War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
At the commencement of the Second World War, due to the initiative of Professor Cairns and Mr. Tudor Edwards, special provision was made for the treatment of head and chest casualties, both in hospitals in the United Kingdom and in the theatres of war. Elaborately equipped mobile surgical units were organised with all the essential equipment for head and chest surgery, including instruments, appliances and theatre furniture, and special vans were built to house the equipment.page 196
The New Zealand Medical Corps did not have any special chest unit or surgeon, either in the forward areas or at the Base. A special unit was developed, however, in the Middle East Force by the RAMC and attached to one of the Cairo hospitals. British chest units were then developed as part of the staff of a base hospital in a similar way to orthopaedic units, and not, as at first constituted, as separate mobile field units.
It was the established policy of the 2 NZEF for all New Zealand patients to be treated in our own hospitals. As far as chest cases were concerned, we never arranged for our men to be treated in the British units, but we always availed ourselves of their advice and special knowledge, and our consultants and many senior officers paid frequent visits to the units.
The first experience of wounds of the chest as far as 2 NZEF was concerned were Australian casualties admitted to 2 NZ General Hospital during the first Libyan campaign in 1940. Then followed the campaigns in Greece and Crete, when the large majority of seriously wounded men were taken prisoner and so never reached our base hospitals.
Experience of war wounds had by that time been gained by surgeons in Britain in connection with the campaign on the Continent and the bombing of England, and also by the British and Australians in the MEF. It was soon realised that in the forward areas major operative procedures were impossible in the severe chest cases and unnecessary in the less severe injuries, which formed the large majority of the cases. Most deaths occurred in the first twenty-four hours and were due to the severity of the injury, and any treatment was unavailing. The cases demanding urgent treatment were the sucking wounds and the rare tension haemothorax. The sucking chest required immediate closure, and a firm pad, kept in place with strapping, was first tried as a first-aid treatment.
The British approach to gunshot chest injuries at the beginning of the war was an attempt to apply Cask's ideas of radical operative treatment in some cases, but with the realisation that more conservative treatment was indicated in the majority of the cases. Barrett reported that 40 per cent of his cases required immediate surgery for early excision of wounds, for bleeding, for sucking wounds, and for haemothorax with retained foreign body.
In the MEF a radical approach was never adopted, partly possibly because the conditions for forward surgery were unsuitable, partly because experienced chest surgeons were not available in the forward areas, and also because the first chest specialist from the outset adopted a conservative attitude. The NZEF hospitals, with no special chest surgeon, always employed conservative methods.page 197
The Australians had considerable experience of acute cases at Tobruk in 1940–41. Their treatment was markedly conservative and, apart from the early suture of the sucking chests, was largely concerned with early aspiration, and drainage for the relatively few cases of empyema. Chest cases were retained in the forward areas for seven to ten days. The removal of foreign bodies was carried out in their base hospitals if the foreign bodies were of sufficient size to warrant it, over half of them being removed.
During the second Libyan offensive in November 1941 the New Zealand Division had severe casualties, including many chest cases. At that time the vaseline pack was utilised for the early treatment of sucking wounds, and aspiration was carried out after forty-eight hours. Some cases which had been sutured in the forward areas were found to be very septic at the Base.
A swing-over from the more radical procedures of the First World War to a more conservative attitude was the most striking feature of the discussion at the Surgical Conference, Cairo, in 1942, on penetrating wounds of the chest. In haemothorax the general opinion expressed was that, although the ideal treatment was early aspiration with air replacement, under prevailing conditions the best procedure in forward areas was simple wound toilet only and evacuation, provided the Base was likely to be reached within a week. The great majority of patients with haemothorax did not exhibit dyspnoea at rest and travelled well. In a minority early aspiration was required. The risk of infection was greatly lessened by sulphonamide therapy along the line of evacuation, and by delaying aspiration until it could be done under the optimum conditions at the Base. Removal of intra-thoracic foreign bodies was rarely required in forward surgery; even for later removal the indications were probably few.
During the Battle of Alamein (23 October to 3 November 1942) observations showed that severe shock was frequently present in chest cases and that blood transfusion as well as tapping of the chest was almost routine in the serious cases, which often had to be retained in the CCS for forty-eight hours. Sucking wounds were dealt with by vaseline pack kept in position by a loose stitching of the skin after excision of the wound.
At the end of the Tunisian campaign it was again emphasized that the serious chest cases gave rise to much anxiety in the forward areas, showing great distress from respiratory and cardiac embarrassment. Aspiration frequently gave little relief, and blood transfusion was fraught with danger and was normally limited to one pint. These cases deteriorated seriously on shifting and had to be held in the forward areas. The light cases gave little trouble. A high incidence of infection was noted by the chest centre in Tripoli page 198 in cases tapped in the forward areas. The only cases demanding early surgery were large chest wounds, open sucking wounds, and occasionally bleeding from an intercostal artery. Aspiration was being done earlier and more frequently, air replacement still being carried out at the first aspiration, if done in the first twenty-four hours. Some surgeons, especially in the First Army, were urging the early frequent and thorough evacuation of all haemothoraces. A number of men recovered rapidly from large haemothoraces and were retained in the Middle East.
In Italy at the Sangro the serious cases were still a difficulty; repeated tapping was carried out and intercostal drainage for infected haemothorax was being used at the CCS. Penicillin then became available and was especially set aside for the chest cases. Infection had become more frequent and severe in the Italian campaign than it was in the Desert. Early and repeated aspiration, followed by the introduction of penicillin into the pleural cavity, then became the routine treatment of haemothorax. At the same time the necessity for careful excision of the chest wound, especially the sucking wound, was realised.
Much improved results were obtained during the Cassino battle following treatment by wound excision, penicillin, and early aspiration. The formation of fibrin clot in a small proportion of the cases gave rise to much thought at that time and the removal of the clot by decortication was practised by the chest units. A review of chest cases in the 2 NZEF was undertaken by the Consultant Surgeon at that time, and this brought out clearly the main problems and the results of treatment.
