PART III
OBSERVATIONS ON WOUNDS AND DISEASES OF THE CHEST IN THE ZONE OF INTERIOR
CHAPTER IX
Management of the Sequelae of Combat-Incurred Wounds, Zone of Interior
Brian B. Blades, M.D., B. Noland Carter, M.D., and MichaelE. DeBakey, M.D.
STATUS OF RETURNING CASUALTIES
The mission of thoracic surgeons in Zone of Interiorhospitals as it related to combat-incurred wounds was twofold, (1)reconstructive surgery and (2) rehabilitation of the casualty. From the time thecasualty was wounded, the goal of management was the achievement of a completelyhealed wound and a fully functioning and expanded lung. When these objectiveshad been accomplished, the casualty was restored to the physical state in whichhe could perform the duties expected of a soldier returned to duty or couldcarry on as a civilian discharged from the Army.
Generally speaking, in all theaters, the status of returning casualtiesdepended upon a number of factors, including the character of their wounds andthe evacuation policy existing in the particular theater at the particular time,as well as upon the treatment they had received. During the last year of thewar, patients received in Zone of Interior hospitals from the Mediterranean andEuropean Theaters of Operations, U.S. Army, had usually been treateddefinitively at thoracic centers in Italy or the United Kingdom Base. Most ofthem had also had some form of reconditioning. By January 1945, from 70 to 75percent were surgically well when they reached the Zone of Interior. They werewell nourished and in excellent general condition. This had not been true ofthoracic casualties received in the first months of the war from the NorthAfrican Theater of Operations, U.S. Army, or for the first month or two of thecampaign in Western Europe.
With few exceptions, casualties received from the PacificOcean areas were never in as good condition as those received from othertheaters. Their state of nutrition and their general physical status wereusually considerably below the level of similar casualties received from theMediterranean and European theaters, and until the end of the war they presenteda relatively high incidence of hemothoracic empyema and other complications. Forthis state of affairs, there were three obvious explanations:
1. The environmental differences between the theaters (terrain, heat,disease, insects, fungous infections, and so forth.
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2. The longer timelag before initial wound surgery, which was frequentlyinevitable in the Pacific for logistic reasons.
3. The almost complete lack of experienced thoracic surgeons in all PacificOcean areas.
Casualties who required further treatment on their arrival inthe Zone of Interior included those with chronic hemothorax or hemothoracicempyema; retained foreign bodies; bronchopleural fistulas; and various defectsof the chest wall, including chronic draining sinuses. Those who required nofurther treatment either were ready for duty after evaluation of their generalphysical and thoracic status or were at the stage of recovery at whichdisposition would be possible after 2 or 3 months of reconditioning. Somereturned casualties had recovered from their chest injuries but had associatedinjuries, chiefly peripheral nerve or bone injuries, which prevented theirreturn to duty.
Disposition-Many casualties who were returnedto the Zone of Interior could have been sent back to duty overseas except forthe time limits imposed on their convalescence by theater holding policies. Hadthe war lasted longer, there is no doubt that many others who were evacuated tothe United States would have been kept in combat zones and returned to fullduty. An attitude of extreme caution concerning these casualties was adoptedearly in the war for several reasons: The initial severity of many wounds; therecollection of the poor physical and thoracic status of so many thoraciccasualties in World War I; and lack of experience with casualties managed undernew policies, which made medical officers uncertain about their ability toresume full military duty.
This attitude was apparent in the Zone of Interior as well asin oversea hospitals. In October 1943, Maj. (later Col.) Brian Blades, MC, headof the thoracic surgery service at Walter Reed General Hospital, Washington,D.C., wrote to Lt. Col. (later Col.) B. Noland Carter, MC, Chief, SurgeryBranch, Surgical Consultants Division, Office of The Surgeon General, that thedisposition of soldiers who had undergone lobectomy was creating somedifficulty. More than 50 such operations had been performed at Walter ReedGeneral Hospital during the past year, and about half of the patients hadalready been returned to duty. It was anticipated that many of the others wouldsoon be ready for disposition. Yet, in spite of the excellent results secured,disposition boards seemed to have a great deal of hesitancy in returning to dutymen who had had any sort of chest wound or disease, and line officers had acorresponding hesitancy in accepting them for service. The attitude grew moreliberal as the war progressed, but the original hesitancy concerning thesepatients never entirely disappeared.
