CHAPTER VIII
Management of Retained Foreign Bodies in theHeart and Great Vessels, European Theater of Operations
Dwight E. Harken, M.D.
ANATOMIC LOCATION OF MISSILES
Over a 10-month period in World War II, thoracic surgeonsworking in the thoracic surgery center set up in the 160th General Hospital,15th Hospital Center, Cirencester, Gloucestershire, European Theater ofOperations, U.S. Army, performed 134 operations for the removal of missilesretained in and about the heart and great vessels. There were no deaths in theseries, and all patients were discharged with normally functioning hearts.
The experience of World War II confirmed the difficulty,commented upon elsewhere, of accurate localization of metallic foreign bodies inrelation to wounds of the heart. In about half of the patients referred to thechest service at the 160th General Hospital as harboring foreign bodies withinthe heart, the objects were found, after careful fluoroscopic examination, to beextracardiac. Furthermore, early in the experience on this service, it was foundat operation that about a third of the fragments thought to be intracardiac wereextracardiac. Even on exploration, it was not always easy to determine whetheran object lay within the pericardium or within the auricle; this wasparticularly true if an infected hematoma was present.
The location of the 134 foreign bodies in this series, asproved by operation, was as follows (fig. 144):
Of the 56 foreign bodies in and about the heart, 13 wereintracardiac, 26 were entirely within the pericardium, and 17 partly within thepericardium but chiefly within the lung. Of the 13 foreign bodies removed fromthe chambers of the heart (fig. 145), 7 were in the right ventricle, 4 in theright auricle, l in the left ventricle, and 1 in the left auricle.
The great vessels were involved, directly or indirectly, in 78 cases. Inseven instances, the missiles were intravascular; the three of these whichbecame embolic are discussed in detail elsewhere (p. 380). In 35 instances, thefragments lay on the great vessels or within the vascular walls. In 17 cases,they were directly adjacent to the vessels but were chiefly within the lung. In19
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instances, they were within the mediastinum but were not in direct proximityto the great vessels.
The fact that no missiles were encountered within the lumenof the thoracic aorta and that in only one instance was a missile found in theleft ventricle seems to warrant the assumption that the direct entrance offoreign bodies of any considerable size into either of these areas was seldomcompatible with survival. The anatomic distribution of these missiles suggestsfurther that fragments small enough to enter the left ventricle as migratoryforeign bodies were probably swept out of it by the high systemic pressure, incontrast to those which entered the right ventricle, where physiologiccircumstances were more favorable for their lodgment.
Over the same 10-month period during which these 134successful operations were performed, 4 unsuccessful operations were undertakenfor the removal of foreign bodies in and near the heart. In two instances, themissiles
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FIGURE 145.-Missiles removed from chambers ofheart, with their location.
could not be recovered at cardiotomy, and in the other twoinstances, exploratory pericardiotomy revealed that their removal would havebeen attended with unjustifiable risks.
In 15 other patients in whom foreignbodies in or about the heart were encountered, operation was not undertaken, forone reason or another, and the objects were permitted to remain in situ.
FOREIGN BODIES IN AND ABOUT THE HEART
Indications for Surgery
The diagnostic confusion, already mentioned, of determining whether aretained missile was or was not within the heart added to the difficulties ofassessing the risk to life and health of retained intracardiac missiles. Inspite of numerous isolated reports of foreign bodies which have lodged in theheart
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and remained asymptomatic, there is also considerableevidence in the medical literature that these objects may be lethal.Experimental evidence, furthermore, suggests that their presence may give riseto bacterial endocarditis.
As the war progressed, therefore, a working policy for the management ofintracardiac missiles was formulated from the medical literature, from a limitedamount of experimental work previously done on animals, and from the individualsurgeons' own concepts and their accumulating experience. Although the policywas originally based upon somewhat uncertain premises, it was substantiated bythe clinical evidence secured in the various chest centers in the Europeantheater during the course of the war.
The indications for the removal of foreign bodies in and about the heart werechiefly based on possible risks, which included embolism, bacterial endocarditis,recurrent pericardial effusions, and myocardial damage. The development ofsymptoms and the existence of cardiac neurosis also served as indications.
The risk of embolism-The development of embolism from a foreignbody or from the thrombus associated with it was not merely a theoreticalpossibility. Several such accidents had been recorded in the prewar literature,and at least two are known to have occurred in the European theater duringWorld War II. One of these cases is included in the series analyzed in thischapter. The missile lay in the interauricular septum and right auricle and wasremoved from the auricle; the thrombus was found in the left auricle. Hemiplegiaoccurred in this case soon after wounding. In the second case, reported by Lt.Col. Arthur D. Nichol, MC, the embolism arose from a missile in the leftventricle. It is significant that the hemiplegia which followed it appeared morethan 2 weeks after wounding.
The risk of infection-The removal of retained intracardiacobjects because of risk of the development of bacterial endocarditis was, asalready intimated, partly based on the results of experimental work on dogs. Theimplantation of foreign bodies in various locations in the heart was followed bythe development of bacterial endocarditis characterized by typical bacterialvalvulitis and of septic embolic infarcts. The experimental evidence waslimited, but it was naturally feared that foreign bodies retained in the humanheart might give rise to the same consequences.
Clinical support for this hypothesis was confined in thisseries to a single case: The patient ran a course suggestive of subacutebacterial endocarditis, with spiking fever, tachycardia, and one acute episodeof pain in the right upper quadrant associated with jaundice. Response tosurgical removal of the missile and the attached thrombus from the right auriclewas immediate and dramatic. Although the patient was almost moribund whenoperation was undertaken, his recovery was prompt and uncomplicated.
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The bacteriologic support for the indication of infection in this series ofcases is somewhat more conclusive. No cultural studies were made in 4 of the 13intracardiac foreign bodies. There was growth of bacteria on cultures made fromonly one of the five fragments removed from within the right ventricle; thisparticular foreign body lay in an abscess within a mural thrombus in theventricular chamber. Cultures were also positive for pathogenic organisms inthree of the four cases in which foreign bodies were removed from within theauricle. One of these missiles was found in a small abscess in the center of amural thrombus in the right auricle.
It cannot be said positively that the infected niduses in these casesrepresented true bacterial endocarditis, nor can it be said that the infectionspresent would eventually have produced it. Nonetheless, the findings seemed tofurnish further support for the removal of intracardiac missiles because of thepossible development of infection.
The risk of recurrent pericardial effusions-The risk ofrecurrent pericardial effusion as an indication for the removal of intracardiacforeign bodies has been repeatedly stressed in the medical literature and iswell established. On the other hand, in the only two instances of pericardialeffusion observed at the 160th General Hospital, the symptoms were not severeenough, and the fragments were not large enough, to justify surgicalintervention.