It was found that there was a mortality of 39 per cent and that over four-fifths of the deaths took place in the first: twenty-four hours. The large majority of the deaths were due to the severity of the injury and occurred during the initial stage of shock. Infection had become uncommon, very few cases requiring drainage of the chest.
At the end of the Italian campaign the treatment of chest cases had become stabilised as regards early treatment. The chest wounds, particularly the sucking wounds, were adequately excised and injured rib and foreign bodies removed from the wall and pleura. Suture of muscles closed the chest, and a pad was anchored by a few loose skin sutures. Penicillin was then instilled, no drain being used, but the chest kept dry by repeated aspiration. Blood transfusion was still limited in amount to replace actual blood loss and shock largely treated by rest, warm drinks, and the removal of fluid from the chest, the patient being nursed flat till the condition of the circulation warranted the sitting posture. The serious cases were held in the forward areas till the stormy initial crisis was over.page 199
The importance of respiratory exercises as a preventative and curative treatment of atelectasis and the patchy pneumonic changes that occurred in chest wounds was stressed and the exercises became a routine in these cases. The removal of foreign bodies at the base hospitals was carried out commonly from the seventh to the fourteenth day in about half the cases reaching the special centres. Decortication for clotted haemothorax was frequently done between the third and fourth week, though in our series only one patient required operation. Convalescence was accelerated by high protein and vitamin diet, and blood transfusion in anaemic cases.
In England similar measures were adopted and infection became much less common. Operating for foreign bodies was undertaken about six weeks after wounding, but in the presence of marked infection the operation was postponed until a sinus formed or several months after healing. Just as in our cases, clotted haemothorax had become uncommon following aspiration and penicillin. Morphia in moderate dosage was held to be beneficial, as was oxygen if efficiently administered.
Chest Wounds in 3 NZ Division
There were 20 cases of chest injury admitted to 2 NZ CCS, and in 9 of these grenade or mortar bomb fragments produced a haemothorax. No case of open or tension haemothorax was seen. Aspiration was not carried out before admission to the CCS, but this was done at the CCS and sometimes later at 4 General Hospital. Dark fluid blood, or less commonly blood-stained serous fluid, was withdrawn. Clotting or infection was not observed. At the time most casualties were received no X-rays were available at the CCS. In three cases metallic foreign bodies were removed at the base hospital. All cases recovered satisfactorily.
We now pass from the chronology of developments to a discussion of separate problems in the management of chest wounds.
Evacuation of Chest Cases from the Field
The evacuation of the severe chest casualty to the forward operating centre called for the gentlest of handling, as these cases were severely shocked and had both respiratory and cardiac distress. Breathing was relieved by slightly propping up the patient if his circulatory condition warranted this. Blood transfusion had to be given with the greatest caution unless serious external bleeding had been present. Moderate warmth and warm fluids were generally the only treatment necessary except attention to a sucking wound, which had to be adequately dealt with at the earliest possible moment. Lieutenant-Colonel Button observed that ‘chest cases on page 200 arrival at a CCS tended not to travel well by comparison with other types of injury. They frequently showed considerable dyspnoea and shock.’
The severe chest cases were generally suffering seriously from shock accentuated by respiratory distress. At times this was due to deep-seated injury of heart, main blood vessels, or of lung, and there was a heavy mortality among such cases on the battlefield. Moreover, wounded who survived to reach a medical unit were often suffering from such grave injury that they did not live much longer.
In our series of cases in Italy, 40 per cent of the deaths were brought in dead to a medical unit, and another 43 per cent died in the first twenty-four hours after admission, so that 83 per cent of deaths in those with chest wounds not buried on the battlefield died in the first twenty-four hours. Most of these cases had hopelessly severe injuries. Resuscitation was very difficult. If a sucking wound was present, its closure was of first importance. It was necessary as a rule to keep the patient lying down till the severe circulatory disturbance had subsided sufficiently to warrant sitting up for the relief of respiratory distress. Oxygen was administered when required in the serious cases by means of a BLB mask.
Transfusion of blood was indicated when definite blood loss had occurred, but there was some doubt as to whether blood was otherwise desirable, and many were of the opinion that any excess of transfusion above the amount of blood actually lost was definitely harmful to the patient. At first blood was given in quantity similar to that given to other shocked cases, but by the Alamein period it was realised that blood transfusion to any degree was fraught with danger and that normally only a pint should be given. Excess of transfused blood was held to be harmful and unnecessary, tending to put strain on the already overloaded heart and liable to overtax the pulmonary circulation. In blast injuries, particularly, blood transfusion was contra-indicated, and plasma or serum given in small quantities instead, along with general treatment by oxygen, rest, and morphia.
This was carried out in 22 per cent of our New Zealand cases. This consisted essentially in wound excision of the sucking and other large chest wounds with suture of muscle layers, but not of the skin. The lesser penetrating or perforating wounds were not operated on. Operation for other conditions was rarely performed by our New Zealand surgeons. At one time extensive operative procedures page 201 in the forward areas, such as Gask carried out in the First War, were practised by the Americans, but they found the mortality was high and the results did not warrant the continuance of the radical procedures. There were certain conditions, however, that did call for operation, such as:
Foreign Bodies in the Wound or in the Pleural Cavity contiguous to the Wound: Large foreign bodies in these situations often caused trouble through sepsis, and their removal was desirable. With X-ray examination the suitable cases could be chosen, but often the foreign bodies were located and removed during the treatment of the chest wound.
Bleeding from the Chest Wall: This arose most commonly from a damaged intercostal or internal mammary vessel, when bleeding would occur either externally into the wound or into the thorax, giving rise to respiratory distress and being unrelieved by aspiration. The presence of fresh blood on re-aspiration and general signs of blood loss pointed to continued bleeding. The vessel was exposed in the wound, removal of a portion of the rib being carried out if necessary.