CLINICAL CONSIDERATIONS
The management of the sequelae and residua of chest injuriesobserved in Zone of Interior hospitals was conducted on the same generalprinciples and practices as in oversea hospitals. For that reason, and tomaintain con-
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tinuity, most complications have been discussed in detail under specialheadings, including:
Hemothorax (p. 237).
Hemothoracic empyema (p. 272).
Retained foreign bodies (pp. 325 and 353).
Bronchopleural fistulas (p. 169).
Chest wall defects (p. 181).
Draining sinuses of the chest wall (p. 180).
Lung abscess (p. 175).
Hernia of the lung (p. 197).
Diaphragmatic hernia (p. 186).
Traumatic osteomyelitis (p. 179).
Only a few of these conditions need any further discussion from thestandpoint of their management in Zone of Interior hospitals.
ORGANIZING HEMOTHORAX
As a rule, more than 8 weeks had elapsed between their wounding and thereception of thoracic casualties in Zone of Interior hospitals. Mosthemothoraces that had been correctly treated originally therefore needed littleor no attention on their arrival. Figures from the chest center at the WalterReed General Hospital are typical: Of the first 107 casualties with hemothoraxreceived, 77 were in satisfactory condition, and in 24 of the remaining 30patients, the lung reexpanded satisfactorily after continued aspiration. This isan unusually high percentage of good results from conservative treatment aftersuch a timelag.
In the six remaining cases, however, an extensive organizing process hadoccurred, and four of them furnish interesting lessons concerning the propermanagement of hemothorax. All four wounds had been caused by rifle or machinegunbullets. All wounds were relatively minor as compared with most of the wounds inthe other 103 cases in the series, in all of which recovery was withoutcomplications. None of the four wounds had originally been of the sucking type.In no instance was the lung damage extensive. No patient had a history ofhemoptysis. In every instance, however, aspiration of the chest had beendelayed, apparently because the primary wound was not severe and becauserespirations were not immediately embarrassed. A single case history will serveas an illustration for them all:
Case 1-This patient, who had sustained a machinegun wound, had his firstaspiration 10 days after injury. The procedure was repeated several times, butthe largest amount of blood obtained at any aspiration was 180 centimeters.About 30 cc. of air was injected into the chest each time blood was removed.
When this patient was received at Walter Reed GeneralHospital several weeks after wounding, he was having daily low-grade temperatureelevations. He was extremely emaciated. The left chest was flattened, and theexpiratory excursion on this side was
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greatly limited. Thoracentesis yielded only a few cubic centimeters of dark,bloody fluid. It was necessary to open the chest, evacuate the organized clot,and decorticate the lung.
Comment-If this man had been treated originally by simple aspiration ofthe chest soon after wounding, he would probably have been saved weeks ofinvalidism and a second operation.
Policies of Management
Organizing hemothorax encountered in Zone of Interior hospitals was treatedby exploratory thoracotomy. An overlying rib was resected, the cavity was widelyopened by means of a rib spreader, and fluid and organized clots were evacuated.If careful inspection showed no need for further surgery, the chest was closedat once. If it showed that the lung could not reexpand because of the pathologicprocess present, decortication was performed.
Case 21-A commander of a tank company, wounded in action on12 July 1944, sustained a penetrating shell-fragment wound of the left chestwith a fracture of the eighth rib. Treatment overseas consisted of debridementand closure of the wound on the day of injury, supplemented by two laterthoracenteses. When the patient arrived at Halloran General Hospital, StatenIsland, N.Y., on 1 September 1944, roentgenograms of the chest (fig. 184A)showed an encapsulated hemothorax on the left side and a shell fragmentoverlying the seventh intercostal space near the vertebral column. Thoracotomy,performed on 30 October, revealed a cavity containing 150 cc. of old blood clotand a rigid fibrous membrane covering the adjacent portion of the lung. Theblood clot was evacuated and the limiting membrane removed, after which the lungwas reexpanded. Closure was effected without drainage. Removal of the shellfragment was not attempted. The lung was completely reexpanded on the 15thpostoperative day (fig. 184B), and the thoracotomy wound was completely healedat this time (fig. 184C).
Comment-This case history illustrates the successful management of asmall chronic hemothorax by decortication. The rigid limiting membrane revealedat thoracotomy contraindicated any other procedure.
