Ann Thorac Surg 2004;77:372-378
© 2004 The Society of Thoracic Surgeons
Our surgical heritage
Changing dogmas: history of development in treatment modalities of traumatic pneumothorax, hemothorax, and posttraumatic empyema thoracis
Thomas F. Molnar, MD, PhDa*,
Jochen Hasse, MD, Dscic,
Kumarasingham Jeyasingham, ChM, FRCSd,
Major Szilard Rendeki, MDb
a Department of Thoracic Surgery, University Medical School, Military Hospital, University of Pécs, Pécs, Hungary
b Department of Intensive Therapy, Military Hospital, University of Pécs, Pécs, Hungary
c Surgical Clinic, University Medical School, University of Freiburg, Freiburg, Germany
d Frenchay Hospital, Bristol, United Kingdom
* Address reprint requests to Dr Molnar, Department of Thoracic Surgery, University of Pécs, H-7633 Pécs, Ifjuság u., 13, Hungary
e-mail: mft{at}iseb.pote.hu
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Abstract
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Development of treatment modalities for chest wounds and traumatic empyema thoracis is reviewed in the light of war experience. Mortality from thoracic injury was more than 50% before World War I and was about 25% during World War I. It came down to 10% in World War II and was about 5% during the Korean War. It improved further during the Vietnam War, until it ranged at 2% to 4%, where no further improvement could be imagined. Thoracic surgery was born in the field hospitals of World War I. Established drainage methods and standardized anesthesia made thoracotomy a standard procedure in World War II. As experience increased in chest trauma, surgical aggression diminished. Drainage ruled primary chest trauma treatment algorithms during the Vietnam War and coexisted with the full arsenal of cardiothoracic surgery when it was needed. Optimization of thoracic surgical aggression includes a case-tailored approach when major chest surgery with or without interventions on the central cardiovascular system is needed. This is where we are now, provided a proper logistic, Medevac system exists. If we let the past fade away, the danger of committing the mistakes of our predecessors increases without having their excuses. Our present is only the past of the future.
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Introduction
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The aim of this review of the history of treatment of chest wounds and traumatic empyema thoracis is to highlight the changes in decision-making attitudes. Dogmas as rigid systems of ready-to-use answers represent a crystallized consensus based on broad experience that has become indisputable in the course of time. Mass experience collected in military conflicts has influenced surgical policies concerning pneumothorax, hemothorax, and (consecutive) empyema thoracis as well. A vast amount of cases in a short segment of time resulted in an enormously large experience. Papers reporting wartime medical experience differ from those of standard peacetime publications. Their common feature is a relatively high freedom from nonmedical influences. No factor other than the unquestionable patriotic will to contribute to the common aim of increasing the number of surviving fellow soldiers prevails. Both data collection and interpretation have to comply with the military environment. Strict hierarchy makes the system quite rigid. These negative features are counterbalanced by the lack of business-related economic interests and other bureaucratic aspects. The homogeneity of patient groups and treatment panels are secured. The different modalities are uniform at a maximum possible level so that important study criteria are spontaneously fulfilled.
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Ancient wars
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Lung injuries and attempts at their treatment are reported by Homer from the Trojan War [1]. Doctors in ancient Egypt attempted treating chest wounds as well [2]. Bitter experiences obviously limited surgical enthusiasm. Hippocrates laid down the basic principles of treatment for empyema thoracis, writing "ibi pus ubi evacua." Galenus and Celsus in the Roman age advised metal tubes in order to drain the empyema cavity [3], a teaching that ruled the Middle Ages (Fig 1).
Debate over the optimal form of evacuation, either by using tubes of different material or draining it through an opening, and applying a loose tampon in the window, bridges the teachings of the 14th century author Guy de Chauliac from Montpellier [4] and the US Army Empyema Committee headed by Ewart Graham [5] at the end of World War I. Barber-surgeons, frequently facing traumatic chest wounds (Fig 2)
and their consequences, refined the art of drainage [6]. Centuries passed by without further significant impact on the treatment of posttraumatic empyema.