Thoraco-abdominal operations have been dealt with elsewhere.
The Sucking Chest: This condition was for obvious reasons recognised right from the beginning of the war as one demanding urgent treatment. The serious respiratory and cardiac distress caused by the open chest made it imperative to close the hole at the earliest possible moment.
In Britain at the time of the Dunkirk withdrawal this was accomplished by means of a firm pad kept in place with strapping till such time as operative treatment could be undertaken. Excision of the wound and muscle and skin closure were carried out later in early cases and an intercostal drain inserted for thirty-six hours. In the case not seen for thirty-six hours a vaseline pad was strapped on and an intercostal tube inserted but no operation undertaken on the wound.
The Australians during the first Libyan campaign in 1940 considered the pads unsatisfactory and inefficient. They carried out immediate closure with a few deep silkworm stitches even at the RAP, and they continued the same treatment in the Pacific campaign.
During the second Libyan campaign in 1941 the New Zealand Divisional units utilised the vaseline pack. Some cases which had been sutured in the forward areas were found to be very septic page 202 on arrival at the Base. As a consequence of this, early suture was given up and the vaseline pad became the routine treatment, but better fixation was obtained by using skin sutures to anchor the pad. The progress of the wounds treated in this way was generally satisfactory, though some sepsis still occurred. It was then realised that the usual excision of the wound as applied to wounds elsewhere in the body was just as necessary in chest wounds if infection was to be prevented.
During the Alamein period in 1942 surgical toilet of the wounds was carried out and then a vaseline gauze pack applied and kept in place by sutures. Sepsis was then seldom troublesome and the wound was found to become rapidly sealed off in a few days.
It was reported by the NZ CCS at the Cassino period in 1944 that only 4 cases out of a series of 30 had become infected. Lieutenant-Colonel Button, NZMC, writing of his experience at the CCS at that time stated:
Sucking wounds of the chest required early operation to relieve distress. The wound was excised down to the ribs and the rib ends were trimmed. The haemothorax was emptied by suction. No attempt was made to remove the missile at this stage, unless X-rays showed it to be easily accessible. A stab wound was made in the dependent part of the pleural cavity and a self-retaining catheter introduced and clamped off. The wound in the chest wall was closed by the approximation of the soft tissues—a vaseline gauze dressing was then placed over the muscle layers and the skin approximated over this by one or two silkworm gut sutures. Penicillin, 15,000 units, was instilled into the pleural cavity daily for four days, or as necessary, following the aspiration of the haemothorax. The self-retaining catheter which allowed of closed drainage for forty-eight hours was removed after this time. With this technique these patients did well. The incidence of infection, pneumonitis and intra-pleural infection became minimal and re-expansion of the lung occurred early.
This treatment gave excellent results, and New Zealand forward surgeons then practised thorough excision of the sucking chest wound, followed by suture of the muscles and the application of a pad. Delayed primary suture was then performed as in the ordinary flesh wound. In wounds of the lower part of the chest suture of the pleura to the diaphragm was of value in closure of the chest. Sepsis was often associated with a sucking chest wound until, with the introduction of penicillin and the thorough excision of the wounds, it became infrequent. The immediate temporary closure of the wound by pad till the operation centre was reached was still an urgent matter.
Tension Pneumothorax: This condition, which can give rise to serious respiratory disturbance, was given great prominence in the early period of the war. Pneumothorax was caused by an injury to the lung by means of which a valvular action occurred and air page 203 was forced into the pleural cavity on inspiration. It proved, however, to be very uncommon and was of little importance.
In a review of 192 cases, including 44 thoraco-abdominals, in Italy, pneumothorax was mentioned in only 6 cases, and in none was it of any significance. It was recognised by the hyper-resonance of the chest and the absence of breath sounds associated with respiratory distress. Treatment consisted in needling with a wide-bored needle, generally in the second intercostal space, but sometimes in the sixth space in the axillary line.
Emphysema: This complication was not common and generally was not of much importance except when it was a sign of some deep-seated injury.
In the majority of cases the condition was of minor degree, but in New Zealand casualties in Italy 2 severe cases were seen, 1 dying from severe mediastinal injury. Altogether 9 cases were reported in the series of 192 in Italy. No special treatment was called for, and rapid absorption of the air took place.
Haemothorax: This was the most common complication of wounds of the chest and one normally calling for treatment. The treatment changed in some important aspects during the war. At first aspiration was carried out in the forward areas only when some respiratory embarrassment was present, and after an interval of forty-eight hours following wounding. It was thought that any earlier withdrawal of blood from the pleural cavity would lead to a recurrence of the bleeding. When the fluid was withdrawn air replacement was carried out so as to ensure the continued collapse of the lung, again to prevent further bleeding. Normally air replacement was done only at the first tapping. It was found, however, that recurrent bleeding did not take place unless there was present some special serious mediastinal injury, except from vessels in the chest wall, generally the intercostals, in which case the air replacement was useless. Then air replacement was used only to a small extent to relieve any distress occurring at the end of the aspiration of a large quantity of fluid. Finally no air replacement was done, and the aspiration was stopped for a few minutes if there was distress, or repeated the next day. It was also realised that early tapping did not give rise to fresh bleeding and that, in fact, fresh bleeding from the lung was very uncommon. Some surgeons, notably the Australians, were impressed by the desirability of early tapping of the haemothorax so as to permit of rapid expansion of the lung. There was some fear that this might lead to infection of the pleura, and Major Nicholson drew attention during the Tunisian campaign to the presence of infection in nearly 40 per cent of patients following tapping in the forward areas. Early aspiration, however, gained in popularity and was done earlier, page 204 especially in cases showing respiratory distress. The blood-taking sets combined with a Higginson's syringe proved very efficient for withdrawing blood from the chest. It was not only done early, even during the first twenty-four hours, but tapping was repeated till the chest became dry. The interval between the tapping was also reduced so as to bring about as quickly as possible the full expansion of the lung. Tapping every second or third day was commonly carried out and thorough evacuation was aimed at.
