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Appendix

Contents

APPENDIX

Pertinent Circular Letters

HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 512

15 MAY 1943

CIRCULAR LETTER NO. 13

MEMORANDA ON FORWARD SURGERY

1. Surgical Echelons.
  a.  The welfare of the patient and the tactical necessity for rapid evacuation demand a clear understanding of the function or mission of each unit of the Army Medical Corps. This is best arrived at by dividing the treatment of a casualty into two stages--primary and definitive. Separate groups of units provide each stage of treatment. In general, the equipment of each group is designed for that purpose only.
  b.  Stations of the first and second echelons--Aid Stations, Collecting Stations and Clearing Stations are equipped and staffed for the primary phase of treatment. Arrest of hemorrhage, splinting of the injury, resuscitation measures needed to make the patient transportable and administration of sulfonamides are the urgent functions of these stations. In addition, the treatment of minor injuries that allow immediate return to duty is carried out without evacuation. A Clearing Station is not designed to provide definitive treatment of battle casualties.
  c.  During combat, especially with long distances in evacuation to the rear, Surgical Teams are attached to certain Clearing Stations. It is their function to give emergency surgical treatment to selected cases requiring immediate operation. This treatment would not otherwise be available in this echelon. The lack of facilities for pre-operative X-ray examination and for post-operative care of adequate duration place a grave responsibility on the surgeon in the selection of cases for surgery. These same limitations exist during quiet times. The length of the evacuation line to the next echelon and changing tactical conditions require frequent redefinition of the surgery undertaken in the clearing station.


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  d.  It must be remembered that the lightly wounded soldier, or a casualty due to accident may regain full combat status within the Theater if proper surgical treatment is carried out, but the Theater may be deprived of his service by faulty surgical judgment. Because a surgical procedure appears simple is not sufficient reason for performing it in a Clearing Station unless the man can be returned to immediate duty without evacuation to the rear.
  e.  Hospitals of the third echelon (Evacuation Hospitals) are designed to initiate definitive surgical treatment to battle casualties. The more delay there is before reaching this echelon and the more hands the patient passes through in reaching it, the poorer will be the final result. The evacuation line is not an assembly line in which each surgeon does his bit to the patient. It is a conveyance line along the course of which the progress of the patient may be halted to save life or limb or render him transportable.
  f.  While Evacuation Hospitals are adequately equipped and staffed to perform rehabilitation operations, it is not the function for which they were designed. Even in quiet times these patients are evacuated to the fourth echelon for operation unless the Commanding Officer assumes full responsibility based on a knowledge of the existing tactical situation as well as the surgical aspects of the individual case.

2.  Surgical Procedures.
  a.  Dressings: Ideally, the primary phase of treatment is completed in the first unit reached that is equipped to provide it. The dressing is then left undisturbed until the patient reaches an Evacuation Hospital for operation. There are certain safeguards and adjustments that must take place enroute, but these do not include inspection of the wound by removal of the dressing unless definite indications are present. A compound fracture is halted at the Clearing Station for more adequate immobilization or resuscitation, but this need not involve redressing the wound unless there is reason to arrest continuing hemorrhage. A wound is not redressed solely for the purpose of reapplying local sulfonamide. Oral administration is sufficient safeguard.
  b.  The same principles apply after operation has been completed and the patient is being evacuated to the rear.
  c.  Uninformed hands do unnecessary dressings. The best safeguard for the patient is an adequate and legible record that accompanies him. A receiving officer is then in a position to refer to the record instead of looking at the wound. Many wounds after debridement and arrival at the base can be closed by secondary suture. Infection arising from contamination at the time dressings are changed makes this impossible.
  d.  Wound Management: Common mistakes in war surgery are: (1) Suture of wounds. (2) Tight Plugging by Packs . Hemorrhage is controlled by a stitch ligature if from a large vessel. Otherwise, by a temporary pack, elevation and firm pressure. If a pack is left in a wound make a note that it should be removed at the first opportunity. Vaseline gauze is laid loosely in a wound, not packed in. (3) Failure to Immobilize Site of Injury. Large wounds


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are immobilized even though fracture has not occurred. (4) Overexcision of skin. Circular defects are slow to heal. Very little skin need be excised, and in some instances none at all. (5) Failure to Open Deep Spaces during definitive treatment by freely incising fascial planes.

*  *  *  *  *  *  *

  p.  Compound Fractures
: It is essential to distinguish splinting applied for a limited time as a transportation splint from apparatus or splinting designed for reduction and prolonged or rigid immobilization. An adequate transportation splint prevents additional soft part injury and further deformity. It cannot in itself cause nerve injury, pressure sores, or jeopardize the circulation of the extremity. It. provides adequate fixation for ambulance transport over rough roads, but may not secure the fragments in rigid fixation or exert the traction necessary for further reduction.
  q.  Plaster Casts: A more liberal use of plaster of paris casting is urged. Plaster casings or slabs applied as temporary transportation splints are padded and either bivalved or completely split. Encircling bandages and cotton rolling under the cast are also split as it soon becomes inflexible with dry blood or serum. Plaster casings applied directly to the skin are rarely found advisable in forward areas. If a skin plaster is applied for a definite indication, bony prominences are padded and the cast is immediately split in its full length. No encircling bandages or adhesive strips are placed under a plaster.
(1) All plaster casts applied in forward areas should be split or bivalved as soon as sufficiently dry.
  r.  Skeletal Traction
: There is no indication for the use of skeletal traction or skeletal fixation in conjunction with transportation splinting in the forward area.
  s.  Internal Fixation: The use of bone plates or screws is not recommended in stations forward of an Evacuation Hospital.
  t.  Humerus: Skin traction, skeletal traction and high abduction spica plasters or splinting are not only uncomfortable but dangerous transportation methods. A hanging plaster is unsuitable for transportation purposes. A simple U plaster slab running from the affected shoulder over the anterior aspect of the forearm amid upward to the axilla is usually sufficient. The wrist is supported by a bandage sling. Following definitive surgery, the same type of splinting may be used for further transport, or a carefully applied spica with limited abduction (30° - 35°) may be used.
  u.  Femur: Traction applied by a clove hitch, ankle bracelet or through the boot is not advisable for longer than six hours. This type of traction should be changed to skin traction at the Clearing Station.
  v.  Attention is drawn to the Tobruk transportation splint highly recommended by the R. A. M. C. reports from the Middle East. Medical Officers  should  familiar with the design and methods of application of this splint and a more frequent use is suggested.


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  w.  If a plaster spica is used the extremity is fixed in slight abduction and care taken to see that the upper part of the cast does not impinge on the costal margin. If the other leg is not tied into the spica, and it rarely need be, the plaster casing is extended well above the costal margin with fenestration provided for the abdomen.
  x.  Spica casting for either the upper or lower extremity must be well applied with adequate padding to avoid discomfort and pressure sores during transportation. These complications as well as easier application have led to the development of the Tobruk splint.
  y Amputation:  In military surgery an amputation is a two-stage operation--the first stage performed in the overseas theater, the final stage, if necessary, in the Zone of the Interior.
(1) The circular type Guillotine is the amputation of choice. The indications for primary amputation are control of hemorrhage, destruction of circulation, removal of irreparably destroyed extremity and as a step in the debridement of a traumatic amputation. The site of primary amputation is the lowest possible level of viable tissues regardless of the eventual utility of the stump so formed.
(2)  Delayed amputation is performed for circulatory insufficiency, infection, gas gangrene in which more conservative measures have been inadequate or in the judgment of the surgeon will be inadequate, and uncontrollable secondary hemorrhage. The site of secondary amputation is determined by the  judgment of the surgeon with respect to preservation of maximum bone length.
(3)  Sulfanilamide is dusted on the end of the stump and vaseline gauze dressing applied. Skin traction is applied on the operating table and continued until the stump is healed. All lower leg amputations are splinted with a posterior slab to prevent flexion deformity of the knee. The splint extends below the level of time stump. Transport in ½ ring Thomas splint with support of the stump and continued skin traction.
(4)  Adhesive plaster traction is recommended in the forward areas where a bulky dressing may be desirable. Stockinette applied with skin glue may be substituted at the base. Adhesive plaster traction strips must extend to the edge of the incised skin and be anchored by two circular strips. They should not extend upward beyond the base of the limb.
(5)  Secondary closure of amputation stumps is not recommended.
  z.  Peripheral Vascular Insufficiency :  Following wounds that jeopardize the blood supply of an extremity  transport beyond an Evacuation Hospital is delayed until the collateral circulation has been demonstrated adequate or until amputation has been performed. Immobilization for transport, or the additional trauma and shock incident to transport may be a determining factor in producing gangrene.