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Fig 1. Monk probing a thoracic sinus. Note the midaxillary approach at the dependent point. Illustration from Chirurgia of Theodoric (late 13th century). (Reprinted from Rutkow IM, Surgery: An Illustrated History; 1993; 95, 146, with permission.)
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Fig 2. Military surgeon removes an arrow from a wounded soldier on the battlefield. Woodcut of Gersdorff, 1517. (Reprinted from Rutkow IM, Surgery: An Illustrated History; 1993; 95, 146, with permission.)
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Conflicts in the 19th century
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Military surgical practice in the Napoleonic Wars abandoned the previously mandatory practice of exploration and probing for projectiles entering the chest cavity. This approach left a 10% to 20% chance for survival in cases of thoracic injury. Larrey, chief surgeon to Napoleon, closed sucking chest wounds, which was against contemporary teachings, but increased survival [2] Application of rubber tubes and invention of syringe and needles in the mid 19th century were seemingly minor but extremely important factors in the development of chest surgery. Thoracic injuries remained a feared injury with good reason. The English Expeditionary Forces suffered an 80% in-hospital mortality rate [8] due to chest wounds in the Crimean War (1853 to 1856). Mortality of treated thoracic wounds in the US Civil War (1861 to 1865) was just more than 60% [8, 9]. The increased numbers of posttraumatic empyema revealed the risks of the closed treatment. In the Franco-Prussian war (1870 to 1871), the German losses due to chest injuries were reported just below 57% [9] At the battles at Sedan and Metz, French and English surgeons experienced similar outcomes [4]. In his 1896 textbook of thoracic surgery, Paget states that mortality is "probably not less than 60% of all chest wounds classed as penetrating, and much higher than this for actual gunshot wounds into the lung" [4]. In the era of the then newborn notions of asepsis and antisepsis, an age ruled by Lister, it was not only Billroth who felt sceptical about Bergmann's theory, born in the Russo-Turkish war in 1877 to 1878, stating that projectiles were sterile [6]. In the Boer war [1899 to 1901], the British mortality from chest wounds was as low as 14%. On the contrary, in the Balkan Wars (1911 to 1912), the overall thoracic wound mortality was about 40%. Apart from the effect of the local climate, the lack of proper field medical services and transport were responsible for the threefold difference. Basics of techniques like thoracentesis (tapping), drainage, fenestration, decortication, and thoracoplasty to cope with chest injury and complications were developed in the late 19th century [2, 3, 7]. Manipulations on the lung parenchyma were reported anecdotically since Rolandus, a war surgeon from the University of Salerno in the 13th century. However, safe and advisable procedures on the lung itself required the development of anesthesia and their integration into standard surgical procedures. This stage was not achieved until the 20th century. As a rule, simple dressing and a wait-and-see policy in the absolute majority of chest trauma resulted in surprisingly good outcomes before 1914.
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The Great War (1914 to 1918)
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Six percent of the 11 million war wounds suffered during World War I involved the chest [10]. In contrast to the overall mortality of 8%, chest wounds inflicted death in more than half of the cases, second only to that of the frequency for abdominal wounds (68%). Sauerbruch in 1914 counted 300 dead soldiers on a battlefield and found 122 (37%) who had gunshot wounds of the chest [11]. Overall mortality of chest wounds was 24% to 27% for the British Expeditionary Forces and the US Army [4, 8, 10]. Among those who arrived at a hospital with surgeons possessing expertise in chest wounds, mortality varied between 10% and 12%, in all armies of the war [10]. The main causes of death were bleeding and empyema. On the western front, the frequency of chest wounds in patients admitted to hospitals was about 3% to 3.5%. On the more mobile eastern front, this ratio was 10% to 13%. Shrapnel and other artillery pieces were more dangerous than penetrating small arms bullets. About 66% of all survivors after chest injury were those exposed to small arms fire [12]. Hospital mortality in cases of penetrating wounds did not exceed 12% [10, 12]. The first series published in 1914 to 1915 [5, 10, 11] recommended noninterference with closed pneumothorax. Open penetrating chest wounds and sucking wounds were temporarily closed by suture, but no tubes were advised according to English sources [13]. Military surgeons of the Axis powers followed similar rules, with the significant difference of leaving a chest tube on underwater seal, invented by von Bülau [14]. Immediate thoracic surgery was rather an exception and was indicated only in cases of major bleeding and uncontrollable pneumothorax, even as early as 1914 on the German side [11, 15]. No major surgeries with this indication took