The advent of penicillin and its introduction into the pleural cavity brought about a marked change in the progress of this type of case and a very marked diminution in infection. It became the routine to introduce penicillin into the pleural cavity after each tapping. Early tapping was adopted in every haemothorax, and was repeated daily if the chest refilled. It was proved conclusively that no complication such as fresh bleeding followed the early tapping and that, on the contrary, the return of function to the lung and convalescence were much accelerated. Regular breathing exercises were instituted at an early stage to assist in the return of function. It was generally agreed that the routine of early and repeated aspiration led to a marked diminution of such complications as infection and clotted haemothorax, with their associated serious effects on lung function.
Atelectasis: This condition was given much thought during the war. The idea that the collapse of the lung was due to mechanical disturbance in the thorax by the presence of fluid or air in the pleural cavity was not considered the true explanation. It was commonly agreed that the condition was due to the presence of bronchial secretion producing obstruction in the bronchii and thereby leading to massive or localised collapsed areas in the lungs. Preventative treatment consisted in the care in operating in the presence of respiratory infection, in the preservation of a clear airway during anaesthesia, and in the suction of any excessive secretion through the bronchoscope. Active treatment by suction through the bronchoscope was held to be not very satisfactory, but all agreed that forced respiration was of great value. This was ensured by immediate regular deep-breathing exercises, especially following any anaesthesia, and by the encouragement of coughing. The relief of pain by the injection of local anaesthetic into the lower intercostal nerves facilitated both deep breathing and coughing. Major Hodgkiss, NZMC, at the Rome conference in 1945 said that atelec-tasis showed a high incidence and that catarrh of the upper respiratory tract and bronchial tube was very common in Italy even in summer, and tenacious mucous sputum was found in the mugs in the ward. To combat this he recommended light anaesthesia with quick recovery, and also the passage of a gum elastic catheter into page 205 the bronchial tube with suction at the end of the operation. Cyclopropane, if available, was the best anaesthetic. He advised regular movement of the patient in bed two to three times a day, lying him first on one side and then on the other, and then returning him to the sitting-up position. This facilitated the coughing up of sputum. In atelectasis more prolonged posturing was required to drain the bronchus. Intercostal anaesthesia was introduced when pain was preventing the effective coughing up of sputum. Expectorant mixtures were also given. Small doses of morphia were also helpful.
Major Nicholson, RAMC, found that regular aspiration of the bronchus at the end of late operations was unnecessary as little mucus was present.
Closed Injuries: The stove-in chest was treated by strapping the chest, and the blast injuries by oxygen, rest, and morphia.
Infection of the Wound
This was a common complication of chest wounds during the earlier part of the war, except in the small penetrating and perforating wounds, which generally healed up satisfactorily. The larger chest wounds were very prone to infection, especially the sucking wounds. This was partly because the urgent need of treatment was the closure of the hole in the chest and the risks of infection were not so obvious. The wounds were at first often sewn up or a pad strapped or sewn over the hole without surgical toilet. The wounds frequently became septic and suturing was given up. Later it was shown that careful excision of the wound was essential if sepsis was to be avoided, and that wounds in the chest, as elsewhere in the body, should not be sutured primarily.
Injuries to the ribs added to the risk, and careful trimming of the bone had to be undertaken. At first sulphonamides were used both locally and by mouth, and later penicillin was utilised locally and parenterally. Associated injury of the liver often led to infection of the wound.
Six cases in our series of New Zealand cases in Italy had wound sepsis:
One case had suture for a sucking wound at the RAP, and two days later the wound was again sucking and pouring pus.
Two cases, one of them being almost moribund at the time, were stitched up over a pack. One of these developed cellulitis in the wound and the other serious wound sepsis.
One had septic wound associated with a large foreign body in the pleura.
One had a chest wall abscess.
Infection of the Haemothorax
Infection of the haemothorax was very common during the First World War and also at the beginning of the Second World War. The Australians, however, reported a very low incidence following the first Libyan campaign and the defence of Tobruk. The incidence was still relatively low at the special chest centre in Cairo at the end of the second Libyan campaign early in 1942. A higher incidence was reported from the chest centre in Tripoli during the Tunisian campaign in 1943. In the early part of the Italian campaign infection was much more frequent, but with the introduction of penicillin a very marked improvement took place. In our New Zealand series of 148 cases rib resection was necessary in only 3 patients, an incidence of 2 per cent. All 3 cases were associated with sucking wounds. In no case was there any question of a chronic empyema or permanent non-expansion of the lung.
In a group of 44 thoraco-abdominal cases reviewed during the same period rib resection was carried out in 4 cases. Three of the cases had had sucking wounds and 2 had injuries of the liver. Foul fluid was present in the cases with liver injury and in 1 of the chest cases. The main factors in the production of sepsis in the pleural cavity were sucking chest wounds, associated wounds of the liver, and foreign bodies in the pleural cavity.
Mr. Tudor Edwards reported a low incidence of infection of 8.7 per cent in cases admitted from the north-west European front to chest centres in Britain. He considered that early aspiration had reduced the incidence of infection at the 1943 period and that penicillin had been responsible for the marked improvement in 1945.