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(1)  Principles guiding treatment of a limb with defective circulation are as follows: (1) Immediate restoration of blood volume with plasma supplemented by whole blood transfusion to establish normal oxygen carrying capacity of the blood. (2) Prevention of loss of body heat by dry woolen coverings for body and limbs. (3) Do not ligate a major artery in continuity. Divide the vessel between ligatures. (4) Ligate and divide the companion vein. (5) The extremity supplied by the divided vessel should not be elevated but slightly depressed. Wrap in wool or cotton. Do not directly heat.
(2) To stimulate the development of collateral circulation the following measures are recommended: (1) Heat the body (not the limb) under a cradle. (2) Novocain block of sympathetic chain repeated daily if necessary. (3) Under special circumstances, sympathectomy. (4) Vasodilating drugs are of questionable efficacy. (5) Passive vascular exercises. (6) Incision of deep fascia planes if a tense hematoma is present.
(3)  Arterial spasm may be encountered when a missile passes close to an artery or there is an adjacent fracture. There is no external bleeding or hematoma. The limb is cold, numb and muscle action lost. Peripheral pulses are absent. There is no pain in contrast to occlusion of the artery by an embolus.
(4)  Peripheral pulses return in a few days as color amid warmth reappear in the limb. Treatment is directed toward warming the body, and the use of sympathetic novocain block. If the vessel is exposed during debridement direct application of procaine may be tried.
(5)  All casualties with defective circulation in an extremity, particularly of the leg should be under close observation for the development of gas gangrene.

 *  *  *  *  *  *  *

(S)  F. A. BLESSE
  F.  A.. BLESSE, Brig. General, AUS, Surgeon.

DISTRIBUTION:
  CG, Fifth Army   500
  CG, II Corps   450
  CG, NAAF   300
  CG, ABS   500
  CO, MBS 800
  CO, EBS
  CO, Hq. Comd., AF   50
  SURGEON, NATOUSA  100


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HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

9 JUNE 1943

CIRCULAR LETTER NO. 16

SUBJECT: MEMORANDA ON FORWARD SURGERY ESPECIALLY APPLICABLE TO AMPHIBIOUS OPERATIONS

1.  General Principles of Wound Management:
  a.  Surgical operation performed under unfavorable conditions without facilities for proper after care is often more hazardous than prompt evacuation if the patient is transportable or can be made so.
  b.  Wounded evacuated by water should, particularly during early phases of combat, be so bandaged and splinted that they can swim or at least remain afloat should emergency require it.
  c.  Overdosage with morphia produces dangerous coma and respiratory depression that may delay the administration of an anesthetic or render evacuation transport hazardous.
  d.  All wounds are left open after debridement, frosted with sulfonamide and loosely filled with vaseline gauze. There are no exceptions. (See below for specialized regional situations).
  e.  Only bruised and devitalized skin need be excised, and this with narrow margin. Avoid circumcision of wounds leaving circular defects by using linear extensions to gain exposure.
  f.  During debridement open all deep pockets and transversely divide fascial planes.
g.  Do not pack wounds with gauze or sulfonamide.
h.  Immobilize site of extensive injury even if fracture is not present.
i.  Continue oral administration of sulfonamide.
j.  Make notations on casts and on Field tags and records, (casts are frequently changed) particularly of what was done at operation. These notes are not merely for statistical purposes although essential as such. They are required for the subsequent care of the patient.

2.  Plaster Casts.
  aSplit or bivalve all casts as soon as dry. There are no exceptions.
  b.  Pad all casts and split padding as well as cast. Non-padded plaster is not suitable for transportation splinting.
  c.  Apply no circular adhesive or bandage under cast.


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  d.  Maintain foot in neutral position with correction of tendency toward equinus, valgus or varus.

3.  Compound Fractures.
  a.  Objects to be achieved in initial surgery are control of infection and safe, comfortable transportation. Reduction and rigid fixation of fracture can be accomplished at The Base.
  b.  Careful debridement as priority case. No internal fixation forward of Field or Evacuation Hospitals. Do not pack wound--loosely fill with vase-line gauze. Splint for transportation. Skeletal fixation or traction not recommended for transportation splinting.
  c Femur:  Evacuate in Tobruk splint (See Appendix) as early as circumstances permit to reach Base for correction of deformity. A fractured femur should reach a General Hospital in the rear within 10 days. Do not. evacuate with clove hitch or boot traction--use skin adhesive.
dKnee-joint: In debridement minimize incisions that compound joint. Remove accessible foreign bodies. Irrigate joint with saline. Close synovial membrane. Loosely fill debrided wound with vaseline gauze. Evacuate early, immobilized in plaster or preferably Tobruk splint.
eLeg: Careful debridement all wounds in multiple injuries, as circulation frequently impaired and gas gangrene likely. Penetrating wounds of calf may require incision for hemostasis as deep hematoma impedes circulation. Bivalve rather than split casts so inspection dressings may be possible without losing position in compounded fractures. Hold patient if circulation is questionable, otherwise evacuate as early priority.
   f.  Humerus: Use modified Velpeau plaster bandage to hold arm to trunk, or ‘‘U” plaster. Skin traction, skeletal fixation, high abduction spica and hanging cast unsuitable for transportation splinting.

 *  *  *  *  *  *  *

10.  Amputations:
  a.  Circular type guillotine is amputation of choice. In forward surgery performed for control of hemorrhage, destruction of circulation, removal of an irreparably destroyed extremity, and as a step in the debridement of a traumatic amputation. The site is the lowest possible level of viable tissues regardless of the eventual utility of the stump.
  b.  Gas gangrene infection occurs in certain cases with 24 hours delay in evacuation from the field. Amputate only if more conservative surgery and full dosage (80,000 to 100,000 units of polyvalent anti-toxin) are judged inadequate.
  c.  Apply skin traction on the operating table and maintain during evacuation.


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  d.  No sutures. There are no exceptions.

(S) F. A. BLESSE
F. A. BLESSE,  Brig. General, AUS, Surgeon.

Incl:  Appendix
DISTRIBUTION:
  To all Medical Officers
  CG-Fifth Army   900
  CG-NAAF 450
  CG-ABS   500
  CG-MBS 800
  CG-EBS   700
  CO, Hq. Command AF 50
  Surgeon, NATOUSA 250

APPENDIX

Tobruk Transportation Plaster. – Recommended for fractures of the femur, wounds involving the knee joint and fractures of the leg near the knee.