The risk of myocardial damage-Myocardial damagewas clearly evident in three cases in this series. The damage to the rightventricular wall overlying the site of a migratory missile noted in thefollowing case seems of special significance in several respects. In particular,it demonstrates that the mere presence of a foreign body in a cardiac chambercan produce considerable damage to the overlying myocardium in a period of 3months, and it also indicates that surgical removal of the object does not, ofitself, cause myocardial injury of any consequence:
Case 1-A 29-year-old infantry sergeant was injured in the rightlower posterior chest on 21 July 1944, in the fighting about Saint-L?.Fluoroscopic and roentgenologic examination (fig. 146) showed a metallic foreignbody lying in the anterior portion of the right ventricle, just to the left ofthe midline, and pulsating with the heart. An electrocardiogram 4 days later(fig. 147) showed no abnormalities except for inverted T-waves in theright-sided precordial leads (CF1, CF2,and CF3). By 8 August, the T-waves in CF3had become upright, and the tracing appeared entirely normal.
First operation-Operation was performed on 15 August in thedorsal decubitus position (fig. 148). When the missile was grasped through anincision in the right ventricle, it was jerked from the grasp of the forceps bythe movements of the myocardium and was lost to both sight and palpation in thebloodstream.
Roentgenograms taken immediately after the operation (fig. 149) showed themissile lying in the right auricle, over the opening of the inferior vena cava.Another electrocardiogram on 17 August (fig. 150) showed elevated ST segments inleads I and II, which fell by 1 September. Later, the T-waves also becamesharply inverted in leads I and II and in the left-sided precordial leads CF4to CF6. It was speculated that while thisdamage
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might be related to the surgical incision made in the right ventricle nearthe septum, in the anterior surface of the heart, it might also result from anassociated pericarditis.
Second operation-At a second cardiotomy on 16 November, 3 months afterthe first, with the patient in lateral decubitus (fig. 148), the missile wasvisualized and palpated in the right auricle, just above the entrance of theinferior cava. Again it escaped, this time falling back into the right ventricle(fig. 151). Incidentally, a significant diagnostic point is demonstrated by theroentgenograms taken after operation: They were not made in the true lateralposition, and the impression was that the missile was in the chest wall. Hadthese been the first roentgenograms taken, considerable diagnostic confusionmight have been caused.
Electrocardiographic examination (fig. 152) showed nospecific acute change after the second cardiotomy. There was merely aprogressive return toward normal of the T-waves and of leads I and II and CF5and CF6.
Third operation-On 19 February 1945, at the patient'sown request, a third cardiotomy was performed. The anterior approach was used,as in the first operation, but this time the patient was placed in the reverseTrendelenburg position (fig. 148). The scar
FIGURE 149 (case 1).-Roentgenogramsshowing position of fragment in right auricle after first (unsuccessful)operation. A. Posteroanterior view. B. Lateral view.
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of the first incision in the right ventricle, made6 monthsearlier, was found solidly healed. This was demonstrated visually (plate I) aswell as clinically by the colored motion pictures taken at the operation. Theconsiderable fibrous pericarditis that had developed did not limit cardiacmotion or obstruct the blood flow. Near the apex of the right ventricle,however, the muscle wall was thin, flabby, and discolored (plate II). Themissile was palpable in the right ventricular cavity, just under the area ofmyocardial damage, which presumably had been produced by the friction of themuscle wall over the fragment during the 3 months after the second operation.
The heart was opened through the area of damage and the shell fragment (fig.145) was grasped by forceps and was removed with only moderate difficulty (plateIII). Intracardial manipulations were carried out in three episodes, over aperiod of about 3 minutes. Showers of extrasystoles were noted during theremoval of the missile (fig. 153).
In spite of the successive migrations of this foreign body (fig. 154), thispatient suffered no significant cardiac damage (fig. 155) and was in excellentcondition (fig. 156) when he was discharged to the Zone of Interior.
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PLATE II (case 5) (left, bottom).-Techniqueof dislocation of heart from pericardial sac.
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Case 2-Another instance of myocardial damage occurred in the only casein the series in which the foreign body was in the left ventricle.Roentgenokymographic studies showed diminished amplitude of pulsation at theapex and passive left ventricular dilatation during systole, suggestive of anearly ventricular aneurysm or hernia. Electrocardiographic studies (fig. 157)showed a persistent pattern characteristic of extensive damage to the anteriorleft ventricular wall, consisting of low voltage, deep Q1, absent R1,and inverted T1, together with inverted and W-shaped QRS complexesand sharply inverted and coved T-waves in the left-sided precordial leads.
At operation, the foreign body was found in the left ventricle, as theroentgenograms (fig. 158) had shown, in a cystic zone of myocardial damage 1.5cm. in diameter. It was ballotable in the defect in the cardiac wall, andparodoxical pulsation of this area of the ventricle was noted. A mural thrombus,which was not disturbed, permitted removal of the missile without hemorrhage.The myocardial defect, after closure, was covered over with two superimposedpericardial grafts.
In this case, electrocardiographic tracings taken at frequent intervalsduring the operation showed no evidence of cardiac irritability at any timeexcept for a few ventricular extrasystoles during the process of endotrachealintubation. It was believed that removal of the missile and repair of themyocardial defect prevented progression of the myocardial damage and avertedpossible rupture of the heart. Direct inspection at operation left no
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doubt that the risk of rupture of the myocardial hernia was real and that itwas aggravated by the presence of the foreign body in it.
Case 3-A third instance of damage to cardiac structures by a retainedforeign body was observed by Maj. Fred J. Jarvis, MC. In this instance, the wallof the right ventricle underwent such a degree of degeneration from the presenceof the underlying migratory missile that death ensued.
Other indications for surgery-Two additional factorssometimes assumed importance in the decision to remove intracardiac foreignbodies. One was pain, the other cardiac neurosis.
Pain was associated with some of the pericardial foreign bodies in thisseries, but with only one of the intracardiac missiles. In this case, the objecthad migrated from the auricle to the ventricle. A similar case was observed byLt. Col. (later Col.) Laurence Miscall, MC.
Cardiac neurosis sometimes became a pressing indication for surgery. In spiteof every effort to reassure them, all the patients in this series with foreignbodies in or near their hearts wanted them removed. Their apprehensions bore outGrey Turner's (1) remark, "In addition to the characteristic cardiacsymptoms * * * there may be neurotic manifestations which mainly depend on theattitude of the patient to the knowledge that he harbors a foreign body in oneof the citadels of his well-being."
Size and location were other factors which influenced thedecision for and against surgical intervention. Small foreign bodies left insitu were regarded as less hazardous than larger ones, and it was also thoughtthat they were associated with less risk of myocardial damage. An additionalreason for leaving them undisturbed was that they became encapsulated morereadily and more firmly than larger missiles and were therefore technically moredifficult
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to remove. For these reasons, small, silent foreign bodies inand near the heart were allowed to remain in situ in 15 cases at the 160thGeneral Hospital during the period in which 13 similar fragments were removedsurgically.