The treatment of infected haemothorax depended on the severity of the infection and the time after wounding. In early cases with mild infection repeated tapping with instillation of penicillin was often successful. When infection was more marked and tapping unsuccessful, drainage was instituted. At first a Malecot catheter was introduced through a trocar and cannula between the ribs at the lower part of the chest, and the drainage made airtight by leading the tube under water. Penicillin, when it became available, was run in daily, the tube being clamped for six hours. This type of drainage proved satisfactory up to a period of ten days, when it was found that, if the infection still persisted, rib resection and ordinary tube drainage was necessary though still rendered airtight to prevent collapse of the lung, and attached at times to a suction apparatus. It was thought advisable to evacuate to the Base patients requiring drainage, and not to persist in the treatment in the forward areas. If repeated tapping did not bring page 207 about a rapid improvement, then the decision was made either to evacuate at once to the base hospital so that immediate drainage should be instituted there or, in the infection was serious, to introduce a Malecot catheter and then evacuate to the Base. Evacuation after rib resection was not so satisfactory.
Resection of rib at a dependent part of the chest was generally carried out at the base hospital and drainage continued till the cavity was obliterated. Loculation was very apt to take place, especially in cases of infected clotted haemothorax, and vigilant observation assisted by X-rays was necessary in these difficult cases, which were often gravely toxaemic. Such cases were rarely seen at the end of the war. If the infection was associated with a foreign body of any size removal was often undertaken early, especially if the foreign body was in the pleural cavity and of easy access. In the case of a chronic empyema, removal of the foreign body was postponed till the empyema had cleared up and a sinus only remained.
Sucking wound, patient almost moribund at forward operating centre. A pack was stitched on to the wound. Aspiration was carried out and 20 oz. of fluid removed—aspiration was subsequently repeated frequently, penicillin being instilled each time. A week later the rib ends were trimmed, the clot sucked out of the pleural cavity, and the wound closed with a superficial drain. Aspiration was continued. The wound became infected and a multilocular infected pleural collection developed. Rib resection was carried out, and tube drainage instituted posteriorally. Later a large anterior pocket was drained. Collapse of the lung was marked and expansion was slow, but eventually satisfactory expansion was assured before patient's evacuation to New Zealand.
Sucking wound sutured at the RAP though the wound was noted to be infected. Two days later again sucking and pouring pus. Wound was excised and sutured, but pyopneumothorax, as well as lobar pneumonia, developed. Rib resection and suction drainage was instituted, and the chest cleared up steadily. An acute gangrenous appendicitis necessitated appendectomy during convalescence.
[If penicillin had then been available, and had been given locally and parenterally, the case would undoubtedly have been saved from infection of this type. The suturing of the infected wound at the second operation was ill advised.]
Infection of the Lung: This was very rare. In our New Zealand series in Italy no such case was recorded. It was generally a late complication.
Anaerobic Infection: No case occurred in our New Zealand series nor were cases reported in the MEF or in Italy. The clinical diagnosis of this condition depended on a crimson purple colour of the chest fluid and the foul odour.page 208
Evacuation to the Base
The severe chest cases travelled badly and they also took a long time to recover from the initial injury. The minor cases without any respiratory distress, on the other hand, travelled well, and were shifted readily by air if the plane was kept at a low altitude.
Major D'Abreu, RAMC, stationed at Bari, was of the opinion that cases evacuated from the forward areas early (from second to eighth day) arrived in good condition if the first effects of shock, haemorrhage, open pneumothorax, and large haemothorax had been corrected by resuscitation, closure of the sucking wound, and aspiration of haemothorax fluid and air. On the other hand, those with infected pleural cavities, especially with septic open pneumothorax inadequately closed by dressings, travelled badly. It was noted by the Australians in New Guinea that cases travelled well during the first week, but not when infected. Air transport was very satisfactory, and even at 8000 feet no calamity occurred.
Major Hodgkiss, NZMC, on the other hand, thought that few of the serious cases could be evacuated in less than seven to ten days and that air evacuation of patients with a pneumothorax was dangerous at high altitudes. He considered that for that reason chest centres should not be too far removed from the forward areas. There was general agreement that the severe chest wounds go through a stormy initial crisis and must be held in the forward areas till this subsides. Those in the forward areas considered the bad cases should be held for from seven to ten days.
Here is a case illustrating the danger of early evacuation:
Operation was performed at the CCS for a chest wound and for fracture of the radius and ulna. The patient's condition appeared satisfactory and he was transferred by road to another CCS on the lines of communication. He developed a haemo-pneumo-thorax during transit and died of heart failure within 72 hours of wounding. Blast injury of the other lung was also present.
Operation was undertaken at the base hospitals, and at the special chest units stationed there, for infection, for clotted haemothorax, and for the removal of foreign bodies, as well as for the secondary suture of wounds.
In our series there were 13 cases subjected to late operation, 1 of these being for amputation of the thigh, leaving 12 for conditions associated with the chest:
Foreign bodies were removed from the lung in 2 cases.
Foreign bodies were removed from the chest wall in 2 cases.
Fibrin clot was removed in 1 case.
Wound suture was done in 4 cases.
Drainage was carried out in 3 cases.
In some of the haemothorax cases clotting occurred to a marked degree. This not only prevented the proper expansion of the lung, but also acted as a nidus for infection. The clot became organised and often formed a dense layer adherent to the pleura. Its presence was suspected when dullness and signs of pleural effusion were present, but tapping failed to draw off anything but very small quantities of fluid. X-rays showed density, generally of an irregular patchy type, with irregular air spaces. The cause of the clotting was not clear. At first infection was held not to be an important factor, but later this view changed and infection, especially by the staphylococcus, was often observed to be present. Other factors were also thought to be responsible.
Major Scadding, RAMC, and Major Nicholson reported 6 per cent of cases with clotted haemothorax in their series. They operated by a thoracotomy in the sixth space, removed the clot, and provided temporary drainage of the pleura through an intercostal stab drain. Major D'Abreu, RAMC, found that uninfected clotted haemothorax cleared up quickly, but when infection was present he either operated or instilled penicillin.
Nicholson operated on many of these cases in Italy and reported an incidence of 9 per cent. He stated that infection was present in three-quarters of his cases, the staphylococcus being the commonest organism.
The common type was multilocular with fibrin webs dividing the pleural cavity; rarely was there a solid haematoma. Clotting was twice as frequent on the right side, probably associated with wounds of the liver.