1.  Dress wound and retain dressing with strips of adhesive plaster. No circular dressing or bandages should ever be put on under a plaster case.
2.  Support patient with a pelvic rest, or bowl under sacrum. One assistant holds the foot by the heel and toes and exerts traction. The foot is kept at right angles. A second assistant supports the fracture and keeps the knee bent at 10 degrees flexion with the palms of the hands not the fingers.
3.  Apply traction strapping as close up to the wound as possible. Fold distal ends of straps into cords.
4.  Pad the heel and malleoli with wool. Turn back the traction straps from the region of the malleoli while winding the wool round. Pad the knee prominences similarly. There have been some cases of foot drop from pressure on the external popliteal nerve. Pad the upper part of the thigh close to the ring of the splint with a layer of wool. Pad the entire extremity with sheet wadding or stockinette.
5.  Lay a strip of tin (obtainable from ration boxes etc.) wrapped in paper over time anterior surface of the length of the limb to beyond the toes.
6.  Prepare a plaster slab (6 thicknesses)--apply posteriorly as high as possible and distally over heel and sole of foot to project 3-4” above the toes.
7.  Complete plaster cast with circular bandages round the slab enclosing the whole of the leg and foot except the dorsum of the toes and mould. Do not cover over traction straps further than just above time malleoli.
8.  The traction straps are now emerging from the plaster just above time malleoli. Turn them back and cut the plaster away from where they emerge,


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sufficiently to free the straps from the plaster. This allows the traction to be on the leg and not on the cast. Trim the plaster over the dorsum of the toes.  See that the little toe is free.
9.  Apply Thomas Splint preferably half-ring and fit lower part of ring against Tuber Ischii and adductor muscles. Hold up ring so as to obtain correct position and insert pads of wool anteriorly and laterally between the ring and the thigh to maintain the position. Tie traction straps to notch in splint and insert spreader and Spanish Windlass.
10.  Wind plaster bandages round the side bars of the splint, and round the limb to anchor the splint to the limb.
11.  Support distal end of splint with splint bracket.
12.  When plaster is moderately firm cut down on thin strip over whole length plaster and withdraw strip and split the plaster . Cut the underlying padding within scissors or knife. It is not unnecessary to cut stockinette.
13.  With indelible pencil draw diagram of fracture and write simple details, (late of wounding, treatment, date of application of plaster, unit, etc.

NOTE:  This splint is only intended as a transportation splint for the journey to the base. There is no need to aim at accurate apposition in the Forward Area. On arrival at the Base Hospital X-ray examination should be made, position corrected if necessary and routine treatment employed.

This form of fixation will do quite well even for fractures of the upper third of the femur for transport.

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

26 JUNE 1943

CIRCULAR LETTER NO. 19

*  *  *  *  *  *  *
Operations on the Knee Joints........... IV

*  *  *  *  *  *  *

IV – OPERATIONS ON THE KNEE JOINTS.

1.  Careful surgical judgment is to be exercised in the selection of cases for excision of semilunar cartilages. A history of locking is essential. Instability of the knee joint is a contraindication. Post operative care in the form of early weight bearing without crutches and exercise of time quadriceps muscle groups instituted early under supervision is essential to recovery.


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2.  Operations for major knee disabilities such as repair of collateral or cruciate ligaments, or removal of both cartilages are to be undertaken only on recommendation of a Disposition Board of a General Hospital.

For the SURGEON:
(S) E. STANDLEE
E. STANDLEE,  Colonel, M. C., Deputy Surgeon.

DISTRIBUTION:
  CG, Fifth Army 600
  CO, ABS 500
  CG, MBS   600
  CO, MBS Center District 200
  CG, EBS 600
  CG, NAAF   450
  CG, Force 141  300
  CO, HQ Comds.., AF 50
  Surgeon, NATOUSA 150

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

22 JUNE 1943

CIRCULAR LETTER NO. 20

SUBJECT:  Tunisian Campaign--Comments by Hospitals of the Zone of Communications on the Treatment of Battle Casualties in Forward Areas.

NOTE: At the end of the final phase of the Battle of Tunisia, several hospitals of the Zone of Communications were asked to submit comments on the surgical treatment of battle casualties received during the campaign. Although quotation marks have been eliminated, the following paragraphs are direct transcriptions of these comments and suggestions. Specific case histories have been assembled in the Appendix with designations as footnotes. Many of the principles emphasized in these comments have been incorporated in Circular Letters, and they should be carefully observed by all Surgeons in the Theater.

Figures in parentheses refer to case histories in the Appendix. Comments in parentheses were not received from the hospitals.


309

1.  General Consideration.
  a.  In general, the great majority (90%) of patients received from the combat zone have been well and adequately treated, and good judgment has been exercised in selection of cases suitable for evacuation to this general hospital.
  b.  In several instances time severity of the injury has not seemed to warrant evacuation to this point, where, with a large proportion of the cases prospectively to be evacuated to the Zone of the Interior, it is inevitable that the patients should acquire an exaggerated idea of the severity of their injury, and a reluctance toward return to duty. (1)
c.  There are rare instances of patients who were so critically ill on admission that their evacuation has appeared unwise and unduly hazardous.
d.  Many patients might have been returned to full or limited service if they had not been told that they were to be sent to the Zone of the Interior, or that they would not regain full function of an injured part.
e.  Almost all of our patients have spoken will appreciation of the skilled and kindly treatment they have received in the most forward areas--litter bearers, battalion surgeons, and on back. Most of the patients have had excellent treatment and in particular the work of the Surgical Teams has been outstanding.
f.  A number of our patients have received wounds due to shell fragments. The vast majority of these wounds have been satisfactorily treated by excision and left open. Most of them have healed kindly and have required only secondary closure or skin grafting for complete healing.
  g.  Judging from the comparatively small number of war casualties treated in this hospital it seems evident that delayed primary suture of wounds, particularly in patients who are to be evacuated is an ill-advised procedure (This does not apply to secondary suture in a Base Hospital where the patient can be held until healing is complete.) The suture of wounds using a gauze pack as a drain should be avoided. The pack dries and acts as a plug rather than a drain.

2.  Initial Treatment of Wounds.
  a.  Adequate debridement of wounds in combination with a filling of vaseline gauze and the use of sulfa drugs and plaster immobilization has produced clean wounds in most instances. The patients have arrived in good condition, relatively comfortable, and have only rarely shown even slight temperature elevation.
b.  The extent of some wounds suggests that skin removal has been too extensive in many cases.
c.  Large numbers of foreign bodies are still present in the wounds in many cases. The metallic foreign bodies only occasionally are responsible for persistent draining sinuses. In one case fragments of cloth were found just beneath the skin, where even casual debridement might have discovered them.
  d.  Conservation of digits. Numerous fingers with compound injuries and lacerated tendons have been treated conservatively, often with tendon


310

suture and splinting. An over heroic attempt has been made in the presence of sepsis to preserve digits devoid of function. The protracted splinting in these cases results in diffuse stiffness of the hand unrelieved by late amputation of the useless digits, and necessitating evacuation to the Zone of the Interior. From the standpoint of military usefulness the results of early amputation in badly damaged fingers have been more satisfactory.
  e.  There have been several instances of attempted primary tendon repair in severe crushing or gunshot wounds of the hand. None of these has been successful.
  f.  Packing. The commonest criticism of the packing of wounds is that excessive amounts of gauze have been used, frequently acting as a plug, and often introduced through a small wound of entrance. In several cases through and through gauze strips have been used to pack perforating wounds of the extremities. Coarse meshed dry gauze has been used for packing in many cases, the removal of which is difficult and unnecessarily traumatizing. When it is necessary to use dry gauze packs to control bleeding, early removal is urgent and a notation that such packing has been employed would ensure an early change of cast.
g.  On many occasions when time casts were removed and the wounds dressed, tight vaseline packs were found in place and when these were removed there was a gush of dammed back discharge. It seems desirable that the vaseline gauze strips be laid from the bottom of the debrided wound out over the skin in an axis at right angles to the wound. Having lain such strips all about the circumference of the wound the remaining central cavity can be filled with vaseline gauze folded back and forth. It is worth repeating that the debridement should be complete, the sulfanilamide sprinkled into all crevices of the wound and the vaseline packing inserted loosely.
(It is recommended that the term “pack” be dropped from common usage and reserved specifically for a temporary procedure used to control hemorrhage.)
  h.  Immobilization. Many casts are excessively thick and heavy. Insufficient padding, or padding carelessly applied, has resulted in pressure sores in several cases. The use of circular bandages inside casts, or of slings, may result in constriction or pressure sores. Simple linear incision of a circular cast is not sufficient safeguard against swelling and circulatory embarrassment. In one instance of simple uncomplicated fracture of both bones of the leg, amputation was barely averted because of circulatory damage which could have been avoided by proper padding or bivalving of the cast.
  i.  We particularly condemn the use of the skin tight plaster on the acute injury, even those split up the front. We have had about 20 cases of fracture of the leg and a few of the arm come to us in plasters applied directly to the skin at the time of debridement in forward hospitals. With very few exceptions the skin has been blistered when these casts were removed. Sheet cotton, stockinette, cloth of any kind or even newspaper should be used to protect the skin.
  j.  Insufficient splinting and immobilization has been applied. (2) (3) Contractures have developed which have been very troublesome and in some