Combined indications-As might have been expected, more than oneindication for surgery was sometimes present, as the following case historydemonstrates:
Case 4-This soldier, following injury by a shellfragment in the left anterior aspect of the chest, developed an empyema, fromwhich both hemolytic Staphylococcus aureus and Clostridium welchii werecultured. He had been treated by decortication followed by open drainage at the160th General Hospital. In the 6 months after injury, he had three massiveepisodes of bleeding and two minor episodes. He also had bouts of pyrexia to 103?F., which did not appear to be connected with his empyema. Posteroanterior andlateral roentgenograms (fig. 159) revealed a shell fragment in the left auricle.Electrocardiographic studies before operation (fig. 160) showed right axisdeviation with low R1 and deep S1, low diphasic T1,and upright, pointed T2 and T3. The precordial leads werenormal. The abnormalities suggested damage to the anterior wall of themyocardium but were not helpful in localizing the missile.
At operation (fig. 161) on 18 May 1945, the empyema was found to communicatewith a laceration in the pericardium and the underlying left auricle; theauricle was adherent to the pericardium. A laceration in the auricle was pluggedby a large, infected, intracardiac hematoma. The missile, which was 2 by 1 by 1cm. and was surrounded by cloth, lay in this clot. It was readily removed fromthe left auricle, together with the cloth and the infected clot. Cl. welchiiand Escherichia coli were grown on direct culture from the materialremoved.
After operation, the empyema rapidly resolved and there wereno further episodes of hemorrhage or pyrexia. Serial electrocardiograms (fig.162) showed deep and sharp inversion of T1 and inverted T in CF6but no other significant change.
This case appears to embrace most of the indications for removal of anintracardiac foreign body (including an extensive thrombus), a potentialembolus, gross intracardiac contamination and infection, pericardialinvolvement, and damage to the myocardium with repeated hemorrhages.
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Principles of Surgery
A successful attempt to remove a foreign body from the heart depended uponthe observance of certain fundamental principles governing exposure of theinvolved area and manipulation of the heart itself. The most important of theseprinciples were:
1. Adequate, direct exposure of the affected area. This necessitated the useof a variety of approaches (fig. 163), depending upon the special problem athand. The pleura was opened routinely, but no standard or inflexible cardiacapproach was relied upon.
2. Conservation of the skeleton of the thoracic cage. Thefree division of ribs, cartilage, and sternum was often necessary to reach theheart. The division of bone and cartilage did no harm, but it was essential thatthese structures be preserved in situ. Complete reconstruction of an intactchest wall was necessary at the end of the operation. No tissue or bone wasresected, and nothing was discarded. As a result, there was neither deformitynor defect at the end of the operation.
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3. Maintenance of a moist epicardium during the period of cardiac exposure.It was thought that the 1 percent procaine hydrochloride solution used to keepthe epicardial tissues moist might also have the additional advantage ofreducing cardiac irritability.
4. Minimal dislocation of the heart from the position of optimal function. Toperform cardiac surgery with minimal cardiac dislocation often taxed theingenuity of the surgeon, but it was essential for a successful result.
Surgical Technique
Both the approach and the procedure for the removal of foreign bodies in andabout the heart depended upon their location. The various approaches describedwere all used successfully in one or more cases in this series. Anotherextracardiac approach to the heart, by way of the pulmonary veins to the leftauricle or even the left ventricle, was tentatively discussed, but no occasionto use it arose.
Right ventricle-When the object was in the right ventricle (fig. 164),the best approach was through the fifth or the fourth intercostal space (fig.165), which exposed the left portion of the right ventricle and the left borderof the left ventricle. The pectoralis major was split laterally and dividedmedially. The intercostal muscles were divided, and the internal mammary vesselswere ligated. The cartilage superior to the incision was divided near thesternum, after which the rib-spreader was inserted. If additional exposure
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was necessary, it could be obtained by the optional T-incision and divisionof the sixth and seventh costal cartilages.
After the pericardium and pleura had been opened widely, this approachpermitted palpation of a foreign body in the right ventricle. As a rule, thecardiac chamber was not opened, nor was any attempt made to remove the missile,until it had been located by palpation. When it had been located, two rows ofsutures were placed immediately over the object, on either side of the projectedincision. These sutures, which served as hemostatic guy or control sutures, wereused by the assistant to prevent blood loss from the opened heart betweenintracardiac maneuvers. The second row of sutures also served as a
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sort of second line of defense, in the event that any of the sutures in thefirst row pulled out.
After the missile had been stabilized as well as possible with the fingers, asmall epicardial incision was made with the scalpel, and a pointed forceps wasthrust through the myocardial wall and spread open; an opening sufficientlylarge to permit the insertion of a Kocher clamp was thus created. The foreignbody was then grasped and extracted with this instrument. During thesemanipulations, the assistant crossed the control sutures and thus producedhemostasis.
Once the fragment had been removed, the inner row of control sutures was tiedacross the incision. The second line of sutures was then tied over a small freepericardial graft, over which a second, larger, free pericardial graft wassutured into place. Postoperative cardiac tamponade was avoided by leaving thelateral angle of the pericardial incision open into the pleural space.
Chromic catgut sutures No. 00 were used, on atraumatic noncutting needles. Inretrospect, it might have been wiser to use silk for the ventricular closure.
Diaphragmatic surface of the heart-When the foreign body lay farther tothe right or was on the diaphragmatic surface of the heart, the intercostalincision described was combined with a transverse sternal section (fig. 166).Tudor Edwards' double retractor could be usefully adapted for this procedure.The sternum was readily reconstituted with wire.
When the auricle or the right side of the ventricle had to beapproached, the reverse of this incision could be used by following preciselythe same technique on the right side of the chest.
Right auricle-When the missile was in the right auricle (fig. 167), aright anterior approach was usually best (fig. 168). The third, the fourth, oreven the fifth interspace was used, depending upon the location of the foreignbody. The third interspace, for instance, was incised, with section of the
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third and fourth costal cartilages near the sternum, to provide exposure ofthe upper portion of the right auricle. After the pericardium had been opened,control sutures were placed in the auricular wall by the technique described fortheir application in the ventricular wall. The auricular myocardium was oftentoo thin to hold sutures. If the structures were adherent, as in the caseillustrated, pericardial tissue could be included with auricular tissue in thesecond suture line.
Left auricle-If the foreign body was in the left auricle, the approachshown in figure 161 was used. In this case (case 4, p. 367), the laceration ofthe auricle and pericardium was plugged by an infected clot, and the fusion ofthe two structures made the intracardiac portion of the operation perfectlysimple.