place before 1916 in the hospitals of the Allied forces [16]. Emergency thoracotomy and suture of parenchyma wounds were performed occasionally, even as early as in the first year of the war. Even positive-pressure ventillation was available sporadically [15, 17]. The majority of procedures were performed under local anesthesia [16]. The air collected in the pleural space was aspirated occasionally, as no drains were left behind after thoracotomy. Postoperative mortality was 9%. Moynihan preferred general anesthesia [12]. In the early phase of hositilites, the treatment of hemothorax was primarily and nearly exclusively conservative, the bedrest and "Priessnitz" method. Morphine was administered to cope with the pain and the feared coughing reflexes, an experience gained from the treatment of turberculosis. Emphasis was put on the erect body position of the patient. Patients with chest wounds were considered not transportable between the first and fifth days, for fear of rebleeding [10, 11, 17]. Robert Graves, the famous English writer, gives a vivid description of his personal experiences, when suffering blunt chest trauma in Flanders [18]. Immediate aspiration of noncomplicated hemothorax was discouraged. Advice varied from waiting for a week with evacuation, to frequent probe tappings [12] for fear of overlooking an undetected empyema, and the lack of experience with X-rays. Erosion and bleeding presenting 2 to 3 weeks later was another danger [19–22]. Tapping was indicated in cases with lung compression [10, 19] or heavily infected wounds [22]. Replacement with air after tapping (artificial pneumothorax), in order to prevent rebleeding, was generally advised [21, 23]. American authors discussed and condemned this practice, warning of the danger of empyema [10, 24]. About 1 in 10 hemothorax patients developed empyema [12, 17]. In one-third of cases hit by shell fragments, the injury resulted in pleural sepsis [25]. The standard procedure of empyema treatment consisted of resection of ribs, and loose tamponade of the hole stuffed with gauze, which was soaked with sublimate of mercury or iodine. Morphine and local cooling with ice completed the treatment. The overall hospital mortality was about 10%. Between 15% and 20% of posttraumatic empyema patients needed operations (aggressive rib resection and debridement), with a mortality varying between 20% and 50% [10, 12, 22]. Irrigation utilizing hydrogen peroxide or sodium hypochlorite, a solution prepared by Dakin [26] and popularized by Carrel, was also applied. Thoracoplasty and drainage of empyema by rib resection were standard methods. Whereas drainage and von Bülau's method were favored on the German and Austro-Hungarian side (Fig 3),
surgeons of the Allied forces preferred the policy of open treatment [12]. This dogma leading to pneumothorax resulted in rib resection for mainly streptococcal empyema in 1918 and was responsible for a mortality rate of 30% to 70%. The US Army's Empyema Commission [27] recommendations changed the treatment of empyema from early, sometimes prompt open treatment, to repeated aspirations followed by closed drainage. It resulted in a rapid fall in mortality to less than 15%. Apart from the pleural sepsis, contraction of the chest with mediastinal displacement, even in cases of uninfected hemothorax, have challanged pleural evacuation [24]. The idea of decortication [28, 29] saw a rebirth pioneered by Lilienthal (US Army) in cases of traumatic empyema [30]. Eggers also applied an aggressive treatment to improve pulmonary function and avoid thoracoplasty [31]. Fluoroscopy and microbiological examinations [32, 33] also contributed to the improving survivals. The experience in the Great War reduced fears and made thoracotomy a possible, performable, and relatively simple procedure. A good number of surgeons returned from the trenches with experiences of the capabilities of their own hands and of the lung to survive trauma and aggressive treatment. Their enthusiasm was generated by handling "otherwise normal lung," and was reflected by the increase in pulmonary surgery worldwide. Tuberculous lung was a different matter. Many surgeons had to share the sobering facts of outcomes that Roberts described as "what real thoracic pathology means" [34]. However, lessons learned dealing with lung parenchyma were not forgotten, and the need for parenchymal resection as a standard procedure persisted. From our present point of view, ignorance of the importance of intercostal tubes, the lack of standardized and reliable anesthetic techniques, and machines producing positive pressure were the greatest obstacles to further development of lung surgery. Lockwood, looking back 22 years later, recalled a statement by Lundy, the Senior Anesthesist at the Mayo Clinic, "Out the last war came chest surgery" [35]. In the interwar period, the Spanish Civil War emerged with the realization of the importance of blood transfusion and the logistics of organization rather than theory. Chest injuries were treated by paradigms ruled by conservativism. Bethune, the Canadian thoracic surgeon, understanding the importance of the supporting factors in the success of any operation, organized the blood bank system during the Spanish Civil War [36].