311

cases have necessitated evacuation to the Zone of the Interior for this reason alone. Cock-up splints for radial nerve injuries are generally too short. Patients with peroneal palsy are not protected against foot drop.
  k.  Hip spicas in the majority of cases are carried unduly high and cause a considerable amount of unnecessary discomfort. In shoulder spicas a common error is to place the arm in too great abduction, and in or behind the frontal plane of the body rather than forward of it. Patients transported in “hanging casts” for fracture of the humerus do not travel well. (4)
  l.  Of the 272 patients treated, 111 were compound fractures, all but four of whom entered this hospital by air ambulance in excellent condition. The great majority of these patients had been treated by early debridement, local application of a sulfonamide packing with vaseline gauze and application of a padded plaster cast.
m.  Fractures have been well immobilized and the plaster work has been excellent. In only a few instances has it been necessary to remove plaster because of constriction.
n.  In badly comminuted fractures where good position has been obtained at operation loss of position is to be feared with change of cast. These cases are problems. While we favor the 10th to 12th day change of plaster we have allowed them to go several weeks pending soft tissue fixation of the fragments. It would be helpful if plasters in such cases could be bivalved rather than split down the center, so the dressing might be done and a new cast applied over the remaining half.
(Bivalving plasters prior to transportation means strengthening the halves by slabs and secure approximation before evacuation.)
  o.  Penetrating or perforating injuries of the knee have frequently been opened surgically in forward hospitals, foreign bodies or bone and cartilage chips removed, the joint irrigated thoroughly, sulfanilamide inserted into the joint, the synovial membrane closed and the wound then packed open. All so treated have done well with a minimum of synovial reaction. After the operative procedure all cases should be immobilized in a long leg plaster to the groin and the use of a cross stick at time ankle to prevent rotation.

3.  Amputations.
  a.  The small number of amputations seen would have benefited had they been transported in Thomas splints with skin traction applied to the skin flaps. The open wounds were clean but the skin had retracted to the point that reamputation will probably be necessary to accomplish a serviceable stump.
  b.  In two instances a final amputation was done at too high a level to permit use of an artificial limb. Several cases of amputation have arrived within severe flexion contracture of the knee for lack of a posterior splint. Several cases of severe hip flexion contracture have been received as a result of omitting posterior splints following thigh amputations.
  c.  Out of twelve cases of anaerobic gas bacillus infection in one hospital, 2 were in sutured amputation stumps.


312

  d.  In the following case, (5), a conservation type of amputation was performed through a level far below the site of vascular occlusion in an infected leg. I think the lesson here is that the line of demarcation in infected extremities with vascular occlusion does not mark the level at which an amputation stump will be sustained. Circulation just enough to maintain viability of tissues will not withstand an amputation or cope with an infection. Amputation in such cases must be high, if possible above the level of vascular occlusion.

 *  *  *  *  *  *  *

(S)   F. A. BLESSE
F. A. BLESSE, Brig. General, AUS, Surgeon.

Incl: Appendix
DISTIBUTION
  CG, Fifth Army 600
  CO, ABS 500
  CG, MBS   600
  CO, NIBS Center District   200
  CG, EBS 600
  CG, NAAF   450
  CG, Force 141   300
  CO, HQ. Comd., AF   50
  Surgeon, NATOUSA 150

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

18 NOVEMBER 1943

CIRCULAR LETTER NO. 48

PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED -- .I
PARAGRAPH III, CIRCULAR LETTER NO. 191S AMENDED -- .II
USE OF EXTERNAL SKELETAL FIXATION APPARATUS (ROGER ANDERSON) IN TREATMENT OF FRACTURES OF THE EXTREMITIES --  III
DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF COMPOUND FRACTURES WITH OR WITHOUT SECONDARY SUTURE OF WOUND -- IV
FRACTURES OF CARPUS -- V
HERNIATED NUCLEUS PULPOSUS -- VI
“PARRY”OR MONTEGGIA FRACTURE -- VII
THE TOBRUK SPLINT AND HIP SPICAS -- VIII
TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA -- IX

I – PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED AS FOLLOWS:

Operation of the Knee Joint
Follow-up studies on over 200 operations performed in this theater for removal of dislocated or ruptured semilunar cartilages and other derangements of the knee joint have been compiled. Appraisal of these results lead to the following recommendations:

1.  Operations for the repair or reconstruction of the collateral or cruciate ligaments of the knee, or for recurrent dislocation of the patella, are not to be performed in this theater.

2.  Careful study and mature surgical judgment will be exercised in the selection of cases for excision of a semilunary cartilage or joint mouse.
  a.  Elective arthrotomy of the knee will be performed only on the Orthopedic Service of a General Hospital.
  b.  Initial injuries of the semilunar cartilage without locking and those that unlock by gentle manipulation, or after 5 to 6 days of skin traction, will not be subjected to operation. Pressure support, rest, graduated to protected, then full weight bearing and carefully supervised quadriceps exercise for 2 to 10 weeks, are suggested as a method of management. Following symptomatic relief these soldiers may be returned to duty.
  c.  Arthrotomy will be limited to:
(1)  The persistent locked knee.
(2)  The unlocked knee in a soldier who cannot perform noncombat duty because of his disability. This will be only the exceptional case.
 d.  Contraindications to be considered are age, arthritic changes, instability of the joint and, in particular, any but the most favorable mental attitude of the soldier.
  e.  Recurrent cases, not locked, and those recurrent cases that unlock within non-operative therapy, are to be returned to duty unless the total period of disability in any calendar year exceeds 90 days. Under such circumstances, they will be transferred to the Zone of the Interior.
  f.  Operation for the removal of both cartilages from one knee or for one cartilage from each knee is to be performed only on written recommendation of a Disposition Board of a General Hospital.

3.  A General Hospital in which arthrotomy of the knee is performed will be expected to hold the patient for a minimal period of six weeks, so that the operating surgeon may supervise the regimen of post-operative exercises and motion essential to a good result. Proper post-operative supervision is as essential to recovery as the operation. If prevailing evacuation policies indicate that the patient cannot be lucid for at least 6 weeks post-operatively, he should be transferred farther to the rear for operation.


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4.  After 6 weeks in a General Hospital, the patient may be transferred to a Convalescent Hospital for further care with full instructions relative to continuation of corrective exercises.

II – PARAGRAPH III, CIRCULAR LETTER NO. 19 IS AMENDED AS FOLLOWS:

Operations for Recurrent Dislocation of the Shoulder Joint or Chronic Dislocation of the Acromio-clavicular Joint

1.  The history of a patient relative to previous dislocation of the shoulder is notoriously unreliable. Before making a diagnosis of recurrent dislocation, one or more episodes should be confirmed on Army Medical Records, preferably with supporting X-Ray evidence.

2.  Operations of this type will be performed only with written approval of the Disposition Board of a General Hospital following demonstration that the disability is of a nature that the soldier cannot perform non-combat duty and when his age and mental attitude give a reasonable prospect of military rehabilitation.

III – USE OF EXTERNAL SKELETAL FIXATION APPARATUS (ROGER ANDERSON) IN TREATMENT OF FRACTURES OF THE EXTREMITIES.

1.  This is a highly specialized method for the treatment of carefully selected cases, chosen on the basis of special indications.

2.  The use of external skeletal fixation is to be limited to surgeons with training and experience in the method. If a special indication for use of the method is found in a hospital without such a surgeon, the patient will be transferred to a hospital with this trained personnel.

3.  A patient within the apparatus in place is not to be transferred from one hospital to another within the theater except under emergency conditions. When a transfer is essential, he is to be routed to a hospital where there is a surgeon experienced in the method. Patients are not to be evacuated to the Zone of the Interior with the apparatus in place, but will be held for a sufficient time to permit the removal of pins and the substitution, if indicated, of conventional means of splinting.