Case 3-This soldier sustained a perforating wound of thechest on 29 March 1945; the shell fragment lodged in the soft tissues of theback, at the level of the second lumbar vertebra. No immediate effort was madeto aspirate the complicating hemothorax. When the patient reached HalloranGeneral Hospital almost 3 months later, examination showed contraction andmarked limitation of motion on the right side of the chest. Roentgenogramsshowed an encapsulated hemopneumothorax in the right axilla.
Because of an attack of malaria, the patient could not be operated on until21 July 1945. At this time, exploration revealed a cavity of approximately300-cc. volume, and a rigid fibrous membrane overlying the lung. The membranewas excised and the wound closed without drainage after the lung had beeninflated. The postoperative course was complicated by a second hemothorax, whichcould not be controlled by aspiration because the blood clotted so rapidly. Asecond decortication was therefore performed on 13 August, after the blood clothad been evacuated. The wound was closed temporarily with a silk and gauzetampon, which was left in place for 7 days. The cavity finally closed on 1December 1945.
Comment-The first operation on this casualty wasunsuccessful because the blood that had accumulated in the pleura had clottedand could not be removed by aspiration. This is a complication that is always arisk after pulmonary decortication. When post-
1This history and the subsequent case histories in this chapter concernpatients observed by Maj. Richmond L. Moore, MC, at Halloran General Hospital.
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FIGURE 184 (case 2).-Encapsulatedhemothorax managed by decortication. A. Posteroanterior roentgenogram of chestshowing encapsulated hemothorax on left and metallic fragment in seventh leftintercostal space near vertebral column. B. Same, 15 days after evacuation ofclot and decortication of lung. Note that lung is completely reexpanded. C.Photograph of patient on 15th postoperative day, showing primary healing ofwound.
operative oozing was profuse and difficult to control, as it was in thiscase, it was safer to establish and maintain some form of closed drainage untilthe lung had reexpanded and the pleural space was closed.
Case 4-A large encapsulated hemothorax on the right, with areas ofcalcification in the thickened membrane on the surface of the lung (fig. 185),was an unexpected finding in a soldier who was evacuated from the AleutianIslands in the spring of 1944. He had no history of a combat injury to hischest, but he stated that in August 1941 he had been knocked down by anautomobile. No roentgenograms of the chest were taken at that time. Operationwas recommended and refused.
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FIGURE 185 (case 4).-Traumatichemothorax. A. Posteroanterior roentgenogram of chest showing large encapsulatedhemothorax on right side. Note areas of calcification in thickened membrane onpulmonary surface. B. Lateral roentgenogram showing same findings.
HEMOTHORACIC EMPYEMA
Empyema, most often originating in an earlier hemothorax, was the mostfrequent complication of wounds of the chest observed in Zone of Interior chestcenters. It decreased in frequency as the war progressed, and it also decreasedin seriousness, at least in casualties received from the Mediterranean theaterand the European theater. The circumstances of the Pacific Ocean areas, asalready pointed out, were different and much more difficult. No matter from whattheater they were received, however, few patients reflected the effects of thechronic sepsis and general debilitation so typical of similar patients in WorldWar I.
Early in the war, there were many errors in the management of patients withempyema, including the basic error, failure to treat hemothorax by frequent andvigorous aspiration. In a few instances, initial surgery had beenultraconservative, and revision of the thoracotomy was necessary to provideadequate drainage. In most instances, simple revision, combined with intensivephysiotherapy, was sufficient, and complete obliteration of the cavity resulted.If additional surgery was necessary, the patient's general condition wasinvariably greatly benefited by the preliminary revision.
Also early in the war, an occasional patient was received with closedintercostal drainage in effect. This technique created serious problems duringtransportation, and drainage was never satisfactory. Later, practically allsurgeons overseas abandoned this method and treated empyema by dependent opendrainage.
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Still another error observed early in the war was theplacement of the drainage incision. In October 1943, Maj. (later Lt. Col.)William F. Hoyt, MC, reported from the chest center at Hammond General Hospital,Modesto, Calif., that almost all the patients with empyema received there fromoverseas had been drained anteriorly and their empyemas had become chronic.Major Blades, transmitting this information to Colonel Carter, stated that thesame error was being observed in casualties received at the Walter Reed GeneralHospital chest center. Reoperation was necessary in all such cases to establishadequate drainage.
