Since 1958, a series of 112 patients with severe or moderately severe chest injuries have been treated. An aggressive policy has been adopted toward correcting or preventing major paradoxical chest wall movement by intramedullary pinning of ribs, costal cartilages, and the sternum. Whenever possible, positive-pressure mechanical ventilation and tracheostomy have been avoided. Fifty patients underwent stabilizing operations. The surgical approach was anterolateral in 12 (average 3.3 pins), posterolateral in 35 (average 6.8 pins), and midsternal in 3. Tracheostomy was performed in 8 of these 50 patients. Three died, on the first, third, and twenty-fifth days after injury. The tracheostomy was used only for aspiration of secretions in 3 others and for postoperative intermittent positive-pressure ventilation in 2 others. The duration of intermittent positive-pressure ventilation was 14 days and 1 day, respectively, Orotracheal intubation with positive-pressure mechanical ventilation after operation was required for more than a few hours in 3 patients, 1 of whom died. The 2 survivors were ventilated for 1 and 5 days. There was a total of 11 hospital deaths in these 50 cases. However, in 2 patients the severity of the initial injuries was thought to make death inevitable. Three of the patients who died were over 70 years of age. Operative stabilization permits avoidance or reduction in the duration of tracheostomy and mechanical ventilation. Permanent chest wall deformity is lessened or avoided.