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Fig 3. Sucking wound treatment in the battlefield. Royal Hungarian Army, Russian, 1942. (Reprinted from the Photo Archive of The Institute and Museum of Hungarian Military History, Budapest, Hungary, with permission.)
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The Second World War (1939 to 1945)
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Mortal chest wounds were responsible for about 30% to 40% of immediate battlefield mortality in this war as well [4, 10] The other element of combat mortality from chest wounds, apart from those who were killed in action (primary mortality), are those who died of wounds later. The main causes of this secondary mortality remained early hemorrhage and suffocation, late bleeding, erosion, and infection. The overall mortality of thoracic wounds varied between 9% and 11% [4, 10, 37]. Six percent to 8% of all cases treated in field hospitals had suffered chest injuries in Europe [38]. In North Africa and in the Pacific theater [39], it was less frequent (3% to 4%). Chest surgery activity in the forward area was limited to closure of sucking wounds, hemostasis, and relief of tension pneumothorax in the English school [40]. Limitations on the battlefield were obvious, as is shown in a photo taken in 1942 (Fig 3). An underwater seal was part of the standard procedure in cases with sucking wounds (open pneumothorax) [41]. As an emergency procedure, a large-bore needle ending in a perforated finger of a rubber glove was advised. A rebirth of the World War I Thiersch method, using a holed condom or the inverted air-inlet valve from a transfusion set [42] was also applied. Intrapleural blood was considered a time bomb, requiring defusion by early removal. Few trusted in spontaneous absorption of hemothorax. The hypothetical tamponade function of clotted blood supported the conservative approach. The English experts agreed in tapping with replacement by air or oxygen [43]. Thoracotomy in the presence of shock to control the hemorrhage was discouraged. During the English desert warfare, of 2,500 battle casualties with chest wounds, no major surgery was performed in 1942. Empyema was seen in less than 5% of the cases. Sauerbruch and Zenker advised early thoracentesis [38, 44]. Aspiration to relieve parenchymal compression was limited to 500 to 1,000 mL. The peacetime experience of artificial pneumothorax treatment for tuberculosis reappeared in this war too [46]. It was to cope with the supposed danger of rebleeding as the hemothorax plugging the bleeding surface is removed. Some German and many American authors were opposed to artificial pneumothorax as a potential contributor to empyema [47]. Open drainage in the early stages of pleural infection was avoided [48]. As a new feature, respiratory exercises were begun within 48 hours after interventions, especially in the British practice [49]. Improvements in anesthesia [50], antimicrobial agents, and technical expertise [51] have modified surgical attitude towards an aggressive approach. Immediate exploratory thoracotomy for pleuropulmonary injuries increased in number until the middle of the war, but declined as experience gathered [52, 53]. The rate of septic infection of the hemothorax caused by penetrating/perforating injuries was around 20%, whereas in nonpenetrating injuries, it was just above 10% [24]. In general, pyopneumothorax developed in 13% to 18% of chest wounds [54]. Drainage and continuous suction was considered as ideal primary treatments [55], but lack of facilities led to a simple drainage in the majority of cases [13, 54]. Chest irrigation remained an advisable method [32, 56]. An eminent example of the positive impact on organization and the resulting concentration of thoracic surgical experience was seen in the North African campaign of the Allies. The experience gained by the Americans in Bizerta had proven again that chest wound in itself is not an indication for thoracotomy. Benefit of early decortication [57] was verified. Timing of the intervention is closely related to the question of logistics, which became A crucial element on a level never seen before [58]. The official German teaching required 14 days of rest before long-distance transport; others proposed 6 weeks [59, 60]. Outcomes of forward area lung surgeries were extremely poor, with some exceptions, when early operation and delayed transport were advised [61]. The use of novocain for intercostal blockade [71] in treatment of rib fracture and flail chest