Dr. SHAW. When bone is struck by a high velocity missile it fragments and acts much like bowling pins when they are struck by a bowling ball--they fly in all directions.
Mr. SPECTER. Will you continue now and further describe the treatment which you performed?
Dr. SHAW. The bony fragments were removed along with all obviously damaged muscle. It was found that the fourth and fifth intercoastal muscle bundles were almost completely intact where the rib had been stripped out. There was damage to the latissimus dorsi muscle, but this was more in the way of laceration, so that the damage could be repaired by suture. The portion of parietal pleura which had not been torn by the injury was opened along the length of the resected, portion of the fifth rib. The jagged ends of the fifth rib were cleaned with a rongeur; approximately 200 cc. of clot and liquid blood was removed from the pleura cavity; inspection of the lung revealed that the middle lobe had a long tear which separated the lobe into approximately two equal segments. This tear extended up into the hilum of the lobe, but had not torn a major bronchus or a major blood vessel. The middle lobe was repaired with a running No. 3 O chromic gut approximating the tissue of the depths of the lobe, with two sutures, and then approximating the visceral pleura on both the medial and lateral surface with a running suture of the same material--same gut.
Upon repair of the lobe it expanded well upon pressure on the anesthetic bag with very little in the way of peripheral leak.
Attention was next turned to the lower lobe. There was a large hematoma in the anterior basal segment of the right lower lobe extending on into the median basal segment. At one point there was a laceration in the surface of the lobe approximating a centimeter in length, undoubtedly caused by one of the penetrating rib fragments. A single mattress suture No. 3 O chromic gut of an atromitac needle was used to close this laceration from which blood was oozing.
Next, the diaphragm and all parts of the right mediastinum was examined but no injury was found.
The portion of the drainage tube which had already been placed. in the second interspace in the anterior axillary line which protruded into the chest was cut away, since it was deemed to be longer than necessary. A second drainage tube was placed through a stab wound in the eighth interspace in the posterior axillary line and both of these tubes were connected to a water sealed bottle. The fourth and fifth intercoastal muscle bundles were then approximated with interrupted sutures of No. O chromic gut.
The remaining portion of the serratus anterior muscle was then approximated across the closure of the intercostal muscles. The laceration at the latissimus dorsi muscle was then approximated with No. O chromic guts suture. Before closing the skin and subcutaneous tissue a stab wound approximately 2 cm. in length was made near the lower tip of the right scapula and a latex rubber drain was drawn up through this stab wound to drain subscapular space. This drain was marked with a safety pin. The subcutaneous tissue was then closed with interrupted sutures of No. O chromic gut, inverting the knots. The skin was closed with interrupted vertical mattress sutures of black silk.
Attention was next turned to the wound of entrance. The skin surrounding the wound was removed in an elliptical fashion, enlarging the incision to approximately 3 cm. Examination of the depths of this wound reveal that the latissimus dorsi muscle alone was injured, and the latex rubber drain could be felt immediately below the laceration in the muscle. A single mattress suture was used to close the laceration in the muscle. The skin was then closed with interrupted vertical mattress sutures of black silk. The drainage tubes going into the pleura cavity were then secured with safety pins and adhesive tape and a dressing applied to the entire incision. This concluded the operation for the wound of the chest, and at this point Dr. Gregory and Dr. Shires entered the operating room to care for the wounds of the right wrist and left thigh.
Mr. SPECTER. What did you observe, Dr. Shaw, as to the wound of the right wrist?
Dr. SHAW. Well, I would have to say that my observations are probably not accurate. I knew that the wound of the wrist had fractured the lower end of