History of chest trauma treatment


The oldest medical and scientific document known is the Edwin Smith Surgical Papyrus. This is thought to be an undated version of documents prepared by Imhotep around 3000 BC. Greek soldiers in the Trojan War, in the 1st century AD, were removed from the battle field and looked after in certain barracks or ships which seemed to be the earliest trauma centres. Valetudinaria had been established along the frontiers of the Roman Empire to treat legionaries who had suffered trauma.

With the development of more effective management of injuries, the concept of a flying hospital or ambulance volante was developed by Napoleon's army surgeons when it became obvious that rapid transfer, together with early active management, produced the best results. In terms of the historical management of chest injuries, it is interesting that De Chauliac, the "Father of Surgery", was surprised to see such paucity of literature in the management of chest injuries when he wrote his Chirurgia Magna in 1365. Only Hippocrates had mentioned the association of chest wall injuries and haemoptysis as a result usually of rib fracture.

The importance of pneumothorax and haemothorax was realized in the 18th Century and many devices were devised to suck wounds out of the chest, sometimes using the mouth of a specialist to use his own inspiration to suck air or fluid from that of the injured. Later devices such as the Arel Syringe were developed which certainly improved the hygiene of this technique. Although trocars had been developed, caution in the use of these instruments was urged as early as the 18th Century and it was felt, even then, that the insertion of a finger in a carefully made incision was preferable to introducing a sharp pointed trocar which may damage the lung and other intra-thoracic structures.

There has been much misinterpretation in recent literature as to the nature of contusions, but it is interesting that Morgagni refused to use the concept of contusion when it came to lung injury, even though he was familiar with it elsewhere in the body. He, rather wisely, described lacerations of the lung as the mode of injury in blunt chest wall damage. Perhaps if we had learnt from Morgagni we would not have gone through the cycle of attempting to treat lacerations of the lung with steroids and diuretics as we have in the past when the word "contusion" was loosely applied to such injuries.

Underwater seal systems owe their development to a series of English physicians, and flutter valves were also used in the American Civil War. The Heimlich valve was a successor of these early flutter valve and the more effective flutter valve incorporated in the 'Portex Emergency Chest Drainage Bag'(Trade mark Portex Ltd) is the ultimate outcome of many less effective systems which have undergone development. The first scientific description of the flutter valve was by R. McDonald in Dublin Quarterly of Medical Science in 1864. Since that time, however, the underwater seal has become the mainstay of safe drainage of the thorax.

Operations were carried out in the 19th Century notably by Dupuytren and Kafstein who were repairing major lacerations of the lung with early recovery and good outcome. At the outbreak of World War 1 there were few surgeons with wide experience in the management of chest trauma and it was felt that the best treatment for the vast majority of chest injuries was conservative. However, it was felt by medical specialists in all armies that an unnecessarily high mortality resulted when conservative management was used for virtually all injuries. Quite independently, Moynihan in the British Army, Sauerbruch in the German and Pierre Duval in the French Army decided that better results could be obtained if early thoracotomies were carried out for lung lacerations. At the time of such operations other injured areas of the thorax were actively treated and the mortality rates in these very ill patients treated in those primitive circumstances was less than 20%. These surgeons were undoubtedly brave, skilled and experienced and were therefore prepared to operate. Today however, less brave, less skilled and less experienced surgeons who are not familiar with the thorax on a day-to-day basis, and do not have large experience of thoracic injuries, may prefer to treat almost every thoracic injury conservatively.

Undoubtedly with improved diagnostic techniques, better training of intensivists and vastly superior monitoring devices, together with the advent of effective cardiac inotropic agents and antibiotics, conservative management of many thoracic injuries has become safer than it was even a few decades ago. Although only 15% of patients in the Vietnam War had thoracotomy for penetrating chest injuries, the trend throughout the war was from an early adherence to the dogma of conservative management to a later inclination towards more active intervention. In one centre, after the deaths of four young men who had pulmonary contusions following missile injury to the lung, it was decided that further patients with similar contusion, with or without other indications for thoracotomy, should in fact have exploration of the chest. The majority of patients in the subsequent group did not have other indications for thoracotomy and the mortality in this series was reduced to 11%, casting doubt on the adherence to conservative management in the first group (Fischer RP). The tendency towards active management of selected lung injuries where "contusion" was the main injury was noted by other medical teams in the Vietnam War.

More recently, as a result of the major conflict in Lebanon, Dr. Zacharia (Zakharia AT) and his colleagues carried out early thoracotomy in the majority of their patients with tube thoracostomy only being used in less than 30%. In those patients undergoing surgery, 22% required pulmonary resection. Only 2% of those patients undergoing thoracotomy for major injuries resulted in mortality. In Belfast in 300 consecutive admissions with major thoracic injuries, both penetrating and blunt, we have carried out thoracotomy within two hours of admission on 82% of penetrating gunshot wounds to the chest, 41% of stab wounds to the chest and 23% of blunt injuries to the chest. Of 90 patients who had thoracotomy for penetrating injuries of the lung, there was only one death. Overall, for 300 patients in our series, there were 11 deaths, giving an overall mortality of 3.6%.

Unfortunately, recent studies of outcome in trauma in the U.K. have emphasised avoidable causes of death due to intra-abdominal haemorrhage. Many patients with intra-thoracic injuries, which are the cause of inevitable death in the hands of the inexperienced who are not prepared to carry out thoracotomy early, may have their lives saved if they are admitted to specialist units with experienced thoracic surgeons. Equally good results are obtained when these patients are managed by surgeons who have less detailed thoracic training than we have been fortunate to have in Belfast, but who have immense experience in trauma surgery, as was seen in Lebanon and in Vietnam.