became standard practice on both sides [4, 62]. Importance of a proper general anesthesia was realized primarily on the Anglo-Saxon side in this conflict. Only the Americans possessed specially designed anesthetic models for thoracic surgery. The closed-circuit Beecher-type narcosis equipment was able to develop positive pressure without compressed air [50]. The importance of endotracheal intubation was strongly supported by the American experience. Bronchial secretions were removed by bronchoscopy or by catheter suction [60]. Closed-tube drainage of the chest with water seal after pneumothorax and intrapleural operations became standard as well [32, 59, 63]. Physiotherapy was integrated into the chest trauma treatment. Antibiotics like sulfonamides and penicillin in particular have changed the attitude towards primary wound treatment and of the empyema question as well [64, 65]. Organizations of large blood banks among the Western Allies have essentially improved surgical outcomes in our field as well. World War II, or better still, the aftermath of it, contributed to the development of thoracic surgical tools as well. Immediately after the war, Soviet advisers of different fields of economy, culture, and medicine arrived to the countries in the Zone of Control, Hungary included. Eminent Russian surgeons in this role, like Petrovski, became familiar with the extensive use of staplers, originally developed and patented for gastric surgery by Aladar Petz. This pathway of knowledge led to the staplers being known later as the Russian machines, a technique that made safe closure of the parenchyma tears possible as well.
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The Korean War (1951 to 1953)
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Accounts on human loss show that chest wounds were involved in about one-third to one-half of the total killed in the Korean War [66], not different from what Sauerbruch had seen half a century earlier. However, the mortality of thoracic wounds among treated patients fell to 5% [4] The late World War II experience has shown that early and repeated thoracentesis without air replacement is the proper choice. The clue to successful treatment is in securing total expansion of the lung at the earliest possible moment [66]. Decision on a thoracotomy was made easier as facilities and technical expertise were at hand at the base hospitals. This conflict also added new elements to thoracic surgery. An increased number of severely ill patients were alive at admission due to rapid evacuation. Highly specialized centers had the facilities and expertise to cope with complex situations [65]. A new generation of thoracic surgeons was born, ready and able to perform surgery on the heart as well. Their archetype was immortalized in the figure of Hawkeye, the thoracic surgeon in the film MASH. Thoracic surgeons in North Korea like the late Fred Kulka and other Middle European specialists contributed to development of thoracic surgery, on the not so lucky other side of the Iron Curtain as well. In the first period of this war, the frequency of empyema due to penetrating chest wounds was 25% to 30%, similar to the data in World War II. Later, it decreased to 9%, as the hemothorax was approached more aggressively [67]. Surgical decortication was liberally used and primary tube treatment was discouraged [68]. Antibiotics were quantum satis [32]. Enzymatic decortication had its rebirth as streptokinase and streptodornase, and methods to minimize interventional agressivity were applied intrapleurally [69, 70].
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The Vietnam War
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The mortality of chest wounds decreased significantly on the American side, due to a logistic provider system that was even greater than the contemporary civilian standards in the US [71]. Extensive lung contusions caused by high-velocity projectiles were approached by a more aggressive operative attitude in the later Vietnam period than in the earlier phase of the conflict [72]. On the other hand, the Korean lesson had been learned and tube thoracostomy regained its role in the treatment of hemothorax and traumatic pneumothorax. When major surgery was needed, nothing but the time factor seemed to be decisive [73]. Chest surgery was not a special challenge anymore, and the improvement of results did not originate in better surgical technique or indication. Empyema has remained a challenge, but the outcomes have become more favorable [74].