4.  Clinical records of each patient, on whom the method is utilized, will be forwarded through channels to the Surgeon, NATOUSA, after the treatment is completed. This record will contain essential data for identification of the case, date of injury, fracture diagnosis, original treatment, character of the wound if compound, problem involved and indication for use of the method, length of time required to apply the apparatus and reduce the fracture, number of X-Ray films required, date and extent of any observed distraction, incidence of pin infection and other complications, date of removal of the apparatus and subsequent treatment, result. and disposition.


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IV – DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF COMPOUND FRACTURES WITH OR WITHOUT SECONDARY SUTURE OF WOUND.

1.  This procedure is still under trial within reference to indications, hazards, and incidence of serious complications. Its use is restricted to special groups authorized to assume the responsibility as a special study.

V – FRACTURES OF CARPUS.

1.  Greater care is to be exerted in making a precise and early diagnosis of carpal fractures and dislocations. Early reduction is essential if a satisfactory result is to be obtained.
2.  Operative treatment for old unrecognized fractures of the scaphoid will fail to rehabilitate a soldier in this theater. If complete disability is present, he should be transferred to the Zone of the Interior.

VI – HERNIATED NUCLEUS PULPOSUS.

1.  Recommendation Par. II, Circular Letter No. 19, 26 June 1943, is interpreted to apply to all patients, Army, Navy or Allied Force under treatment for this condition in U. S. hospitals.

VII – ”PARRY” OR MONTEGGIA FRACTURE.

1.  Attention is directed to fracture of the shaft of the ulna within dislocation of the head of the radius. Uncommon in civilian practice, this fracture due to direct violence to the forearm (blow with rifle butt or other blunt weapon), is not infrequent in military experience. It is essential that the dislocation of the radius be recognized and proper treatment instituted at the time of initial treatment.

VIII – THE TOBRUK SPLINT AND HIP SPICAS.

1.  Experience has shown that the use of Tobruk splint is best limited to fractures of the lower one-third of the femur, supra-condylar fractures, and wound damaging the knee joint. Even in these injuries it has no advantages over a well applied hip spica.
2.  The most comfortable and efficient hip spica for immobilization of a fracture of the femur for transportation, following initial surgical treatment, is a short waisted, double spica extending only to the knee on the well leg and maintaining 20 to 30 degrees of abduction within the knee slightly flexed. The plaster on the injured leg is carried beyond the toes by a plaster slab, leaving the toes fully exposed anteriorly. Care is taken to avoid equinus and to hold the foot in a neutral position between valgus and varus.
3.  High waisted plasters that extend to or above the costal margin cause discomfort. It is better to tie in the well leg and stop the plaster just above the iliac crest.


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4.  The chief responsibility of the surgeons of the forward area in the management of all compound fractures is the prevention of infection, rather than the anatomic correction of deformity. Early evacuation to the Base (a fractured femur should reach a General Hospital within 10 days) will allow for definitive reduction of the deformity.

IX – TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA.

1.  Meticulous nursing care is essential for the prevention of bed sores. This care is interrupted by rapid evacuation through a chain of hospitals. While it is important to transfer these cases to the Base, when they are transportable, they should not be subjected to long ambulance lifts. On arrival at, an intermediate station, careful nursing care should be provided immediately. If there are signs of pressure sores, the patient should be held for corrective measures before further transfer. These patients do not complain of pain and quite different criteria are required in an estimation of whether they are to be classified as “transportable” than are found applicable in the management of other casualties.

For the SURGEON:
  (S)  E. STANDLEE
E.  STANDLEE, Colonel, M. C. Deputy Surgeon.

DISTRIBUTION:
  Surgeon, NAAF 400
  Surgeon, NAASC 300
  Surgeon, EBS 400
  Surgeon, MBS  300
  Surgeon, ABS   150
  Surgeon, IBS 100
  Surgeon, PBS   500
  Surgeon, AMGOT 25
  Surgeon, CD MBS   50
  Surgeon, Seventh Army  350
  Surgeon, Fifth Army  600
  Surgeon, Hq. Command, AF50
  Surgeon, NATOUSA 200


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HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

19 APRIL 1944

CIRCULAR LETTER NO. 26

SUBJECT:  Wound Management.

1.  The keystone of successful wound management is the initial surgical operation. When this is performed correctly the complications of infection are absent or minimal and secondary suture may be carried out promptly and successfully. To coordinate the initial surgery in the forward area within the definitive surgery at the base observance of the following principles is essential.

2.  Initial Wound Surgery.
  a.  Adequate assistance and instruments, a good light and access to the wound that is unhampered by faulty position of the patient are basic requirements. Ample preparation of a wide field by shaving the skin will allow for extension of the incision or counter incision..
  b.  Bold incision is the first essential step in an operation on a wound. Adequate exposure is necessary to carry out excision of devitalized tissues. On the extremity the line of the incision is placed parallel with the long axis of the limb; elsewhere it follows the natural lines of skin structure. Only the devitalized skin of the margins of the wound is excised in a strip rarely wider than 2 to 3 mm. Circular defects are to he avoided.
  c.  Incision and excision of the fascial layers is carried out in the same manner to give free access to devitalized muscle. Unrestricted exposure of successive anatomic layers permits the complete excision of devitalized muscle and the removal of foreign bodies. The operation on a wound is an anatomic dissection and should never be made to resemble a digital pelvic examination.
  d.  The surgeon must be familiar within the blood supply of muscles, particularly large groups like the gastrocnemius-soleus muscles of the calf and respect these vessels in his dissection. Deep recesses of the wound containing foreign bodies may be approached by counterincisions planned anatomically rather than by sacrificing normal muscle structures.
  e.  Use fine hemostats. Use the finest ligatures compatible with the procedure. Include the smallest possible amount of tissue in ligating a bleeding point. Do not repeatedly bite the wound with tissue forceps. Sponge gently with pressure instead of wiping. Remaining devitalized tissue produced by the missile or by the surgeon must slough before the wound can be closed by secondary suture.
  f.  Large wounds in regions of heavy muscles particularly when complicated by comminuted fracture require especial care. The depths of these


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wounds must be opened by a long incision with counterincision if necessary to allow free drainage of blood and tissue that may not be identified as dead at the time of debridement.
  g.  Only enough vaseline gauze is used to separate the surfaces of the wound. It should be smoothly laid in the wound--not “packed”.
  h.  Local application of sulfanilamide is a minor adjunct to surgery and is used as a fine frosting of the surfaces. It is not to be “rubbed in”.
  i.  Ether, white soap, and benzene have slight but definite necrotizing effects on living muscles. Green soap, hydrogen peroxide and various other substances used as detergents have greater necrotizing effects. Physiological saline solution, petrolatum and boric acid ointment are innocuous. If a detergent is needed, white soap is the least objectionable.
  j.  Old wounds (48 hours or longer) are managed in accord with the same principles except that in selected cases of established pyogenic infection and anaerobic cellulitis with toxicity the general condition of the patient to withstand radical surgery may be improved by immobilization, penicillin and repeated blood transfusions until an optimum time is selected for intervention. In postponement of surgery the advantage that accrues from the immediate drainage of septic hematomas, large masses of dead muscle and fascial plane abscesses is not to be forgotten. Postponement of surgery is not justified if clostridial myositis (gas gangrene) may be present.