The following case history illustrates initial errors of management that ledto chronic empyema:
Case 5.-This24-year-old soldier was struck by a machinegun bullet on 22 September 1944. Thebullet entered the left chest posteriorly, between the scapula and spine, andemerged anteriorly in the midclavicular line, about 2 inches below the clavicle.The lung was lacerated and the posterior portion of the fourth rib and theanterior portions of the second and third ribs were shattered. Both wounds weresutured about 30 minutes after injury. The next day, both wounds were reopenedand debrided, and the lung was sutured. Both wounds were then closed. After thisprocedure, the anterior wound became badly infected and a left empyemadeveloped.
When the patient was admitted to Halloran General Hospital on27 December 1944, he had lost 38 pounds (fig. 186). The left chest wascontracted and fixed. The anterior wound was still draining, and the opening inthe chest wall was large enough to show a large defect in the lung with multiplefistulas. A drainage tube entered a residual empyema at the site of a previousrib resection.
This casualty was transferred to another hospital fordefinitive treatment, and his subsequent course is not known.
Decortication
Generally speaking, if a well-drained empyema cavity showed no reduction involume after a period of 6 weeks, the patient was regarded as a candidate forsurgical intervention. The only reliable way of determining the volume of thecavity was by its accurate measurement with injected fluid. This test wasomitted only if the patient also had a bronchial fistula.
In the Mediterranean theater, where the operation wasintroduced in World War II, the optimum time for decortication for empyema wasconsidered to be within a range of 3 to 6 weeks after wounding (p. 286). Whenpatients with empyema were received in Zone of Interior hospitals, theirinfections had practically always become chronic, and the optimum time fordecortication had long since passed. As a matter of necessity, the time wasextended, and the results were remarkably good.
In 1945, for instance, 67 delayed decortications wereperformed for organizing hemothorax or chronic empyema at the chest center atFitzsimons General Hospital, Denver, Colo., with complete restoration of afunctioning lung in every instance; in some cases, the preoperative pulmonaryfunction on the affected side had been as little as 10 percent of the normal.This operation, however, when it was delayed, was not the universal answer tothe problem,
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FIGURE 186 (case 5).-Hemothoracicempyema managed by anterior drainage. A. Lateral view of casualty with wound ofleft chest 4 months after wounding, showing extreme degree of malnutrition, withcontraction of left chest. The anterior wound below the left clavicle is thepoint of exit of the bullet. The wound in the axilla is the site of the ribresection performed 3? months earlier; it leads into the dependent portion ofthe empyema cavity. B. Posterior view showing wound in left scapular regionwhich is point of entrance of bullet. This wound was completely healed 3 monthsafter wounding. Note the scoliosis secondary to the contraction and fixation ofthe left chest.
as is shown by the fact that at this center, over the same period, 51patients with chronic empyema required some type of thoracoplasty.
When decortication was performed weeks and months afterwounding, it was frequently difficult to separate the greatly thickened fibrousmembrane from the visceral parietes. Some modifications of the standardtechnique were therefore introduced. At Brooke General Hospital, San Antonio,Tex., the practice was to separate the membrane from the parietal surface as thefirst step of the operation. The thickened endothoracic fascia was dissecteddown to the line of reflection from the parietal to the visceral surface. Oncethis line was crossed, the adhesions were filmy and readily separated. The peelwas then freed from the apex to the diaphragm and anteriorly. After this part ofthe operation had been completed, the lung was reexpanded under positivepressure, and separation from the visceral pleura was accomplished by sharpdissection.
Patients who had undergone decortication overseas wereusually in good condition when they reached the Zone of Interior. If there wasany residual, it was usually no more than a small basal empyema, readilycorrected by open drainage.
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Other Procedures
If delayed decortication could not be carried out without too great risk ofdamage to pulmonary tissue, other procedures had to be employed. Internalpneumonolysis was frequently used at the chest center at the Walter Reed GeneralHospital. The operation began with resection of a rib, followed by wideexposure of the entire empyema cavity, as in decortication. If inspection showedthat decortication was not practical, the fibroblastic membrane was incisedaround the periphery of the empyema cavity. Then the incision was carriedthrough the membrane at the juncture of the parietal and visceral portions. Thevisceral portion was left adherent to the underlying lung, which was cautiouslyfreed from the involved portion of the chest, preferably by bluntdissection with the gloved fingertip or with a dissecting sponge. After the lunghad been freed, it was reexpanded by positive pressure (not more than 10 cm. H2O).As a rule, the empyema cavity was promptly obliterated bythis maneuver. Closure was accomplished as in decortication. This operation,which is not a deforming procedure, frequently obviated the necessity forthoracoplasty, which is a deforming procedure.