Pericardium-In this series, intrapericardial missiles were removed by aposterior approach that exposed the left auricle on either the right or the leftside. This technique was not used in any intracardiac operation at the 160thGeneral Hospital. When the patient was placed in ventral decubitus (fig. 169),the posterior incision provided adequate exposure.
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In one case in which this approach was used (fig. 170), anextremely thin-walled auricle was encountered in a completely free pericardialspace. Bleeding from the auricular wall was so free when an attempt was made toplace the hemostatic sutures that this technique had to be abandoned. Anapproach through the auricular appendage proved equally unsafe. An extracardiacapproach was therefore devised, by exposure of the superior vena cava (fig.171). Control tapes were placed around this vessel, an incision was made intoit, and a forceps was slipped down the lumen and into the ventricle. Thismaneuver permitted removal of the missile without difficulties.
Behavior of the Heart During Cardiac Surgery
The electrocardiographic tracings made at operation in somecases in this series were useful in demonstrating manipulations that were notwell tolerated by the heart. These manipulations included cardiac dislocations,hemostatic cardiac grips, and extensive maneuvers within the cardiac chambers.
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Cardiac dislocation-In some instances, dislocation of the heart atoperation caused runs of ventricular extrasystoles, diminished cardiac output,and transitory bundle branch block. Whether the dislocation was accomplishedmanually or by means of an apical suture, it was not well tolerated, as thefollowing case history shows:
Case 5-At operation, this foreign body (fig. 172) was foundextracardially, in a pericardial abscess well back on the diaphragmatic surfaceof the heart. The abscess contained about 18 cc. of pus. To gain access to thisarea, the heart had to be lifted out of the pericardial sac (plate II). Thismaneuver caused a fall in blood pressure, accompanied by circulatory failure,which made it necessary to replace the heart frequently, after relatively shortperiods of dislocation, to permit a return to normal conditions before theoperation could be proceeded with. Many irregularities in rhythm occurred, whichwere apparently extrasystoles, and marked cardiac dilatation, particularly ofthe right ventricle, also developed, so that the heart became too large for thepericardial sac (plate III). After it was replaced, the pericardium was leftpartly open.
Electrocardiograph tracings taken during operation (fig. 173) showedvariations in rhythm consisting of ventricular extrasystoles (at 300), wanderingpacemaker, varying P-R interval, and A-V nodal rhythm. It was at the time thenodal rhythm occurred, during a period of dislocation of the heart, that aparticularly prolonged and alarming episode of circulatory failure developed.After recovery, normal sinoauricular tachycardia returned (fig. 173).
An additional change in the electrocardiograms was alsorelated to dislocation of the heart. At 2:57 o'clock (fig. 173), the S-wavebecame broad and notched and the QRS interval lengthened to 0.13 second, incontrast to the normal complexes at 2:07 and 2:37 before cardiac manipulations.While it is unfortunate that this abnormality was recorded only in lead II, itmay be regarded as indicating at least interventricular block or incompletebundle branch block, probably on the right side. The abnormal QRS complexespersisted throughout the operation, but 4 days later, observations were normal.At operation,
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the delay in conduction could be correlated, by direct visual inspection,with dilatation of the right ventricle. This extremely unusual observation in ahuman subject was considered to be caused, at least in part, by the increasedtime necessary for conduction of the impulse through the greatly dilated rightventricle.
The intolerance of the heart to dislocation was demonstrated in this case intwo ways, (1) by ventricular dilatation with incomplete bundle branch block, and(2) by varying types of arrhythmia and circulatory collapse. Obviously,dislocation of the heart may produce torsion of the great vessels andobstruction to outflow of blood, with (1) a fall in blood pressure resultingfrom the diminished cardiac output and (2) ventricular dilatation resulting fromthe increased resistance to blood flow.
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This sort of experience led surgeons on the thoracic surgery service at the160th General Hospital to avoid the apical suture as a means of exposinginaccessible areas of the heart. The situation encountered in combat-incurredwounds is quite different from the circumstances of civilian surgery, in which aplanned approach permits precise and comfortable exposure of any part of theheart.
Obstruction of the cardiac blood flow-Experience showed that theclassical hemostatic cardiac grips intended to provide a bloodless surgicalfield were also poorly tolerated. These maneuvers disturbed cardiovasculardynamics and were therefore used only as a last resort.
The intolerance of the heart to obstruction of the blood flow was in strikingcontrast to its stability during other cardiac procedures and certainintracardiac procedures. The surface of the heart could be manipulated, suturestaken into the muscle, and incisions made into the cardiac chambers with littleevidence of disturbance.
Intracardiac manipulations-More extensive manipulationsinside the cardiac chambers by the exploring finger or by a forceps inserted toremove an intracardiac thrombus or a foreign body were less well tolerated.Sometimes no abnormalities were noted, but marked cardiac irregularity, in theform of multiple ventricular extrasystoles, were common. The case, alreadydescribed (case 1, p. 357), in which three cardiotomies were necessary,demonstrates this point particularly well. As the foreign body was grasped andextracted from the right ventricle, electrocardiographic tracing (fig. 153)showed showers of ventricular extrasystoles from different foci in bothventricles; runs of ventricular tachycardia lasted as long as 16 seconds. Directobservation of the irregular heart action and examination of theelectrocardiogram raised the
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fear of impending ventricular fibrillation, but at the end of the operation,when the irritating forceps and the missile had been removed from theventricular chamber, the tachycardia ended promptly and the P-R intervalreturned to normal in three beats. All of these irregularities were relativelybenign.
Other causes of cardiac irritability-Minor evidences of cardiacirritability were observed at operation, such as extrasystoles and wanderingpacemaker, varying P-R interval, and even A-V nodal rhythm, but these phenomenawere not usually accompanied by any significant clinical manifestations. Theseminor abnormalities were often evoked by procedures not related to the heart,such as endotracheal intubation, spreading of the ribs, and manipulations of thehilar and mediastinal structures. It was thought that keeping the surface of theheart moist with warm physiologic salt solution or procaine hydrochloridesolution was important in reducing the tendency toward irritability.
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Postoperative Management
The postoperative care of a patient who had undergone cardiac surgery wasessentially the same as the care of a patient who had undergone any seriouschest surgery. Patients who had required ventricular cardiotomy were kept in bedfor 3 weeks, even though the electrocardiographic tracings had usually returnedto normal within a few hours after operation.
FOREIGN BODIES IN AND ABOUT THE GREAT VESSELS
Indications for Surgery
The danger of erosion and suppuration as the result of theretention of large missiles in close proximity to thoracic blood vessels wasquite real. At least three deaths are known to have occurred at otherinstallations in the European theater as the result of erosion from this cause.In the 78 successful operations for removal of such missiles at the 160thGeneral Hospital thoracic surgery center, there was no instance of erosion. Onthe other hand, abscess formation occurred in about 15 percent of the cases;clothing, bone fragments, and other foreign material entered the body with theshell fragment in 30 percent of the cases; and pathogenic bacteria were found on67 percent of the material that was cultured on removal.
