerally excellent results.

10. Patients with blast injuries who survived their stay in forward hospitalcould be returned to civilian life with few cardiorespiratory symptoms and onlymoderate residua caused by damage to the cerebrum or tympanum.

11. Retained foreign bodies, if they were not producing hemorrhage,persistent air leaks, or esophageal trauma, were best handled at the basesection, where the patient was in better condition to tolerate the necessaryprocedures. Asymptomatic foreign bodies in the lung, pleura, and mediastinumwhich were less than 1 cm. in diameter were usually well tolerated, if theevidence of this series is to be believed.

12. Patients with thoracoabdominal wounds handled by the principles employedfor thoracic and abdominal surgery in the Mediterranean theater were returned tocivilian life with few or no cardiorespiratory or gastrointestinal symptoms.

13. Patients with mediastinal injuries seldom survived to reach forwardhospitals. When they did, gratifying long-term results were achieved if theywere managed by the principles and practices just described.

The postwar followup of the patients in this series furnishes every cause forencouragement as to the general results of these principles and practices. Theseries is small, it is true, but it is entirely unselective except in the sensethat the patients were included in it because the original information concern-

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ing their wounds was available and their subsequent records werecomplete enough to be useful.

Only 4 of the 167 severely wounded casualties in this serieswho survived initial wound surgery in forward hospitals died in base hospitals,and no deaths attributable to thoracic wounds occurred in casualties followed upin Zone of Interior hospitals or in those traced in civilian life.

From the records, and from personal correspondence with a number of men inthe group, it was evident that practically all of them were gainfully employed,usually full time; that they were married and had families; that they wereleading useful civilian lives; and that, with few exceptions, they consideredthemselves well from the standpoint of their chest wounds.

The assumption also seems warranted, as already intimated,that the majority of patients in the original panel of casualties (822) do notappear in this followup because they regarded themselves well. Those whoreported to the Veterans' Administration are a group with more persistent illeffects from their wounds-frequently not their thoracic wounds-or a group ofpsychoneurotic patients whose attention was focused on their old chest injuries.

One emerges, therefore, from an analysis of these recordswith the impression that if the patients in the series may be assumedto be representative, the great majority of casualties who survived chest woundswere really rehabilitated and restored to normal, useful lives. If thisimpression is correct (and there are no data to the contrary), it furnishesstrong evidence of the validity of the principles and practices of thoracicsurgery developed in the Mediterranean theater in World War II and recorded indetail in these volumes.

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