Physical Therapy
A competent physiotherapist, with special training in theproblems of chest conditions, was of great help in the accomplishment of maximumreexpansion of the lung and in overcoming the chest wall deformities commonlyseen in chronic empyema and other chest conditions (vol. I).
RETAINED FOREIGN BODIES
It is unfortunate that the Foreign Body Registry, proposed inthe 1944-45 report of the Surgical Consultants Division, Office of The SurgeonGeneral, was not instituted, so that permanent records could have been kept oncasualties with foreign bodies left in situ. The presumedinnocuousness of these objects could then have been established or disproved.The extremely valuable followup information secured by the Peripheral NerveRegistry illustrates what a similar project might have accomplished in thoracicinjuries.
Indications for Removal
The indications for removal of foreign bodies in Zone ofInterior hospitals were essentially the same as in oversea hospitals. Theyincluded their size, their shape (irregularity), the symptoms and signsreferable to them, and psychosomatic indications.
Hemoptysis was infrequent. It was observed only twice at the Walter ReedGeneral Hospital chest center and was equally uncommon at other chest centers.Pain, which was the most frequent symptom, was often difficult to evaluate. Ifthe object was peripheral and lay on either the pleural or the
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diaphragmatic surface, there was little doubt that it wasresponsible for the complaint, and its removal was advised. Retained missileswere removed in a considerable number of instances, however, in which there wasgenuine doubt as to the relation between their presence and the patient'scomplaint of pain, though there was no doubt at all that until psychosomaticdifficulties were thus ended, these men would not again be useful soldiers.
The attitude in Zone of Interior hospitals toward retainedforeign bodies was, in general, extremely conservative. Of the first 30casualties in this category received at the Walter Reed General Hospital chestcenter, 16 were operated on, 12 because of the size of the objects or because ofclear-cut evidence of their responsibility for signs and symptoms, and 4 forpsychosomatic reasons. The proportion at other centers was about the same. AtFitzsimons General Hospital, for instance, only 68 foreign bodies were removedfrom the lung during the entire period of its operation; these were chiefly highexplosive shell fragments. In 19 other cases, foreign bodies were removed fromthe chest wall.
Localization Techniques
In addition to routine techniques of localization (p. 332),certain adjunct techniques were used at the various chest centers. All of thecenters found the Berman locator of much supplemental value when foreign bodieswere deeply embedded in the parenchyma of the lung or in the mediastinum. Itcould be used to explore any cavity that could be entered surgically. A constantvibratory sound was heard when the tip of the probe approached, or came intocontact with, a retained magnetic object, the volume varying directly with thedistance between the object and the probe.
Some surgeons employed a visual-radiopaque technique. A fewcubic centimeters of methylene blue or gentian violet were mixed with Lipiodoland injected into the chest wall at the point at which the object was nearest tothe surface. Routine roentgenograms were then taken.
The angiocardiographic technique employed at the Walter Reed General Hospitalchest center was devised by Lt. Col. George P. Robb, MC, chief of thecardiovascular section. This technique, which was used for the accuratelocalization of foreign bodies in intimate contact with vessels in themediastinum, was carried out in three steps:
1. The circulation time from the arm to the tongue wasdetermined by the injection of a solution of Decholin (dehydrocholic acid) andthe accurate measurement, by a stopwatch, of the lapsed time between theinjection and the patient's report of a bitter taste.
2. The lapsed time was determined between the injection of a solution ofether into the arm and its detection on the patient's breath.
3. After these time factors had been determined, the patient was positionedbetween a stereoscopic cassette, and angiocardiograms were obtained after theintravenous injection of a concentrated solution of Diodrast (iodopyracet). Thisradiopaque agent, instead of disseminating immediately in the vascular
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system, forms a bolus which can be followed from the point ofinjection through the cardiovascular system until it is broken up in theperipheral vessels. By evaluation of the previously determined circulation time,the approximate time of opacification of the intrathoracic cardiovascular systemcould be determined. Separate roentgenograms were made showing contrast fillingof the right ventricle and pulmonary arterial tree, the left ventricle andaorta, the right auricle and superior vena cava, and the left auricle andpulmonary veins. With this information, which was usually remarkably precise, itwas often possible to determine almost exactly the location of mediastinalforeign bodies in relation to the cardiovascular system in the mediastinum.