On the basis of these facts, it became established policy at this chestcenter to remove all foreign bodies in the mediastinum adjacent to the greatvessels if they measured 1 cm. or more in two dimensions. The decision to removesmaller objects or permit them to remain in situ was made on the indications ineach case.
Removal of the foreign bodies seldom presented any technical difficulties. Atthe 160th General Hospital, operation was unsuccessful in only one case, thethird undertaken. The fact that there were no deaths in the 78 cases in whichthe objects were removed seems to support the contention that their removal wassafer than their continued retention.
The only cases in this series which warrant specialdiscussion are the three instances of migratory intravascular objects, whichwill be described in some detail.
MIGRATORY INTRAVASCULAR FOREIGN BODIES
In 1942, Straus (2) collected from the world medicalliterature 32 instances of migratory intravascular foreign bodies and added tothe collection a case which he had himself observed. A second review of the sameliterature in 1945 brought to light nine additional cases that Straus did notinclude in his material. Undoubtedly, other cases were overlooked in bothreviews, while still other cases have not been reported at all.
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Almost without exception, the migratory foreign bodies in these 42 cases werebullets or shell fragments, the majority of which originated in combat-incurredinjuries.
The infrequency of such cases, the bizarre courses of many of the embolicmissiles, and the dramatic developments often associated with their migrationwarrant a presentation of the three such cases encountered at the 160th GeneralHospital thoracic surgery center, together with a brief comment on certain oftheir features.
Case 6-A 30-year-old soldier was wounded in the left infraclavicularregion by a .30-caliber machinegun bullet while in combat in Belgium on 26December 1944. The wound was debrided and sutured the same day at a forwardinstallation. Roentgenograms of the chest taken at this time revealed that thebullet was located posterior to the hilus of the left lung.
When the patient was evacuated to the 128th General Hospital, Bishopstrow,England, it was decided that the size of the missile and its proximity to thehilus of the lung constituted valid indications for its surgical removal. He wastherefore transferred to the chest center at the 160th General Hospital on 8January 1945.
Initial roentgenograms (fig. 174) confirmed the previous findings. Routinefluoroscopic studies for precise localization of the missile suggested nothingmore remarkable than the presence of a pulsating bullet intimately associatedwith the left hilar structures. There seemed no doubt that it could readily beremoved through a conventional posterolateral approach.
Thoracotomy was accordingly performed through this approachon 19 January 1945. After resection of 12 cm. of the seventh rib, the bulletcould be palpated in the central portion of the left upper lobe. Its locationwas confirmed by palpation by the first assistant. When, however, the surgeonpalpated the area for a second time, he was chagrined to find that the missilehad vanished. A thorough search of the entire left lung, including the hilus,and of the posterior mediastinum and the pericardium failed to locate thebullet, and it was suspected that it had fallen into the tracheobronchial tree.When this possibility
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was excluded by immediate bronchoscopy, no further manipulations wereattempted, and the chest was closed.
Recovery was completely uneventful and the patient was allowed out of beddaily after the first 24 hours. Roentgenograms taken immediately after operation(fig. 175) showed that the bullet that had previously been seen in the hilarregion of the left lung (fig. 174) was now lying horizontally, just to the rightof the body of the sixth dorsal vertebra, pointing outward. The pulsationsindicated that it was in contact with the area of the pulmonary artery. It wasconcluded that the missile was definitely in the right pulmonary artery.
A second thoracotomy was performed on 20 February 1945, through the thirdintercostal space anteriorly (fig. 176). The third and fourth costal cartilageswere divided close to the sternum. There was no evidence of altered blood flowin the lungs. The bullet was palpated in the hilus of the right lung at and inthe mediastinum, posterior to the superior vena cava.
The right pulmonary artery was isolated, and a tape was placed about itproximal to the foreign body. The missile, point outward, was digitallymanipulated away from the hilus into the pulmonary artery of the upper lobe, themilking process being continued until its point presented beneath the visceralpleura in the interlobar fissure. Here, the pleura was nicked, and thepresenting tip was thrust upward through the opening and grasped with a Kocherclamp. The missile was then delivered in toto by slowly stretching the terminalbranches of the pulmonary arterial tree. Hemorrhage was controlled bycircumferential mattress sutures of catgut in the lung at the point of removalof the missile. The wound was closed without drainage.
The patient was up and about after the first postoperative day. His recoverywas completely uneventful, and he was returned to the Zone of Interior forrehabilitation on 30 March 1945.
Case 7-This soldier was wounded on 14 October 1944, inaction in France, by a shell fragment that entered through the upper part of theright posterior axillary line. The wound of entrance was debrided and closed thesame day at the 60th Field Hospital. Aspiration of a right hemothorax yielded500 cc. of blood. Roentgenograms of the chest (fig. 177) revealed a foreign bodyin the right upper mediastinum, 3 cm. posterior to the right sternoclavicularjoint.
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After the patient reached the 154th General Hospital, Wroughton, England, apericardial friction rub was heard. On 21 October, a bruit was discovered overthe right supraclavicular fossa, and it was noted that both the brachial and theradial pulses were absent in the right arm. Thoracentesis, repeated on 7November, yielded what was at first thought to be fresh blood. It was laterfound to be old, changed blood of the so-called grapejuice type.
In view of the roentgenologic and clinical findings, the patient wastransferred to the thoracic surgery center at the 160th General Hospital on 10November 1944. There, it was noted that the right hand was cooler than the leftand was waxy-yellow. The blood pressure in the right arm was 102/80 and in theleft 122/68 mm. Hg. Fluoroscopic and roentgenologic examination led to theconclusion that the foreign body lay in close proximity to the innominateartery.
Surgical removal of the fragment was considered advisable because of (1) itssize; (2) its proximity to the large vessels in this region; (3) the evidentvascular damage it had caused, as attested by the bruit and the differencesbetween the blood pressures in the right and left arms; and (4) the possibilitythat fresh bleeding had occurred into the right pleural cavity. The latterconsideration suggested that surgical intervention be instituted promptly.
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Operation was performed on 12 November 1944 underendotracheal gas-oxygen-ether anesthesia. A U-shaped incision was made over theright upper anterior chest (fig. 178). The sternum was exposed. The internalmammary vessels were divided and ligated in the second intercostal space. Theright pleural cavity was opened widely. The deep surface of the sternum wascleared of underlying structures, and the bone was split with a power sawlongitudinally in the midline, from the suprasternal notch down to the level of,and out through, the second intercostal space. When the segment of sternum, withthe clavicle and the first two ribs attached, was reflected upward and outward,excellent exposure of the superior mediastinum and the base of the neck wassecured.