3.  Secondary Wound Surgery.
  a.  On arrival at a hospital where bed care can be assured for a period of 15 days the first dressing is removed in the operating room under aseptic precautions. X-ray films should be at hand. If the primary wound operation has been a complete one, all superficial wounds and many deep wounds may be closed by secondary suture at this time (4 to 10 days). Foreign bodies in soft parts adjacent to the wound are removed. Following suture, the part is immobilized preferably by a light plaster, or if this is impractical, by bed rest.
  b.  The presence of residual dead tissue or established infection indicated by profuse discharge of pus, reddening and edema of the wound margins, persistent fever or toxicity are the common indications for delay in secondary suture. When these indications are present but minimal, the wound is allowed to “clean up”. Moist dressings, heat and azochloramine are generally considered to hasten this process. Additional surgical excision of devitalized fragments may speed the process. Secondary suture can then be performed in a few days. If established infection is severe, or if the patient is toxic and anemic from deep seated sepsis, a course of penicillin therapy and blood transfusions is instituted and followed by radical wound revision.
  c.  Closure of wounds that compound fractures or joints is only to be undertaken when the surgeon is completely familiar with the use of penicillin as an adjunct to surgical wound revision. Penicillin will not “sterilize” a wound that contains devitalized bone, fascia, tendons or foreign bodies. Immediate success may be obtained, but delayed abscess formation, joint infections


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and osteoperiostitis are likely to appear as sequelae. The wound revision that is an essential part of “cleaning up” wounds that complicate fractures or joints for closure, either at the time or subsequently, is not to be taken lightly. Preparation of the patient by transfusions, diet and accessory surgical procedures is essential.
  d.  Wounds that have been properly laid open at the initial operation tend to gape widely and give the impression of extensive skin loss. This appearance is actually due to loss of support of the deep fascia. Skin defects are more apparent than real in the majority of cases and closure of a defect is made from local tissue with suture in a straight line which possible. Undermining with advancement or rotation of flaps provides sufficient skin in nearly all instances and is preferable to grafting.
  e.  Technical considerations that are important to the success of secondary wound closure are:
(1)  Atraumatic handling of tissue (see par 2, e).
(2)  Avoidance of tension sutures.
(3)  Accurate approximation of skin margins. The epithelial bridge is the main support of the wound for a considerable period of time.
(4)  Obliteration of dead spaces by pressure dressings and immobilization.
(5)  Leaving sutures in place for 12 days if stitch infection does not develop.
(6)  Suture in straight lines rather than creation of sharp angles.
(7)  Closure by adhesive plaster strips is not as satisfactory as suture.
  f.  The conditions that most often jeopardize results are:
(1)  Suture of wound that is discharging a large amount of pus. This usually means dead tissue in the depths.
(2)  Hemolytic streptococcus infection.
(3)  Diphtheria wound infection.
(4)  Too early motion. (Wounds breaking down for this reason should be immediately resutured.)
(5)  Unrecognized foreign bodies adjacent to the wound.
  g.  Preliminary bacteriologic analysis of the flora of a wound does not provide information pertinent to making the decision to perform secondary suture or allow the prediction of the result. If the suture is not successful because of infection, appropriate studies and corrective therapy is instituted before resuture is attempted. Infection may be considered indicative of the susceptibility of the individual to the predominate wound organisms.

4.  Specialized Problems.

*  *  * * * * *

  c.  Amputations.

Secondary closure of a circular guillotine amputation stump is not commonly indicated, as it is impossible to suture the inelastic fascia without wasteful shortening of the bone. Bone length can be saved by continuing the skin


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traction for an additional period of time--4 to 6 weeks. Closure of stumps by sliding flaps, plastic resection within sacrifice of bone length, or formal reamputation are procedures to be carried out in the Zone of the Interior rather than in an Overseas Theater. Skin grafting of defects may be performed for temporary resurfacing of stumps that will later require plastic procedures or reamputation. It should not be employed when further use of skin traction will promote healing or covering of the bone end with normal skin. Vertical incisions in the stump made for infection or as part of time initial debridement should be closed by secondary suture while skin traction is being maintained to cover the defect at the end.

* * * *  *  *  *

  e.  Closed Plaster Treatment (Truetta).
The regimen of closed plaster management of war wounds has not been judged applicable to the field conditions of this theater. It is advisable to remove the initial dressing for inspection of the wound in all cases at least by the 15th day. Incorporation of pins or other fixation devices in the initial plaster to maintain the reduction of fractures obtained at the initial operation has been found impractical as a means of transportation splinting.

While the necessity for the rapid turnover of large numbers of casualties might justify an adoption of the closed plaster method of management of compound fractures, a high penalty in the form of skeletal deformity would be the inevitable result. Results obtained by secondary suture do not justify the use of closed plaster for soft part wounds.

Infrequent change of plaster as practiced in the theater has many advantages, particularly when it is desired to allow granulations to cover exposed bone in deep irregular wounds (Orr). It is also an accepted method of management for established infection of bone particularly when the wound has caused all extensive loss of overlying soft parts or there is a boric defect. Small surfaces of bare cortical bone may be removed surgically when this permits closure of the defect by suture. When resurfacing by skin graft is possible in a shallow wound the bare cortical bone may be left for spontaneous sequestration.

  f.  Military Aspects. Secondary wound surgery in an Overseas Theater must be measured against the objectives that are sought. In general, these are:
(1)  To return a soldier to duty with a minimum number of days lost.
(2)  To return patients to the Zone of Interior at an earlier date and in better condition.
(3)  To reduce ultimate disability and deformity by preventing or cutting short a phase of late wound infection with fibrosis and other harmful sequelae.

An aggressive attitude is desired in the case of any soldier who may be returned to duty in this theater. On the other hand, to suture a small clean wound that is compounding a fracture of the femur is merely a stunt, as the soft parts will be healed before the bone unites.


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It is not desirable to embark on elaborate plastic procedures such as crossed extremity skin flap grafts or operations undertaken for cosmetic purposes.

For the SURGEON:
  (S)  E. STANDLEE
E. STANDLEE Colonel, M. C., Executive Officer.

DISTRIBUTION:
  All Medical Installations
  Surgeon, SOS NATOUSA   800
  Surgeon,  Fifth Army 500
  Surgeon, Seventh Army   100
  Surgeon, AAFSC/MTO  800
  Surgeon, NATOUSA 200

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

1 July 1944

CIRCULAR LETTER NO. 36

SUBJECT:  Penicillin Therapy in Wound Management, Surgical Disease, Burns, and Anaerobic Infections

1.  General.
  a.  In World War II, two quite different policies have governed the use of chemotherapeutic agents in the management of wounds. Chemotherapy has been recommended: (1) as a substitute for adequate wound surgery, seeking to delay and minimize operative procedures; (2) as an adjunct to established and progressive surgical measures designed to achieve better results within an increased margin of safety. The latter has been and will continue to be the policy governing the management of the wounded in this theater.
  b.  The use of penicillin as an adjunct to surgery outlined in this circular is defined as therapy rather than prophylaxis. Routine immunization of troops with tetanus toxoid is a prophylactic measure. Administration of penicillin for contaminated wounds and established infection is a therapeutic measure. As with all therapy, if the desired goal is to be achieved, intelligent and precise professional supervision of every detail is essential.

2. Scope of Penicillin Therapy.
  a.  Penicillin is accepted as the best available antibacterial agent for gram-positive bacteria and gram-negative diplococci. It is ineffective for gram-negative bacilli.


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  b.  Penicillin does not sterilize dead, devitalized or avascular tissue, nor does it prevent the septic decomposition of contaminated blood clot. There is no evidence that it can neutralize preformed bacterial exotoxins or inhibit the locally necrotizing bacterial enzymes in undrained pus. These limitations demand that surgical wound management retain the principles of excision of devitalized tissue, dependent drainage of residual dead space, evacuation of pus and delayed or staged closure of contaminated wounds (see Circular Letter No. 26, Office of the Surgeon, Hq. NATOUSA).
  c.  The use of penicillin in an individual patient is based upon the decision that infection is probable or present.
  d.  It is recommended that parenteral administration be the basis of penicillin therapy. The local or topical use of penicillin is a supplement to systemic therapy only in lesions of the central nervous system, serous cavities and joints. The diffusion of the drug into these areas appears slow and limited.