Case Reports
Case 6.-A21-year-old soldier, struck in the right chest by a machinegun bullet on 28 July1943, made an uneventful recovery. The wound healed satisfactorily, and acomplicating hemothorax cleared without aspiration. He had no symptoms referableto his chest until June 1944, when he coughed up a small amount of bright redblood. Another hemoptysis occurred in September. When the patient was admittedto Halloran General Hospital shortly after the second hemoptysis, he was in goodgeneral condition (fig. 187A).
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FIGURE 188 (case 7).-Retainedforeign body without symptoms. A. Posteroanterior roentgenogram of chest 10weeks after wounding, showing large metallic fragment in left chest at level oftenth dorsal vertebra. Another smaller fragment is seen outside the chest cavityin the axillary tissues. B. Lateral roentgenogram taken at the same time,showing the posterior location of the larger fragment.
Roentgenograms (fig. 187B and C) showed a.25-caliber bullet situated posteriorly on the right side, at the level of thetenth intercostal space. Roentgenograms made after the instillation of Lipiodolshowed no evidence of bronchiectasis.
The bullet was removed on 13 October 1944. The space which itoccupied, which communicated freely with the bronchial tree, contained a smallamount of necrotic material, culture of which revealed hemolytic Staphylococcusaureus. Convalescence was satisfactory except for a small empyema, whichhealed rapidly after resection and drainage.
Comment.-Asthis case demonstrates, a foreign body may be embedded in the lung for manymonths before it causes symptoms. The patient's history suggests that thehemoptyses which finally occurred were secondary to the staphylococcicinfection.
Case 7.-Thissoldier received multiple penetrating wounds of the left chest on 28 July 1944.On 30 July, all wounds were debrided and several readily accessible foreignbodies were removed. When he arrived at Halloran General Hospital on 9 October,he was pale and weak and showed evidence of considerable weight loss. Thetemperature was 103?F., the pulse 120, and the respirations 30. Thered blood cell count was 2,270,000 per cu. mm. and the white blood cell count3,900 per cubic millimeters. The hemoglobin (Sahli) was 7.5 gm. percent.Roentgenograms of the chest (fig. 188) showed a metallic fragment, about 2 by 3cm., in the posterior portion of the left lung at the level of the tenth dorsalvertebra.
Treatment consisted of penicillin, repeated bloodtransfusions, and vitamin therapy. A subcutaneous abscess in the left scapularregion was drained on 19 October 1944, and 3 pieces of woolen shirt wereevacuated with 25 cc. of purulent fluid. Culture of the exudate showed Bacilluscoli and nonhemolytic Staph. aureus. After drainage of the abscess,the temperature quickly fell to normal, and convalescence was satisfactoryexcept for an attack of malaria, which responded well to Atabrine (quinacrinehydrochloride). By the middle of November, the patient had gained 19 pounds, andhis red blood cells had risen to 4,870,000 per cubic millimeters. The time wasconsidered optimum for removal of the fragment from the left lung, but since hehad now become transportable, he had to be reported to the hospital registrarfor transfer to another institution for definitive care.
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FIGURE 189 (case 8).-Retainedforeign body without clinical manifestations. A. Posteroanterior roentgenogramabout 6? months after wounding, showing metallic shell fragment in right upperlung field. B. Photograph taken at operation 4 months later. The shell fragmentcan be seen deeply embedded in the lung. C. Photograph of patient 10 days afteroperation, showing surgical wound over second right interspace.
Comment.-Thiscase is an example of the retention of a metallic foreign body in the lung formany months without symptoms. It also shows the ineffectiveness of penicillin incontrolling a suppurative process associated with tissue damage and retainedforeign material when the causative organism is not susceptible to it. In thiscase, it was the fragments of cloth, and not the metallic foreign body, thatwere responsible for the infection.
Case 8.-Thispatient, when struck by a shell fragment on 7 November 1944, sustained apenetrating wound in the right supraclavicular region. Recovery was rapid, andthere were no complaints referable to the chest. When he reached HalloranGeneral Hospital, in May 1945, he was in excellent condition and had nocomplaints. Roentgenograms of the chest (fig. 189A) showed a shell fragment inthe right upper lobe of the lung and a healed fracture of the right second rib.The fragment was removed in September 1945 (fig. 189B). Cultures taken from thecavity which it occupied revealed nonhemolytic Streptococcus andnonhemolytic Staph. aureus. Penicillin was given postoperatively. Healingwas uneventful (fig. 189C) except for a small pleural effusion that clearedwithout aspiration.