The superior vena cava and the innominate veins wereretracted with tapes. The innominate artery was isolated at its point of originfrom the aorta, and a tape was placed about it for hemostatic purposes. It wasthen dissected free up to its bifurcation into the carotid and subclavianarteries. Tapes were placed about each of these vessels. It was not possible topalpate the foreign body within the upper portion of the innominate artery, thewall of which was intact and free from scars. The artery was incisedlongitudinally, and the foreign body was removed. The portion of intima whichhad been in contact with it showed evidences of patchy destruction. Afterthrombi had been removed from the lumen of the vessel, bleeding was free, bothproximally and distally.
The incision in the artery was closed in two layers, with interrupted No. 000silk sutures. The first layer included the entire wall. The second sutures wereintroduced through the adventitia and media; a bite was taken on either side ofthe incision as each suture was placed, but the sutures did not pass through thelips. Fibrin foam was laid over the incision and held in place with the secondlayer of sutures.
The sternum was approximated with three interrupted wiresutures placed in drilled holes that had been so staggered that the medial holeswere lower than the lateral holes. When the sutures were pulled tight, thesternal fragment was therefore drawn downward and inward, and a precise andstable reconstruction of the pectoral girdle was thus obtained. Great care wastaken to accomplish this result because stability had been found to be of greatimportance after section of the sternum; the movement of loosely approximatedsternal fragments was painful and could produce shock.
The pectoral muscles were approximated with interruptedsutures of No. 00 chromic catgut. The superficial fascia was similarly closed,and the skin was sutured with No. 0 black silk. No drains were used.
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Immediately after operation, the pulse in the right arm was barelyperceptible. The first postoperative day, the blood pressure was 122/80 mm. Hgin the left arm but remained unobtainable in the right arm. The secondpostoperative day, the right stellate ganglion was infiltrated with procainehydrochloride. The right arm immediately became warm, and a systolic bloodpressure of 68 mm. Hg could be obtained. On 17 November, the blood pressure was132/60 mm. Hg in the left arm and 98/76 in the right arm. On November 25, therespective pressures were 124/86 and 108/64 mm. Hg. On 15 January 1945, theblood pressures were the same in both arms.
The patient was heparinized for 3 days after operation. Theclotting time usually averaged from 9 to 15 minutes but on a single occasion was45 minutes. The hemothorax still present after operation was evacuated byaspiration and required no further treatment. Hoarseness, the result ofmanipulation of the right recurrent laryngeal nerve, was present for 4 weeksafter operation; then it disappeared completely. Union of the sternum was firm.When the patient was returned to the Zone of Interior on 1 March 1945 forrehabilitation, he was in excellent condition and had no evidence of anycirculatory disturbance.
Case 8-A 22-year-old soldier was struck by a machinegun bullet on 15July 1944, while in action in France. The point of entrance was in the rightaxilla, at the level of the fifth rib. When he was evacuated to the 159thGeneral Hospital, Yeovil, England, on 17 July, routine roentgenograms showed noabnormalities (fig. 179), and the lateral film established the absence ofmetallic objects in the retrocardiac zone.
The patient was symptom-free when he was sent to the rehabilitation barracks,and for about 3 weeks he participated in a vigorous athletic program, with nodifficulties. Then, early in the morning of 13 August, he was wakened byagonizing pain in the lower left chest, accompanied by dyspnea, orthopnea,cough, and hemoptysis. Rales and diminished breath sounds were heard over theleft axilla. On 15 August, roentgenograms of the chest (fig. 180) revealed a.30-caliber bullet in the hilus of the left lung. On 19 August, bronchoscopyrevealed edema of the left main bronchus with an injected bleeding point on theposterolateral wall. The continued hemoptysis and the bronchoscopic findingssuggested that the bullet had eroded from the pulmonary artery into the leftmain or descending bronchus. The patient was therefore transferred to the chestunit at the 160th General Hospital on 22 August.
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Since the possibility of erosion of the bullet from the pulmonary artery intothe bronchus seemed an urgent indication for surgical intervention, operationwas undertaken on 28 August 1944. Thoracotomy was performed through aposterolateral approach, with resection of a 16-cm. segment of the left seventhrib. Exploration revealed discoloration of the lingular portion of the leftupper lobe and, to a lesser degree, of the anterior basic segment of the leftlower lobe. The missile could be palpated through the interlobar fissure in thelower lobe and hilus; it seemed intimately associated with the artery. Afluctuant area, about 1 cm. in diameter, was noted over the base of the bullet.
The hilus was exposed, so that the pulmonary artery could be compressed bygrasping the hilar structures from above downward between the index and middlefingers of the left hand. The digital compression not only was hemostatic butalso served to stabilize the missile. With the situation thus under control, thefluctuant area was incised. The butt of the bullet was found lying in an abscesscavity anterior to, and including the anterior surface of, the lower branch ofthe left pulmonary artery. The body and point of the missile, however, laywithin the arterial lumen, and as soon as the bullet had been extracted, thefull arterial stream issued from the defect. The hemorrhage was at all timescompletely under control, as could be proved by voluntary release of the arteryand immediate cessation of the bleeding when compression was resumed.
The abscess cavity was thoroughly debrided, and mattress sutures were placedthrough its wall and through the subjacent artery. Fibrin foam impregnated withpenicillin was placed over the mattress sutures used to close the arterialincision before they were tied. An excellent closure of the vessel was thuseffected. The gangrenous lingular portion of the left upper lobe was thenresected, and the line of resection was closed with mattress sutures of No. 00chromic catgut. The anterior basic segment of the left lower lobe, althoughsomewhat discolored, was considered viable and was not disturbed. The lungreexpanded readily. Before the chest was closed, 100,000 units of penicillin in50 cc. of 2.4-percent sodium citrate solution were instilled into the pleuralcavity.
The left hemothorax present after operation was aspirated anddid not recur. The patient was up and about the ward within 48 hours, and he wasin excellent condition when he was transferred to a rehabilitation center on 1December 1944.
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Migration and Clinical Consequences
Pattern of migration-In the 42 cases of migratoryintravascular foreign bodies reported in the literature up to 1945 (p. 380),migration was about equally divided between arterial and venous channels,depending upon which the object happened to enter at the time of wounding.
Apparently, there is considerable latitude in the possible patterns ofmigration when a foreign object enters the circulation.
In 11 of the 42 recorded cases, the missile entered one ofthe larger arteries and passed peripherally as an embolus. In five instances, itentered the left ventricle and was swept out into the aorta, to lodge withinthis vessel or within one of its branches. In one case, it passed through theleft ventricle, to become embolic to the right femoral artery. Two missilesentered the ascending aorta and passed downward against the arterial stream; onecame to rest in the sinus of Valsalva and the other in the left ventricle. Onemissile entered the pulmonary artery, migrated downward into the rightventricle, and killed the patient 7 days later, when it became embolic to theright pulmonary artery (3).
