U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Discussion

Medical Science Publication No. 4, Volume 1

DISCUSSION

COLONEL AUGUST W. SPITTLER, MC

My observations on primary surgery as far as the Korean conflict is concerned were made on the casualties as they arrived at Walter Reed Army Hospital.

I do not disagree in general with any of the premises that Colonel Salyer and Captain Esslinger brought out but will elaborate a little on them. As far as the wounds in general are concerned, I cannot emphasize too much the importance of a thorough initial débridement. When an adequate débridement was done, a secondary closure was not as imperative at an early date as is often talked about. Although a closure on the fifth day or soon thereafter gives an ideal result, judgment on those closures must be good, as a closure of an infected wound is worse than not closing. When the débridement had been inadequate, closed or not closed, infection had spread up and down fascial planes. The patients, although afebrile (due to antibiotics) were weak, pale and anemic. Several severe hemorrhages occurred in them on removal of dressings.

Although extremity surgery seems simple, it is a source of our greatest morbidity and, in many cases, a preventable one if débridement is well carried out to include all devitalized tissue, entire muscle bellies that are deprived of blood supply if necessary, and foreign bodies. To sacrifice bone whether attached or detached is not necessary and makes reconstruction difficult. Bone chips are not dead tissue-they usually survive if given a clean bed to lie in, or at least provide a lattice work for new bone formation.

In the phased treatment of fractures, traction on a badly mangled extremity is not as important as actually holding the leg in alignment as there is little muscle spasm.

Either the half-ring splint or the plywood board splint is effective for initial phase. After débridement, plaster is still best. We have worked for some time in producing a lighter type of plaster using a resin mixture in the solution. Unfortunately, no casts made of this material were ever on our patients from Korea, although some was sent to Japan for that use. It is now available mixed in the bandage so that only water and catalyst need be added.

Remember, an arm only directs the hand. Position of the hand is important and it should be placed in a position of function.

In the leg-overpull is to be avoided. A slight shortening produces healing more rapidly.


402

Joint Injuries

Early débridement is essential with closure of capsule. I have seen some joint-injured patients arrive at Walter Reed Army Hospital, however, with synovial drainage from wound and no limitation in joint motion. Spontaneous closure occurred in a few weeks.

The Hand

There is no difference in the initial surgery of the hand from that of any other part.

Try not to sacrifice skin. You may need to tack it down. Do not make a tight closure.

Consider-filleting a useless finger to get soft parts to cover rest of hand. Try to cover tendon with soft parts.

Do not immobilize too long. Early function is important.

Cover with skin as soon as clean wound is assured. Skin from an abdominal flap or a split-thickness graft may be used at times.

More hands are ruined by complete prolonged immobilization than by early mobilization.

Amputation

Open amputation-so-called guillotine-is and will be the operation of choice for traumatized extremities.

Long skin flaps are not necessary if traction is applied and maintained. Long skin flaps may be retained to cover the condyles of the knee.

Dressing a guillotined stump with the changeable dressings outside of the stockinette is advocated.

Traction must be continuous until end of bone is covered.

A guillotine stump is easily converted and is often ready for fitting as soon as an originally closed one, as during the traction stage the adherence of muscles to the end of bone and the shrinkage desired is accomplished.

Four amputations which are now advocated by us are to be thought of in considering a primary amputation of any extremity:

    1. Syme-or modified ankle disarticulation.

    2. Knee disarticulation.

    3. Elbow disarticulation.

    4. Wrist disarticulation.

An open disarticulation can be done as easily as an above-the-joint open operation; it is now to be preferred.

In the ankle every effort should be made to save the heel pad as advocated in the first stage of our staged Syme amputation.


403

Internal Fixation

In the seriously comminuted fractures primary internal fixation is not to be considered. Early medullary nailing in communications zone hospitals in selected cases must be considered for evacuation as well as early return to duty, particularly if the initial débridement was good and effective in securing a clean wound.

Bone

No replacement is yet available as good as bone. Banked bone should still be considered for early use. Particularly the types that can be kept sterile at room temperature should be considered for early implantation even if for later reconstruction only. Bone is a living tissue.

Pearl Harbor experience-7 December 1941, Tripler Hospital where I was Chief of Surgery.

    Problem.

      Triage-All wanted to be this officer.
      Personalities-All wanted only to specialize.
      Shock wards were life savers although Honolulu's blood bank was most effective adjunct.
      Every doctor wanted to suture wounds. All had to be opened later.
      Sulfa drugs were effective.
      Records were poor-suggested personnel for this only.
      Identity of patients was hard to keep when stripped and unconscious and/or later died.
      Tape or wire recording of records now thought excellent method.