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Comment.-Thiscase history is another illustration of the retention of a metallic foreign bodyin the substance of the lung for many months without symptoms. The fact thatthis man did not develop a postoperative empyema, in view of the organismspresent, is probably to be explained by the use of penicillin.
CHEST WALL DEFECTS
The incidence of serious defects of the chest wall in casualties received in Zone of Interior hospitals was remarkably low, especially in comparison with the much larger proportion of such defects observed in the fewer thoracic casualties of World War I. There were several explanations for the low incidence:
1. The excellent emergency care these casualties received.
2. The low incidence of wound infections, due to the adequacy of debridement at initial wound surgery. The extensive infections and massive sloughing wounds so frequent in World War I were scarcely ever observed in World War II, in spite of the greater destructiveness of World War II weapons.
3. The practice of delayed primary wound closure in fixed hospitals overseas.
4. The supplemental use of the sulfonamides and later of penicillin.
It was usually possible to effect satisfactory repair of chest wall defects by the use of regional tissues; that is, the bones, muscles, fascia, subcutaneous tissue, and skin of the chest. Split-thickness skin grafts were frequently used, and pedicle grafts were used as necessary. In the few instances in which tantalum plates were employed to bridge the defect, the results were disastrous. The plate acted as a foreign body, and if it did not slough out of itself, it had to be removed at a secondary operation.
DRAINING SINUSES OF THE CHEST WALL
The draining sinuses of the chest wall encountered in Zone of Interior hospitals were due to the same causes as those observed overseas; that is, injuries to the costal cartilages (with subsequent infection), retained foreign bodies and other foreign material, unwisely selected suture material, and unwise suture techniques. Infections of the cartilages and unwisely selected suture material were the chief causes; they accounted for most of the 62 draining sinuses treated at the Fitzsimons General Hospital chest center. Associated empyema was surprisingly infrequent, probably as the result of the generally excellent initial treatment of the chest wound.
The principle of management of draining sinuses was removal of the offending material, whether it was necrotic bone and cartilage, foreign material, or suture material. Since all of these wounds were infected, primary closure was seldom successful. On the other hand, there were two objections to leaving the wounds open to heal by granulation. The first was the long convalescence inevitable under this plan. The second was the tendency of
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granulation tissue to contract, with resultant exposure of the cut edges ofpreviously healthy rib or cartilage.
The most satisfactory technique of repair was as follows: Thesinus tracts were fully exposed, with due care to preserve as much healthy skinas possible. The affected cartilages were excised down to healthy tissue, andall foreign material, including sutures, was removed. The wound was then dressedwith petrolatum-impregnated gauze and left open. As a rule, clean granulationswere observed in 4 to 7 days. As soon as they were evident, the wound surfacewas covered with a split-thickness skin graft. This simple technique usuallyresulted in prompt healing and greatly reduced the period of hospitalizationrequired when more complicated techniques were used.
ASSOCIATED WOUNDS
Associated wounds in patients with thoracic injuries referredto chest centers were most often regional fractures and regional nerve injuries.Many ribs were splintered and many scapulas shattered by missiles, and somesurgeons thought that such injuries accounted for more residual pain thanordinary fractures. Major Hoyt, at Halloran General Hospital, had the impressionthat casualties with such fractures took a considerable time to regain theirmental equilibrium. Many of them referred repeatedly to the difficulty inbreathing they had experienced soon after injury. When hemoptysis was added tothe respiratory embarrassment, the experience seemed particularly frightening.These patients required a great deal of individual attention, and their physicalrecovery progressed more rapidly as their mental status improved.
A number of chest wounds were complicated by nerve injuries,particularly injuries of the brachial plexus. The position at wounding accountedfor these injuries. If the soldier was crawling forward on his hands and knees,or was advancing in a bent over position, the supraclavicular area was presentedas a target. The entering missile fractured the clavicle and emerged between thescapula and spine or the scapula and ribs. The location of the wound was suchthat the brachial plexus was implicated in it, and partial paralysis of the armand hand resulted. Many of these patients had to be transferred to neurosurgicalcenters for treatment after their thoracic injuries were completely healed.