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In two instances, the missile entered one of the pulmonary veins and passedinto the left ventricle.
The patterns of arterial migration described in two of thethree cases of migratory foreign bodies observed at the chest center at the160th General Hospital do not seem to have been reported previously. In one case(case 6, fig. 181) migration was from the left pulmonary artery into the mainpulmonary artery and thence to the right pulmonary artery. The bullet wasevidently in the lumen of the left pulmonary artery at the first operation andwas dislodged by the exploratory palpation.
In one case (case 7, fig. 182), since the wall of theinnominate artery and the adjacent portion of the aorta were found at operationto be intact everywhere, the course of the missile, it seems, must necessarilyhave been through the right side of the chest and into the pulmonary vein or theleft side of the heart. The fragment was then carried as an embolus by thebloodstream into the aorta and thence to the innominate artery, where it lodged.The pericardial friction rub noted before operation suggested that thepericardium had been traversed and that the foreign body had entered the leftside of the heart,
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whence it passed into the arterial circulation. The case thusrepresents a penetrating wound of the heart or pulmonary artery with arterialembolism of the foreign body to the innominate artery.
In one case (case 8, fig. 183), the exact portal of entry of the bullet intothe circulation can only be surmised. Since, however, the wound of entry was inthe lower axilla and the chest was clear in the films taken immediately afterwounding, it seems reasonable to assume that the bullet was originally in theliver. It probably began its migration in the inferior vena cava, whence it wascarried to the right auricle, then to the left ventricle, and then into thepulmonary artery. It entered the left branch of the pulmonary artery and lodgedin the branch to the lower lobe and lingula in such a way as to occlude thearterial supply to the lingula as it arose from the artery of the lower lobe inthis region. Occlusion of the pulmonary circuit was associated with parenchymalchanges.
No instances of intravenous migration of foreign bodies were observed at the160th General Hospital thoracic surgery center during the war. In 9 of the 42cases recorded in the literature, the object entered one of the larger veins,migrated to the right auricle, and came to rest in the right ventricle.
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In three instances, it followed the same course as far as theright auricle, then traveled down the vena cava before coming to rest in one ofits tributaries. In two instances, it entered one of the pulmonary veins andpassed into the left ventricle. In other cases, the bullet entered the inferiorvena cava and migrated to the junction of the common iliac veins; entered theright ventricle and passed into the pulmonary artery; entered the long duralsinus and then migrated into the sigmoid sinus; and entered the venouscirculation through a wound in the thigh and was found at autopsy in the leftventricle. In the latter case, there was a widely patent foramen ovale. In thecase reported by Straus (2), the bullet entered the right common iliacvein and traveled to the left pulmonary artery. Death occurred 4 days later butwas not caused by the embolic missile.
In one case, a patient who harbored a missile that had migrated into theright ventricle complained of pain over the heart. With this single exception,foreign bodies migrating within the veins caused no symptoms in the recordedcases.
When a missile is in the arterial circulation, clinical manifestations varyaccording to the portion of the arterial tree involved. The embolic character ofthe object is supported by the changing symptomatology as well as byroentgenologic studies and by the findings at operation.
Varying degrees of arterial insufficiency have been reported as the result ofmissiles embolic in the arteries. In the case reported by Paltauf (3) andalready mentioned (p. 388), death occurred when the migratory object becameembolic in the right pulmonary artery. In a case reported by O'Neill (4),gangrene of the left lower extremity developed after a shell fragment becameembolic from the left ventricle to the left common iliac artery; the patientsurvived 5 days. In one of the cases observed at the 160th General Hospital, thepatient experienced severe pain when, presumably, the missile moved from thevenous to the arterial circulation, and lodgment of the bullet in the branch ofthe pulmonary artery supplying the left lower lobe resulted in gangrene of thelingular portion of the lung on that side.
Infection-Infection is a theoretical possibility in allcases of migratory foreign bodies. Lyle (5) seems to have been the firstto call attention to this fact. In his case, the foreign body, which was foundat autopsy in the right ventricle, had fragments of clothing adherent to it. Afibrinopurulent pericarditis was present, and gas bubbles were noted in themyocardium, but the wound of entrance in the thigh showed no evidence ofinfection at any time.
Diagnosis-The possibility of intravascular migration ofmissiles, as the cases observed at the 160th General Hospital indicate, shouldbe borne in mind in all instances of penetrating wounds, and the surgeon shouldmake every effort to locate a missile whose position is not immediately obvious.If a patient who harbors a foreign body develops sudden and unexplainedsymptoms, as in one of these cases (case 8, p. 386), fluoroscopic androentgenologic examinations
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should be resorted to immediately, to determine whether migration of themissile is responsible for the clinical manifestations.
Management
A review of the 33 cases collected by Straus (2), including his own,does not encourage an optimistic attitude concerning migratory foreign bodies.He listed only six survivals, and the pathologist, not the surgeon, was usuallythe one to remove the object and establish the course of the migration. In WorldWar II, in view of the progress which had been made in thoracic and vascularsurgery and in anesthesia between the wars, the thoracic blood vessels and theheart had come within the province of the surgeon, and there were fewintravascular foreign bodies which could not be attacked surgically, and withsafety. As already stated, there were no deaths in the 78 operations for theremoval of intravascular foreign bodies performed at the chest center at the160th General Hospital.
The three cases of migratory intravascular foreign bodies observed there andjust described in detail, together with the cases recorded in the literature,make clear the indications for surgery, which may be stated as follows:
1. Vascular occlusion.-This risk is well demonstrated in the gangrenewhich ensued in the lingular portion of the left upper lobe in case 8. Thepathologic process is interesting; theoretically, gangrene should not haveoccurred with a normal bronchial circulation.
2. Erosion and hemorrhage.-These did not occur in this series.
3. Infection.-This did not occur in any of the three cases described,but, as Lyle's (5) report indicates, it is always a possibility.
4. Embolism.-This is the overriding reason for surgical removal of theobject, for a fatality is always possible, as a majority of the reported casesindicate, whenever a foreign body enters the blood vessels.
Four technical points proved useful in the management of the cases ofmigratory intravascular foreign bodies observed at the 160th General Hospital,as well as in a number of other operations on the mediastinum:
1. Splitting of the sternum (case 7) provided good surgical exposure. Thebone was carefully approximated with wire at the end of the operation, and thepatient did not suffer postoperative pain or shock.
2. Manipulation of the missile from the main right pulmonary artery to theperiphery (case 6) permitted surgical manipulations in the relatively safeperipheral zone rather than in the more hazardous hilar region of the pulmonaryartery. This technique, which apparently had not previously been described, wascertainly less formidable than opening the right horn of the pulmonary artery,removing the missile, and then attempting local reconstitution of the mainbranch.
