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UNITED STATES ARMY FORCES IN THE FAR EAST 
OFFICE OF THE THEATER SURGEON 
APO 501 
7 May 1945 
TECHNICAL MEMORANDUM NO. 4 
TREATMENT CF THORACIC BOUNDS 
1. The treatment of chest wounds is directly concerned with mea- 
sures to restore a sudden disturbance in cardio-respiratory physiology 
and to control hemorrhage, having in mind at all times the prevention 
of infection and the prevention of the formation of organizing mas- 
sive blood clots which will prohibit later expansion of the lung. 
2. The three common chest wound emergencies are the sucking wound. 
tension pneumothorax, and hemorrhage. 
a. Sucking wounds. These require immediate closure by “ 
suture. Occlusive dressings with pads or adhesive plaster are not aia 
tight. When required by force of circumstance the pad should be 
posed of vaseline gauze and should be sutured in place. Is 
b. Tension pneumothorax is indicated by signs of increasing 
dyspnoea, engorgement of the neck veins and developing cyanosis. A 
single or repeated aspiration of air will usually suffice in treatment 
but occasionally a short beveled needle of about 15 gauge must be in- 
serted into the 2nd or 3rd interspace anteriorly and left in place with 
a tube attached leading to an underwater seal or to a finger cot flutter- 
valve . 
c. Hemorrhage. (l) Hemothorax is an almost invariable com- 
plication of gunshot or shrapnel wounds of the chest, find it may occur 
as a result of direct trauma to the chest wall without penetration. The 
bleeding is usually from vessels within the lung. Unless the amount of 
parenchyma destroyed is large or vessels near the hilum are involved, 
bleeding from damaged vessels within the pulmonary parenchyma leads, as 
.arule, to the relatively slow development of hemothorax. The inter- 
or internal mammary arteries are sometimes the source of the 
*HemorH^age. bhen one or more of these vessels are lacerated, the deve- 
hemothorax may be rapid and continuous. 
(2) The treatment of hemothorax has been the subject of 
uk&e controversy. Recent experience, however, has lead to the establish- 
ment oprcertain principles which are set forth in this memorandum and 
given as procedure cf* JEhls* tJaf*ate*. \ / 
INCLOSURii #11 (a) - aspiration. Early arftrfepeated aspiration of 
blood without air replacement is essential in the proper management of 
hemothorax. 
1. Immediate aspiration may be necessary-to ob- 
tain relief when the quantity of blood within the thorax is so great 
that the lung has been crowded and mediastinum embarrassment has 
occurred. 
2. Even without signs of such embarrassment, as- 
piration should be made within 24 to 48 hours after injury and repeated 
as soon as more blood accumulates because of the following reasons: 
a. The removal of blood will prevent the organi- 
zation of deposited fibrin on the pleural surfaces. If such organiza- 
tion is permitted, fibrothorax, with restricted respiratory excursions, 
will result. 
b. Aspiration of blood may prevent empyema or 
limit the extent of an empyema if it does occur, accumulated blood is a 
good nidus for bacterial growth, and the larger the quantity of blood 
the more extensive will be the empyema. 
c. The sooner a collapsed lung is re-expanded 
the easier and more certain the re-expansion will be. 
2. The urgency of aspiration is dictated by evi- 
dences of circulatory or respiratory embarrassment. Subsidence of acute 
symptoms is often obtained only by repeated aspirations, but it may be, 
in instances where bleeding is relatively slight, arrived at spontaneously. 
Even though the effusion is too small to produce symptoms, the blood 
should, nevertheless, be removed after 24 to US hours for the reasons 
stated above. 
4. Transfusion is a necessary adjunct to aspir- 
ation, and preparations for replacement of blood should be made prior 
to aspiration. The amount and frequency of transfusion can be deter- 
mined by the amount of blood removed from the pleural cavity, the amount 
apparently lost by external bleeding, and the condition of the patient. 
Karely in order to prevent recurrence of bleed- 
ing due to re-expansion of the lung it may be necessary to replace by air 
the blood which has been removed. Such air replacement, however, is not 
often necessary and seldom, if ever, after more than the first aspiration, 
6. Penicillin. After each aspiration 100,000 
units of penicillin in solution should be injected into the pleural cavity. 
7. Precautions. During aspirations the patient's 
condition shguld be watched carefully and if undue chest pain, rapid or 
irregular heart action, weakness or excessive sweating occur the procedure 
should be discontinued. It should be repeated on an early subsequent day. 
(b) Thoracotomy 
1. \»hen the hemothorax persists and the thorax 
refills rapidly with blood there is usually laceration of an intercostal 
or internal mammary artery, and this can be dealt with best by exposure 
and suture ligature of the vessel. 
2- 2. If EtBstAe pleural space 
continues and is not from the chest wall, open thoracotomy and suture of 
the lung, or if there has been very extensive damage, lobectomy will 
be needed. 
2. Large intrapleural foreign bodies or debris 
that is readily accessible may be removed by extension of the wound. 
Wounds of large bronchi or the intrathoracic 
portion of the trachea are repaired through a thoracotomy incision. 
3. Later complications in chest wounds include residual ’’clotted 
hemothorax'1 and empyema. These complications must be treated only by 
experienced general surgeons, familiar writh thoracic surgery. Patients 
with chest injuries should, therefore, be evacuated to general hospitals 
within the theater which are especially designated to treat chest in- 
juries just as soon as these patients can be safely transported. 
a. Clotted Hemothorax. The accumulation of massive clots of 
fibrin in the pleural cavity is suspected when clinical findings persist 
and only small amounts of blood can be withdrawn with the needle and if 
in addition, serial roentgenograms show no improvement during the 3d to 
6th weeks. In such cases thoracotomy is done for the removal of clots 
from the pleural cavity and the dense layer of fibrin from the under- 
lying lung. Early decortication in these cases permits normal expansion 
of the lung and prevents chronic empyema and other complications that 
lead to chronic disability. Penicillin is used both systemically and 
locally in the pleural cavity at the time of operation. 
b. Empyema. Empyema complicating hemothorax demands prompt 
surgical intervention by tidal drainage or rib resection, or, v;hen re- 
sponse from these methods of treatment is delayed and when the patient1s 
condition permits, radical thoracotomy with the evacuation of residual 
clots and decortication of the lung. The latter procedure should be 
performed preferably before the tenth week, because the surgical line of 
cleavage becomes obliterated after this time by organization of inflama- 
tory exudate. Systemic and local penicillin is used as an adjuvant. 
4. Other important measures in the treatment of chest wounds are: 
a. Bronchoscopic or catheter aspiration of blood and mucus 
from the tracheo-bronchial tree. 
b. Infiltration of the intercostal nerves with procain hycho- 
chloride solution for relief and chest-wall pain. This enables the patient 
to cough effectively and clear the air passages of blood secretions. 
c. Endotracheal oxygen-ether, administered through a closed 
apparatus capable of maintaining positive pressure, is the form of anes- 
thesia indicated in the operative management of penetrating and perfor- 
ating chest wounds. 
GUY B. DENIT, 
Brigadier General, United States array 
Theater Surgeon 
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