Nicholson favoured operative treatment to aspiration and the instillation of penicillin, so as to ensure lung expansion and to combat infection. He carried out decortication, stripping the fibrous layer from the visceral pleura so as to allow satisfactory expansion of the lung, which could be expanded by the anaesthetist.
Intercostal drainage was utilised for the first two to three days at the apex, at the anterior costo-phrenic angle, and at the base. The decortication facilitated the removal of lung foreign bodies and the suture of bronchial fistulae. It was considered that lung healing was aided by expansion, especially as the operation was usually carried out in the third or fourth week.
Major Nicholson considered that decortication involved no danger even when sepsis was present. He had had no infection in 30 out of 47 cases. Penicillin was given both locally and parenterally in all cases.page 210
Mr. Tudor Edwards considered that decortication should not be done if tears occurred in the lung, and that a small airtight intercostal tube should be inserted at operation. He reported that in cases admitted to chest centres in Britain from the North-Western European front 6 per cent had had operation for turning out clot and 5.5 per cent had had decortication.
In our series of cases in Italy (of 90 living cases) only 1 operation for decortication was carried out and in only 2 other cases was clotting suspected. All these cases cleared up satisfactorily. Observation also showed that in most haemothorax cases expansion of the lung had taken place in a remarkable manner.
The treatment of haemothorax in the latter stages of the war by early and repeated aspiration, combined with the instillation of penicillin into the pleural cavity, had undoubtedly markedly diminished the number of cases of clotted haemothorax, and in the absence of infection operation as a rule appeared to be unnecessary and expansion of the lung took place. In infected cases the clearance of the clot and drainage seemed to be desirable.
A typical case showing clotted haemothorax was recorded as follows:
An inspiration of 25 ozs. of fluid was followed by four negative aspirations (nil, few ccs., one 0z., a few ccs.). There was associated dense opacity of the base. In spite of this the condition gradually cleared up without operation.
The case operated on is of some interest:
Was first in a German CCS as prisoner of war, then in an Italian hospital, and then through an Italian civil hospital, and then on to a Polish hospital. He had a laparotomy performed by right Kocher's incision, and states that he had haematuria. He later developed dyspnoea and the chest was aspirated, 400 ccs. being removed on three occasions. Admitted to 3 NZ General Hospital six weeks after wounding and had 1200 ccs. removed (slightly infected). X-ray disclosed density to 5th rib. Thoracotomy was performed to remove fibrous clot. His progress afterwards was excellent. [It is probable that this was really a thoraco-abdominal injury involving liver and kidney.]
Interest was focused on the retained foreign bodies because of the history of complications following the First World War. There had been reported haemoptysis, some cases of bronchiectasis, and also of abscess of the lung. The large majority of retained foreign bodies, however, had given rise to no trouble, especially if they were relatively small and smooth. The general opinion at the beginning of the war was that all foreign bodies, if of any appreciable size, should if possible be removed, and the Australians page 211 in the MEF did remove all large foreign bodies in their base hospitals. The approach of the British special centres at that time was more conservative, and few foreign bodies were removed in Egypt in the early stages of the war. In Italy at the special centres foreign bodies were freely removed, and Major D'Abreu carried out removal of all accessible foreign bodies at an early stage, generally between the seventh and tenth day. All were in agreement that foreign bodies of more than 1 cm. in diameter present in the wound or in the pleural cavity should be removed, but there was no agreement with regard to the foreign bodies in the lung.
The necessity for the removal of large foreign bodies from the pleura is illustrated by the following case:
The patient had a large sucking wound and was gravely ill both at the MDS, where he was retained for some days, and at the CCS. An infection developed in the wound and drainage of the pleural cavity was carried out at the CCS, and he was then evacuated to the base hospital. He stood the journey badly and the infection became more marked. X-ray disclosed a large foreign body deep in the wound and it was removed from the pleural cavity, but he died of the severe prolonged infection from the pyo-pneumo-thorax.
In our New Zealand series of 90 lung cases, foreign bodies were removed in the forward areas in 4 cases and at the base in 4 cases, 2 from the lung, and 2 from the chest wall. There were 26 foreign bodies retained in the lung.
Major D'Abreu reported that he had removed just over half the missiles from the lung; all but one of the pleural missiles; just over half of those in the mediastinum and heart; and nearly all those in the mid-thoracic fascia. He removed them between the seventh and fourteenth day for two reasons: firstly, the severe physiological disturbances following the wound had ceased; and, secondly, the dangerous period of complications such as lung or pleural infection, organisation of haemothorax clot, and development of broncho-pleural fistulae had not yet arrived.
Radiological localisation and assessment were considered all-important and were carried out with the greatest care, and X-ray was taken on the day of operation as the foreign body tended to shift. Anaesthesia employed was pentothal induction followed by cyclopropane, but positive pressure and dilatation of the lung were not practised.
Excision of rib was preferred to intercostal incision and drainage was avoided whenever possible. Penicillin was utilised both parenterally for lung and chest wall infection and prophylaxis, and intrapleurally and locally for the same reasons.page 212
The usual incision employed was in the seventh or eighth space, with resection of ribs and incision of pleura, according to the site of the foreign body. Anterior thoracotomy by rib and costal cartilage resection, and subscapular approach through fourth interspace (and for pleural and superficial lung missiles a small intercostal incision) were often used. The lung was sutured with catgut after incision for removal of the foreign body, bleeding requiring ligation only being encountered twice. The chest was closed without drainage, unless gross pleural infection were present, and aspiration was carried out later. Pleural missiles, because of their tendency to produce infection, were removed as early as possible, and X-ray was necessary on the day of operation because of the tendency for the foreign body to shift.
If an empyema was present the pleural cavity was cleared of clot at the same time as the foreign body was removed. After all operations air was removed by an artificial pneumothorax apparatus.
