Open chest wounds come in a variety of shapes and sizes. Their
one commonality is an open communication between the pleural space
and the external environment. The wounds have often been sealed
by the soft tissues of the chest wall in the vast majority of patients
with penetrating injuries to the chest. The primary concern with
these patients is the diagnosis and treatment of underlying thoracic,
cervical, or abdominal injuries. Rarely,
small perforations may produce a valve-like entry into the pleural
space, enabling air to be sucked in during inspiration but blocking
air egress during expiration. Thus air will continue to accumulate,
leading to a tension pneumothorax requiring needle decompression
followed by the tube thoracostomy. Larger, more destructive
wounds of the chest may also occur. These are most common in combat injuries.
In civilian practice they are often secondary to shotgun injuries.
The larger wounds are also caused by high-velocity weapons, explosions,
propeller injuries, or fencepost impalements, to name a few. Clothing,
wadding, shell fragments, and pieces of the chest wall may all be
driven into the thoracic cavity. Such injuries are associated with
physical loss of a portion of the chest wall itself, making adequate
ventilation impossible.1 These wounds are called open chest
wounds, open pneumothoraces, sucking chest wounds, and communicating
Wounds of the chest are described in the earliest of medical
documents, the Edwin Smith papyrus. This document dates from the
time of Imhotep (3000 b.c.). It contains
descriptions of 58 cases, 3 of which involved chest injuries per
se. One was actually an open chest wound, case number 40. The patient
sustained a penetrating injury to the anterior thorax through the
manubrium. Treatment consisted of binding the wound with fresh meat
on the first day and, later, with grease, honey, and lint.
During Greco-Roman times, open chest wounds were universally
fatal. In 362 b.c., Epaminondas was
wounded by a spear to the chest at the battle of Mantinea. Once
he discovered that the Thebans had been victorious, he pulled the
spear out, knowing that he would die.
Galen cared for chest wounds in gladiators. Treatment consisted
of a poultice and leaving the wound open. This treatment did not
change until the time of Theodoric, who advised the closing of chest
wounds. In 1267, he was quoted as saying, “The stitches
should be placed in accordance with the size of the wound so that
the natural heat cannot escape in any way nor the air outside be able
to enter.” His advice was not accepted by all. The master
military surgeon Paré left the wounds open for 2 to 3 days
to allow drainage of blood, after which he would close them.
During the Battle of Crecy in 1346, firearms and firearm injuries
were first introduced. In 1382, small guns were used against the
Venetians. Injuries from these weapons were documented in the chronicles
of these battles.