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Recent wars
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The Vietnam War experiences were applied to the wars in the Middle East as well. In the Six-Day War (1967) and in the Yom Kippur War (1973), more than 90% of the cases were treated by tube thoracostomy alone. These wars were fought with very short logistic routes, and the casualties were treated in circumstances not really different from their civilian counterparts, at least on the Israeli side. A ratio of 1:6 to 1:10 tube thoracostomy/thoracotomy ratio was reported in recent wars, such as the Iran-Iraq and the first Gulf War [75]. During the recent wars in the Balkans in the 1990s, the circumstances relating to the difficult terrain and the complex socio-economic background were different. The survival figures of more than 90% for thoracic injuries have reached a theoretical plateau, where no further improvement can be imagined [76].
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Conclusions
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Mortality from penetrating thoracic injury has changed considerably in the last century. Data are variable, but the trend is obvious. It was far above 50% before the World War I, and was about 25% at the commencement of World War II. It then came down to 10% during World War II, and was 5% in the Korean War [4]. The 5.6% mortality recorded during the Vietnam War was largerly accounted for by the 20% mortality of tracheo-bronchial injuries [71]. Most recently, in the Balkan War of 1991 to 1995, secondary mortality from chest wounds was about 2% [76].
Dogmas on the best possible treatment modalities of chest wounds and their sequelae such as empyema thoracis have changed several times during the wars reviewed. Where hemothorax is concerned, the pre–World War I policy of "noli me tangere" changed first. Evacuation of intrapleural blood/air became unquestionable. Tapping was the procedure advised. Air replacement based on civilian experience with poor expansion tuberculous lungs was considered necessary. The European schools favored tapping and drainage during World War II. "As experience increased in the management of penetrating chest trauma, the number of thoracotomies progressively decreased" [77]. In the US Army, the proportion of major surgeries for control of bleeding and to evacuate hemothorax increased in the late phase of World War II. This trend intensified on the United Nations' side of the Korean War, mainly due to the advent of more sophisticated anesthesia. It is interesting to see how dogmas influence and interfere with reality. As soon as early decortication became the preferred option, the decreased number of drainages led to the increasing number of candidates for operative evacuation. This vicious circle seemed to support the philosophy of discouraging drainage. In the Vietnam War, surgical aggression receded, and drainage regained its role in primary treatment. In the 1990s, antibiotics, computed tomography, and chest ultrasonograpy supported the conservative primary approach, without unnecessary delay of intervention. At the same time, cases requiring thoracotomy and major lung/tracheobronchial surgery with or without interventions on the central cardiovascular system are treated with maximal aggressivity. Empyema thoracis is best treated by prevention. This is a teaching that this survey of bygone experience reinforces. In the World War I, drainage of the chest cavity was connected with the resection of a short segment of rib. Tubing through the intercostal bundle was not considered, perhaps due to the overestimation of bitter experiences of injury to intercostal arteries. The dogma of transcostal approach lived long after World War I. Differences between a posttraumatic empyema and one of a tuberculous or nonspecific inflammation were not revealed. Drainage and irrigation as first-line treatment were established in World War II. In the management of traumatic empyema, we have no better modalities nowadays than what we had 100 years ago. What we do have is better survival after a given procedure that was invented by our forefathers, thanks to intensive therapy, better anesthesia, microbiology, antibiotics, and patient care. Highly individualized patient selection and case-tailored application of the full arsenal of contemporary cardiothoracic surgery is where we are now, provided a modern logistic system continues. History teaches us that surgery does not fit into minimax or maximin decision-making patterns. It is a question of optimization, where the agressivity of the intervention and timing must be adjusted to the individualized patient and the biological behavior of the given condition.
There are rules to follow and enough room for the exceptions. There is no present and therefore no future without the live pulsation and tactible presence of the past. If we do not look at the present as the past of the future, and let the past fade away, we are obliged to commit or repeat the failures and mistakes of our predecessors. [45]
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Acknowledgments
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The authors thank Veronika Marto, International Loan Service, University Medical Library, Pécs, Hungary, and Györgyi Kalavszky, Photoarchive of Institute and Museum of Hungarian Military History, Budapest, Hungary, for their invaluable assistance—without whom this work would never have been born.
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Abstract
Introduction