For mediastinal and cardiac missiles the approach was generally extra-pleural, but if necessary the pleura was opened and left open to enable drainage to take place into the pleural cavity. No cardiac missile had been successfully removed, and Major D'Abreu considered that these cases should not be dealt with at that stage. There were several foreign bodies in the extra-pleural tissues, sometimes associated with fractured rib, and the rib fragments were resected at the same time, drainage being provided only in the case of large cavities. Finally, he considered that removal of the missiles was safer than leaving them in situ.
Mr. Tudor Edwards advised removal of foreign bodies over 1 cm. square about six weeks after wounding. In infected cases he advised leaving the foreign body, unless easily detected, until a sinus formed leading to it, or after a period of several months.
It would seem that an evaluation of cases with retained foreign bodies in the lung following the recent war will be necessary before we can decide whether removal of at least the smaller foreign bodies is justified. The relative absence of infection in the latter part of the war may determine that very little trouble will be caused by the retained missiles, and they can well be left alone. The larger and especially the irregular foreign bodies should be removed if this can be done with safety. (Up to 1952 little trouble had arisen in New Zealand cases from foreign bodies in the lung, as a survey later in this article shows.)
Wounds of the Heart
Wounds of the heart were very uncommon in cases living more than twenty-four hours, and in our cases consisted of small retained foreign bodies. Later in the war many foreign bodies were removed successfully, with a low mortality, in chest centres in England.page 213
The importance of X-rays in the diagnosis and control of chest cases cannot be overemphasized. In the forward areas at the CCS the knowledge obtained of the location of a retained foreign body and the condition of the chest as regards the presence of a pneumo-or haemothorax was very valuable, though operative measures were mainly required for the sucking chest, and the taking of an X-ray in this condition was generally contra-indicated. Later the treatment of the ordinary haemothorax was controlled by X-rays, and this was of special value in cases of clotted haemothorax. The removal of foreign bodies depended on their size and position in the chest, and very accurate X-ray films taken immediately prior to operation were essential to success in the operation.
The presence of atelectasis and patches of bruised lung was also demonstrated by X-rays. Clinical signs by themselves were apt to be very misleading in the estimation of chest pathology in the wounded cases.
The value of X-rays in the diagnosis of chest conditions was stressed by many during the war, especially the physicians. The site of needling was best determined by X-rays, the general tendency being to needle too low in the chest. Progress was best ascertained by repeated X-ray examination.
In the earlier period of the war sulphonamides were administered so as to combat infection both in the wound and pleura as well as in the lung. They were given by mouth and also applied to the wound. With the introduction of penicillin the sulphonamides were utilised only in special cases, such as a complicating pneumonia.
This was first used intra-muscularly in cases of chest infection, but with incomplete success, as the cases relapsed when the penicillin was stopped. It was then found that penicillin retained its potency, when injected into the pleural cavity, for twenty-four to forty-eight hours. This led to the suggestion that the early introduction of penicillin into the pleural cavity would tend to prevent the onset of infection in cases of haemothorax. Penicillin was therefore set aside at the beginning of the Italian campaign for this purpose and was thus used in casualties from the Sangro battle at the end of 1943. It was stated at that time that ‘the ideal treatment of haemothorax would be early tapping and complete emptying of the chest with instillations of sodium penicillin into the pleura at the end of tapping. Tapping should be repeated daily, page 214 if necessary, if the chest refills and penicillin again introduced.’ There had been some frequency and severity of infection noted during the early stages of the Italian campaign and this had focused the attention of surgeons on the early treatment of these cases.
The quantity introduced after each tapping was 30,000 units and this proved satisfactory, but doses of 60,000 units were also given. Penicillin was also used in the treatment of infected haemothorax. In early cases aspiration was performed, followed by penicillin instillation into the pleural cavity, and this process was repeated till the infection cleared up. When drainage was carried out penicillin was introduced daily through the tube, which was clamped for about six hours after the injection. Penicillin was introduced after any Operative procedure on the chest. Parenteral penicillin was also used in infection of the chest wall and to combat toxaemia. It undoubtedly was of great value and its use led to the marked reduction of infection.
Early in the war use was made of breathing exercises in the later treatment of lung injuries (to bring about expansion of the lung). As time went on more and more attention was paid to the exercises and special staff was set aside to ensure their regular and efficient performance. The realisation that atelectasis was due to the plugging of bronchii by secretion led to the institution of breathing exercises at an earlier stage as a preventative and curative treatment of this condition.
Coughing was also encouraged as the natural and most efficient method of getting rid of any retained bronchial secretion. In the abdominal cases also breathing exercises were early and regularly employed as a preventative of lung complications.
Colonel Boyd, Consulting Physician, 2 NZEF, drew attention to the variable degree of pulmonary contusion with parenchymatous haemorrhage and oedema and some tracheo-bronchial exudations in the majority of penetrating chest wounds. The Americans called the condition ‘wet lung’. Any pain impeding normal respiration caused shallowness of breathing and an increase in the condition of wetness, increasing the patient's distress and delaying the recovery from shock. The Americans relieved the condition by instituting intercostal blocks on the affected side, enabling the patient to breathe deeply without discomfort and to cough freely. Colonel Boyd considered that extra measures adopted by the Americans, such as the giving of large intravenous doses of atropine and intra-tracheal suction, would be rendered superfluous if the patient could breathe deeply and coughed up his secretions.page 215
Major Telling, RAMC, a physician, recommended at the Rome conference in 1945 breathing exercises for all cases, starting in forty-eight hours after the temperature had become normal in ordinary haemothorax and forty-eight hours after drainage in infected cases. After clean thoracotomy a start was made in twelve to eighteen days after operation, and a similar period was observed for large chest wounds. Immediate exercises were recommended in cases of pulmonary contusion and atelectasis. There was universal recognition of the importance of regular respiratory exercises, particularly in chest and abdominal conditions during the latter part of the war.