3. The digital method of hemostasis, which amounted to using the fingers as atourniquet (case 8), proved both simple and functional.
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4. As soon as the missile was encountered, it was fixed in position, so thatmigration could not occur during the operative procedure. The patient was alsoso positioned as to make circumstances unfavorable for migration. The importanceof this precaution is evident from the experience in one of these cases (case6).
One other technical point might be made concerning the case (case 7) in whichincision of the innominate artery was necessary. This sort of intervention isalways undertaken with some misgivings, since circulatory disturbances in thehomolateral arm, as well as contralateral hemiplegia, are possiblecomplications. These accidents, of course, were less to be feared in the agegroup with which military surgeons had to deal. Nonetheless, their possibleoccurrence points to the wisdom of restoration of vascular continuity of theinnominate artery, rather than ligation, when it must be attacked surgically asin this case.
EXPERIENCES AT THE 155TH GENERAL HOSPITAL THORACICSURGERY CENTER
Analysis of Data
To complete the picture, the World War II experience ofanother chest center, at the 155th General Hospital, near Malvern Wells,England, European theater, is briefly summarized. It included the removal of 172objects from the lungs; 27 from the mediastinum; 37 from the pleura; and 19 fromvarious internal structures, in addition to 63 removed from the deep structuresof the thoracic wall. The 172 cases classified as pulmonary included foreignbodies situated in the paramediastinal surface of the lung, either abutting onthe mediastinum or partly embedded in the mediastinal pleura.
In four other operations, the foreign body was not removed.In two instances, it lay within the substance of the lung at the hilus butescaped detection because of hematoma formation and pulmonary infiltration. Inboth of these cases, the object was later removed without difficulty. In the tworemaining cases, the object was displaced at operation. In one instance, it laywithin the pulmonary artery on one side and slipped into the artery on theopposite side during manipulations. In the other case, it lay in the rightventricle and was displaced into the right auricle and inferior vena cava.
About 93 percent of the retained foreign bodies were high explosive shellfragments. The remaining injuries were caused by small arms fire.
Of the 172 foreign bodies in the lung, 119 were removed bytranspleural pneumonotomy. In 48 cases, the free pleura was not entered; theoperative procedure could be carried out entirely within a zone of adhesionsbetween the lung and the thoracic parietes. In the remaining five cases, inwhich a collection of pus was encountered unexpectedly around the object atoperation, removal was transpleural, and local marsupialization of the lung wasper-
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formed in order to minimize the danger of pleural infection. This policy, asalready intimated, was successful.
The incision, whenever practical, was placed directly over the foreign bodyand was always as small as was consistent with satisfactory surgical exposure. Arib resection was never performed when intercostal incision and division of therib were adequate. When the object could be removed through adhesions whichexisted between the lung and the pleura, postoperative pleural effusion did notoccur, and convalescence was appreciably shortened. The technique employed insuch cases was similar to that used in one-stage drainage of an abscess of thelung. Particularly small incisions were required when it was employed.
Of the 27 foreign bodies in the mediastinum, 7 lay in directrelationship with the esophagus; 7 with the pericardium; 6 with the aorta; 2each with the azygos vein and the innominate artery; and 3 with the vena cava.Seventeen of the objects were removed transpleurally and ten by extrapleuralmediastinotomy, the latter procedure being used exclusively when the foreignbody lay in the anterior or posterior mediastinum.
The 37 foreign bodies classified as pleural either lay free in the pleuralcavity or were embedded superficially in the pulmonary diaphragmatic or parietalpleura and projected into the cavity. In many of these cases, removal waspossible through an intercostal incision, without the necessity for ribresection or rib division.
The foreign bodies removed from the deep structures of thethoracic wall involved the peripleural region, the ribs, the intercostalmuscles, and the root of the neck immediately adjacent to the dome of thepleura. Except for four cases in which the free pleura was inadvertentlyentered, all of these objects were approached through small, accurately placedincisions, for which careful preoperative roentgenologic studies had served asguide.
In the remaining 19 cases, 4 foreign bodies were removed fromthe diaphragm, in which they were completely embedded; 3 each from the liver andthe pericardium; 2 each from the pulmonary artery and the heart; 1 from thesubphrenic space; and 4 from the vertebral column.
Postoperative management followed standard practices. At first, penicillinwas used intrapleurally as well as parenterally. Later, only the parenteralroute was employed, since the intrapleural route was thought to increase thefrequency and size of postoperative effusion.
There were no pleural infections in the 318 operations inthis series, 255 of which were for the removal of intrathoracic foreign bodies.The single death was difficult to explain: A large foreign body, situatedposteriorly and superficially in the lung, was removed through a zone ofvisceroparietal adhesions, without entry into the free pleura. Eight hours afteroperation, while the patient was lying in bed watching a moving picture beingshown in the ward, he suddenly lost consciousness and developed jacksonianseizures involving the right arm and right leg. Death occurred 16 hours later.At autopsy, a cere-
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bral hemorrhage was found, the precise etiology of which could not bedetermined.
Comment
In general, indications for the removal of retained foreignbodies at the 155th General Hospital were conservative, a combination of size(not less than 1 cm. in diameter) and symptoms, of which pain was mostprominent. Objects less than 1 cm. in diameter were removed only if they werejagged or irregular or if they were located close to some vital structure andthere appeared to be danger of erosion because of mechanical factors orinfection.
As the war progressed and the maximum permissible period ofhospitalization was progressively reduced, certain patients who would previouslyhave been operated on overseas were returned to the Zone of Interior forsurgery. Such cases included those in which the foreign bodies were in, oradjacent to, the heart and great vessels, as well as those in the upper abdomenand in, or adjacent to, the liver. Since most patients with intrapulmonary andintrapleural foreign bodies could be returned to duty overseas within arelatively short time, the proportion of operations in these groups remainedfairly stationary throughout the war. Otherwise, operation was not done overseasunless the existence of suppuration or some other complication made theprocedure urgent.
References
1. Turner, G. Grey: A Bullet in the Heart for Twenty-three Years. Surgery9: 832-852, 1941.
2. Straus, R.: Pulmonary Embolism Caused by a Lead Bullet Following a GunshotWound of the Abdomen. Arch. Path. 33: 63-68, January 1942.
3. Paltauf, R.: Geschossembolie der Arteria pulmonalis. Wien. klin. Wchnschr.46: 602-603, 1933.
4. O'Neill, C. S.: Fragment of Shell in the Arterial Circulation. Brit. M.J.2: 719-720, 1 Dec. 1917.
5. Lyle, H. H. M.: Migration of Shell Fragment From Right Femoral Vein toRight Ventricle of Heart. Generalized Gas Bacillus Infection. J.A.M.A. 68: 539,17 Feb. 1917.