3.  Penicillin Therapy in Relation to Sulfonamide Therapy .
  a.  Topical and oral administration of sulfonamides as first aid measures will be continued.
  b.  Intravenous sulfonamide prior to initial surgery will be replaced by parenteral administration of penicillin (par. 6, a).
  c.  At the conclusion of the initial wound operation, the decision will be made either to institute a postoperative course of penicillin therapy or to maintain chemotherapy with sulfonamides. It is recommended that the agents be used individually and not concomitantly. If a course of penicillin is elected, topical frosting of the wound with sulfonamide is omitted. The following observations will serve as a guide in this decision:
(1)  Clinical experience with penicillin has been greatest with wounds of the extremities and the thorax. The drug is recommended for these injuries.
(2)  The value of penicillin in craniocerebral wounds is well established, but an extensive experience has not been accumulated.
(3)  Cleanly debrided soft part wounds uncomplicated by fracture, extensive tissue destruction, or retained missiles are adequately handled by sulfonamide therapy.
(4)  Preliminary evaluation of penicillin therapy for fecal contamination of the peritoneal cavity is encouraging but at the present time is inadequate for comparison with sulfonamide therapy. In view of the difficulties in maintaining a fluid intake adequate to safeguard sulfonamide therapy in this group of cases, substitution of penicillin may be made at the discretion of time surgeon. Forcing of fluids is not necessary solely because of penicillin therapy and in fact, reduces the effective concentration of the drug by rapid urinary excretion.

4.  Routes of Penicillin Administration.
  a.  Intramuscular. This is the standard route for administration. The deltoid, gluteus and thigh muscles are recommended as the sites for injection. The same area may be used repeatedly. Subcutaneous administration is to be avoided.


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  b.  Intravenous. The intravenous route is reserved for patients with shock or immediately life endangering infection. A single intravenous injection provides a therapeutic concentration of the drug that lasts for two hours. If intravenous therapy is indicated to span a longer period, the injection is repeated or constant drip administration instituted.

5.  Dosage.
  a.  Systemic therapy. Current practice dictates a dosage of 200,000 units in 24 hours, given as 25,000 units every three hours by the intramuscular route. Larger initial dosage or greater 24 hourly dosage have no demonstrable merit. Maintenance of full dosage schedules throughout the course of therapy is better than a graded terminal decrease in dosage.
  b.  Local therapy. The powdered sodium salt of penicillin is slightly acid and provokes a burning pain and serous discharge if applied to an open wound. A solution containing 10,000 units per c. c. is well tolerated as an intramuscular injection but may produce headache, meningismus and pleocytosis of the spinal fluid after intrathecal injection. The maximal effective local concentration  is 250 to 500 units per c.c. The usual concentration employed chemically varies between 500 and 5,000 units per c.c. with predominate usage of a solution containing 1,000 units per c.c. The following dosage schedules are recommended for local instillation:
(1)  Intrathecal space 7,500 units
(2)  Pleural cavity   25,000 units
(3)  Peritoneal cavity  50,000 units
(4)  Knee joint 10,000 units
Local instillation of penicillin may be repeated at intervals of 12 to 48 hours in accordance within clinical indications. Needle aspiration and injection is preferable to inlying tubes.

6.  Use of Penicillin in Mobile Hospitals. The following recommendations are made on the basis of procedures that have been found practical in Evacuation Hospitals:
  a.  Upon arrival in the shock or preoperative ward, the wounded will receive 25,000 units of penicillin intramuscularly, unless the wound is certainly of a trivial nature. If shock is present, an additional 25,000 units will be given intravenously.
  b.  Preoperative dosage is continued at 3 hourly intervals. It is more practical to give penicillin to every patient in a preoperative ward at the same time, than to keep each patient on a dosage schedule based on the time of arrival. There is no objection to a time interval of less than 3 hours between the first two injections.
  c.  The decision to continue penicillin or to substitute sulfonamide in the postoperative period is made when the operation is concluded and the nature and extent of the injury evaluated (see par. 3 c).


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  d.  No patient will be held in a mobile hospital solely for the purpose of continuing penicillin therapy. The usual criteria based on the condition of the patient will determine the suitability for evacuation. In general, the drug is continued for 2 to 3 days beyond the period of clinical recovery from the hazard or subsidence of infection. A course of therapy may be associated with slight fever which disappears after the drug is stopped. Suitable periods of therapy are:
(1)  Soft part wounds 5 to 7 days
(2)  Compound fractures  10 to 12 days
(3)  Thoracic wounds 8 to 10 days
(4)  Abdominal wounds 8 to 10 days
(5)  Craniocerebral wounds   8 to 10 days
(6)  Joint wounds   7 to 14 days
  e.  Patients evacuated prior to completion of a course of therapy will carry a notation “On Penicillin” in the space provided under the designation “Special attention needed in transit, or other remarks” on the jacket of the Field Medical Record (Form 52d). This will indicate the need for continuation of therapy in holding stations, hospital ships and fixed hospitals.

7. Use of penicillin in Holding Stations or Hospital Ships .
  a.  Form 52d will be examined in each case upon admission to identify those patients receiving penicillin therapy (par. 5 e).
  b.  25,000 units of penicillin will be administered intramuscularly every 3 hours to all such designated patients.

8. Use of Penicillin in Fixed Hospitals.
  a.  Patients designated as “On Penicillin” (par. 5 e) will have time course continued on admission to time hospital. Discontinuance of therapy will be time responsibility of a medical officer after lie has reviewed the status of time patient.
  b.  Secondary suture of cleanly debrided soft part wounds does not require penicillin therapy. Soft part wounds requiring delayed debridement or secondary debridement or within established infection may properly receive penicillin.
  c.  Reparative surgical procedures on wounds complicated by skeletal, joint, nerve, tendon or vascular injury require penicillin therapy.
  d.  Established wound infection is an indication for penicillin therapy.
  e.  Early secondary reparative operations through recently healed wounds require penicillin therapy.

9.  Surgical Disease.
  a.  Acute or chronic infections such as furuncles, carbuncles, felons, desert sores, tenosynovitis, etc. should be treated with penicillin whenever it is judged that loss of time from duty can be shortened.


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10.  Burns. 
  a.  The local application of sulfonamide crystals or ointments containing sulfonamides is not recommended. Fine mesh (bandage cloth) vaseline or boric acid gauze is preferable. Under no circumstances are tannic acid preparations or other escharotic agents to be used in this theater.
  b.  Extensive burns or burns that may include areas of full thickness skin loss will be treated systemically with penicillin or if preferred sulfadiazine.
  c.  See Circular Letter No. 26 regarding policy of early skin replacement.

11.  Anaerobic Infections.
  a.  Clostridial myositis (gas gangrene). Early and adequate wound surgery remains the most effective preventive measure. Early diagnosis of this complication when it occurs, is essential to adequate treatment. Treatment utilizes surgery, penicillin, antitoxin and whole blood transfusion. It is recommended that penicillin be given in the following manner: Initial dosage of 100,000 units intravenously, within 25,000 units intramuscularly at the same time. A course of 25,000 units intramuscularly every 3 hours day and night is instituted. Larger dosages and other regimens have not afforded any more satisfactory results. Sulfonamides are discontinued during penicillin administration.
  b.  Anaerobic cellulitis and other anaerobic infections. Penicillin therapy is used as with clostridial myositis (par.10 a).
  c.  Amputation for anaerobic infection.
(1)  It is of prime importance to differentiate between clostridial myositis and other anaerobic wound infections to prevent the needless sacrifice of limbs on the basis of clinical findings of gas and putrid wound exudate.
(2)  In the management of clostridial myositis a limb need not be amputated solely as a measure designed to arrest the infection. If trauma vascular occlusion and advancing infection, acting singly or together, have so damaged the extremity that functional restitution is unlikely, amputation is performed as a ready and effective adjunct to the arrest of infection.
(3)  The early diagnosis of clostridial myositis and the employment of penicillin and other adjuncts to therapy, permit the  management  the infection to be confined to the excision of involved muscles. If the excision of muscles judged necessary to eradicate the infection must be so extensive that functional restitution of the extremity is unlikely, amputation should be performed.
(4)  When amputation is performed as a part of the surgical treatment of clostridial myositis, the use of penicillin and other adjuncts to therapy allow other considerations than the eradication of infection to play a part in selecting the level for amputation. Provided all muscles invaded by the infection and


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remaining in the stump are carefully excised, a more distal level of amputation may be selected if the ultimate function of the extremity is thereby conserved.