Blood and plasma transfusion was of value to counteract the loss of blood and the breakdown of body tissues. A high protein and vitamin diet with ample nourishment was also required to ensure adequate resistance to infection and rapid convalescence.
Our New Zealand force did not have any special chest centre, though chest cases were segregated to some degree and put under the charge of surgeons with most experience of these cases. At the CCS level the cases were, except for the actual surgical operation, placed under the charge of a physician, who controlled the after-treatment and arranged aspirations, breathing exercises, and any medical treatment required.
At the Base the chest cases were put under the charge of a surgeon with experience of chest surgery, who worked in association with a physician. The British chest centres were visited frequently by our consultants and senior surgeons and physicians, but normally we treated our own cases. The British centres were sited at the base hospitals, removed a considerable distance from the forward areas, though with air transport access was satisfactory.
Chest teams were not attached to the trinity of neurosurgical, facio-maxillary, and ophthalmic units which worked close behind the CCS. As forward surgery in chest cases was largely restricted to the treatment of the wounds, the closure of the sucking wound and the thoraco-abdominal cases, all of which could be satisfactorily done by the general surgeon, there seemed no necessity to send the special chest teams to the forward areas. Their best location would appear to be at a forward base hospital so as to shorten the line of evacuation, and this location was favoured by Mr. Tudor Edwards and other chest surgeons.
As far as a N'ew Zealand force is concerned, the attachment of a chest surgeon to the best-sited base hospital would be satisfactory.
A review was made of chest injuries in the 2 NZEF in Italy. This included all patients recorded in any medical unit whether admitted dead or alive, and so gives a clear picture of the severity of these injuries. There was a total of 148 patients with 58 deaths and 90 survivors, a death rate of 39 per cent.
Of the total cases:
|BID1 were||15.5||per cent.|
|Died in twenty-four hours||16.9||per cent.|
|Died in twenty-four to seventy-two hours||2.0||per cent.|
|Died after seventy-two hours||4.7||per cent.|
Of the total deaths:
|Died in twenty-four hours||43.1|
|Died in twenty-four to seventy-two hours||5.2||17.3||per cent|
|Died after seventy-two hours||12.1||per cent|
Location of deaths:
|In Field Ambulances||74.1||per cent.|
|In CCS||19.0||per cent.|
|In General Hospitals||6.9||per cent.|
Associated injuries were:
Foreign bodies retained in lung, 26.
Symptoms and Signs:
Shock was specially noted in 10 cases; of these it was severe in. 3 cases.
Distress was noted in 10 cases.
Blast was noted in 3 cases.
Haemoptysis noted in 26 cases; of these it was severe in 3 cases.
Emphysema, 7 cases; of these it was severe in 2 cases.
Pneumothorax was noted in 6 cases.
Bleeding was noted in 9 cases.
Sucking wounds were noted in 25 cases.
Haemothorax was aspirated in 60 cases.
Operation was carried out in 19 cases.
Aspiration was carried out in 60 cases.
Penicillin was used in 37 cases.
Sulphadiazine, 3 cases.
Foreign body removal, 4 cases.
Late: Late operation was carried out in 13 cases.
Foreign bodies were removed from lung in 2 cases. Foreign bodies were removed from chest wall in 2 cases.
Rib resection and drainage in 3 cases.
Sepsis was noted in the wound in 6 cases.
Sepsis was noted in the pleura in 5 cases.
Fibrin clot was noted as probable in 3 cases. (Operation was carried out in 1 case.)
Grading: The large majority were considered unfit for further service overseas; possibly in many cases this was too gloomy a prognosis.
Graded A, 14; B, 1; C, 2; D, 6; E, 64; unrecorded, 3: total, 90.
Associated with the series of chest cases recorded in our Force in Italy from November 1943 to August 1944, from which our data are derived, there were 44 thoraco-abdominal injuries. These are dealt with in the article on abdominal injuries. There were 21 deaths and 23 recoveries. If the chest and thoraco-abdominal cases were treated as one group, the thoraco-abdominals would constitute 23 per cent of the total. Twenty-seven of the thoraco-abdominals were operated on primarily; 4 had subsequent rib resection carried out for empyema.
Campaign in North-West Europe
Tudor Edwards gave details of 1683 casualties admitted to chest centres in Britain from North-West Europe. The great majority were treated by aspiration for haemothorax; the other less common treatments were for the removal of foreign body (15 per cent), turning out clot (6 per cent), decortication (5.5 per cent), and empyema (8.7 per cent). Deaths totalled 9, of which 5 occurred in a group of 251 earlier cases, and 4 in 1432 later cases.
|Series of cases, 1914–18||37||per cent.|
|Julian Smith (A), December 1941||63 cases||5||per cent.|
|King (A), December 1941||66 cases||3||per cent.|
|Logan (CC), Cairo, February 1942||49 cases||18||per cent.|
|Nicholson (CC), Tripoli, 1943||59 cases||30||per cent.|
|Button CCS, Cassino (NZ), 1944||34 cases||12||per cent.|
|D'Abreu (CC) Bari||260 cases||30||per cent.|
|Stout, Italy (NZ)-1944||148 total||2||per cent.|
|1944||90 living||3.3||per cent.|
|Tudor Edwards (CC), Britain 1944||1683 cases||8.7||per cent.|
A, Australian. CC, British chest centre. NZ, New Zealand.
It will be noted that the higher figures are from chest centres, where presumably all the serious cases were sent; most of the less serious cases went to the ordinary base hospitals. The Australian figures probably cover the same group and are from a base hospital. Button's figures are from our CCS at Cassino. Stout's figures cover all New Zealand cases in Italy from November 1943 to August 1944, the lower overall figure being due to most of the deaths occurring in the first twenty-four hours.
Multiple injuries were present in the majority of our cases; only one-third had injuries limited to the chest.
1 Brought in dead