For the SURGEON:
  (S)  E. STANDLEE
E. STANDLEE, Colonel, MC., Deputy Surgeon.
.
DISTRIBUTION:
  Surgeon, Fifth Army   600
 Surgeon, Seventh Army  300
 Surgeon, SOS NATOUSA 800
 Surgeon, AAFSC/MTO 600
 Surgeon, NATOUSA   300

HEADQUARTERS

NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

29 AUGUST 1944

CIRCULAR LETTER NO. 46

 *  *  * *  *  *

SURGICAL MANAGEMENT OF THE WOUNDED........III

 *  *  *  *  *  * *
III—SURGICAL MANAGEMENT OF THE WOUNDED.

Note:  The contents of this circular letter as well as Circular Letter Nos. 26 and 36 are to be brought to the attention of every Medical Officer in the Theater who is assigned responsibility for the management of the wounded.

 *  *  *  *  *  *  *
7.  Reparative Surgery of the Lightly Wounded.
  a.  It is an eloquent tribute to the high standards that have been attained in forward surgery that the suture of wounds at the time of the first dressing at the base is established as a routine procedure. To maintain this standard requires constant vigilance in techniques as described in Circular Letter No. 26. The lightly wounded combat soldier is the most valued military asset entrusted to the care of the Medical Corps. His treatment must be carried out or closely supervised by surgeons within mature judgment and experience. There are no “minor” wounds.
  b.  Forward surgeons will indicate on the record or on the cast the extent of actual skin loss. At the time secondary suture is performed it is difficult


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to distinguish between the gaping of a long incision that can be closed by approximation and the existence of a sizeable defect that will require skin graft.
  c.  An increased use of splinting of soft part wounds following debridement is advisable. Circular plaster encasement if placed proximally on an extremity must be immediately bivalved to avoid constriction.
  d.  In the closure of wounds, particularly those of the extremities, further refinements are desirable in techniques that have a direct effect on restoration of function and early return to duty.
(1)  Transversely divided muscle bundles may be closed by suture, staging the closure of the skin to a later date.
(2)  Very accurate approximation of the skin as in a plastic procedure is desirable. When drainage is required, this should be through a counter incision.
(3)  More use should be made of the principles of plastic surgery, viz., the advancement and rotation of skin flaps, zig-zag plastics and other tricks of closure that, minimize scar contracture and limitation of motion.
(4)  Trauma to skin margins by rat tooth forceps and rough handling is productive of necrosis and imperfect healing.
(5)  Prolonged hospital neglect of unhealed wounds and skin defects must be stopped. It is recommended that the chief of surgical service personally review cases of unhealed soft part wounds that remain in hospital longer than four weeks so that proper treatment can be expedited.

8.  Amputations.
  a.  The most important phase in the management of amputations is the functional rehabilitation of the patient by the fitting of a prosthesis. Amputation centers have been established in the Zone of the Interior for this purpose. It is the expressed desire of The Surgeon General that time early management of amputations in overseas theaters conform within policies that have been set forth in numerous Bulletins and Circular Letters. There will be no deviation from these policies in this theater.
(1)  Forward Area.
  (a)  Level. Amputations will be performed at the lowest possible level except that a proximal amputation will be done in preference to a disarticulation.
  (b)  Technique. The properly performed flapless guillotine stump exhibits slightly concave open cross section of the extremity. A circular incision is made through the skin at the lowest level compatible with viable tissue and the skin allowed to retract; the fascia is then incised at the level to which the skin has retracted. The superficial layer of muscle is then cut at the end of the fascia and permitted to retract. At its point of retraction, the deep layers of muscle are cut through to the bone. After the deep muscles have retracted the periosteum of the bone is cleanly incised and the bone sawed through flush within the muscles. No cuff of periosteum is removed as in a closed amputation. Bone denuded of periosteum will sequestrate if


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infection is present and a ring sequestrum often results when the periosteum has been removed. It is important also that no periosteum be elevated or torn from the bone in the stump by rough handling.
  (c)  Dressing and skin traction. The end of the stump is dressed within fine mesh gauze in such a manner that it does not overlap the skin edges. Skin traction is applied immediately. This may either be by a stockinette cuff attached within ace adherent or by adhesive tape. Traction is obtained preferably by a light plaster cast within a wire ladder banjo. The cast always incorporates the joint above the amputation, e. g., a spica for an amputated thigh. A Thomas splint may be utilized as an alternative. When this is done in lower leg amputations, a posterior splint from midthigh to beyond the stump is provided to prevent flexion contracture of the knee. Medical Supply Item No. 36614--Cord, Elastic, for Traction--is available and is preferable to plasma tubing for the elastic traction. Before evacuation, the traction is examined and if doubt exists as to its effectiveness, it is reapplied.
(2)   Base.
  (a)  All thigh amputations and those of the leg at or near the site of election will be treated by continuous skin traction. Secondary suture or skin grafting of the terminal defect within or without revision will not be done. Removal of the cast or splint and maintenance of 6 to 10 pounds of traction over a pulley at the foot of the bed is recommended. Traction is continued for several weeks (at least 6) until all layers of soft tissue have been firmly fixed by scar formation. Priority air evacuation to the Zone of Interior is available for amputation cases as soon as they are able to be transported. Traction during evacuation is provided for by stockinette and a banjo plaster.
  (b)  Amputations in the lower third of the leg and of the upper extremity may be closed by secondary suture provided the wound is clean and a course of penicillin is instituted. If closure is not feasible, skin traction is maintained.
  (c)  Amputations of the thigh or leg performed in fixed hospitals for trauma, vascular insufficiency or infection will be carried out in conformity within the above principles. In the upper extremity, modifications to scenic primary or early secondary closure are permissible in individual cases.
  (d)  Patients received with injuries that require amputation will benefit by an explanation of why the amputation is necessary prior to the operative procedure. About one in five patients will exhibit psychic reactions, often depressive in type, a few days after the operation. As soon as the patient is surgically comfortable and mentally receptive, an interview within a psychiatrist may be extremely helpful. Particular attention should be paid to what the patient may reasonably expect in the way of aid. The establishment of amputation treatment centers in the ZI may be explained, and assurance given relative to prosthetic appliances, and his potential economic and social status. Fortification of this type, before a patient becomes the target of a sympathetic family and friends, may tip the scales in favor of rehabilitation in contrast to life long disability and resentment.


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9.  Fractures of the Femur.
The program of reparative surgery in fixed hospitals, improvements in skeletal traction techniques, and penicillin therapy are expected to result in unproved apposition and alignment of the fractures and improved knee and muscle function, after the fracture has united. Therefore the following  recommendations and made:
  a.  Fractures treated by skeletal traction.
(1)  Knee flexion produces quadriceps stretch and predisposes to patellar fixation. As flexion increases quadriceps exercises become more difficult. While some knee flexion is necessary for comfort and to aid in reduction of the fracture it should be held to a minimum. For lower third fractures two-wire skeletal traction is recommended. By this method traction is made by a wire (or pin) in the tibial tubercle while a second wire through the lower femoral fragment permits vertical “lift”. Extreme knee flexion is avoided.
(2)  Quadriceps setting exercises and knee motion should be carried out several times daily as soon as wound management permits. Knee motion begun early produces less strain on the fracture site than that begun late after joint "stiffness" has set in.
(3)  Duration of traction. Traction in the great majority of cases must be continued until there is bony fixation clinically and roentgenologically. This will average about 10 to 12 weeks. Prolonged traction permits an increasing range of knee motion and will prevent angulation in a cast during evacuation to the Z of I.
(4)  A low spica extending to the knee on the well side is the recommended splinting for transportation to the Z of I. Uncertainty of evacuation and because a spica is preferably applied at least 48 hours prior to transporting, have resulted in many fractures of the femur remaining in plaster for several weeks or months awaiting and during evacuation, thereby predisposing to restricted knee motion. Collaboration between the surgeon and the disposition officer permits the application of the spica 48 hours prior to evacuation. Fractured femurs immobilized after traction are excellent priority 4 cases for air evacuation.
  b.  Fractures Treated by Internal Fixation.
(1)  Wire loop fixation. Alinement should be protected by prolonged skeletal traction followed by a spica (see 9 a (3) (4)).
(2)  Plating or Multiple Screw Fixation. Postoperative immobilization in a Thomas splint with Pierson attachment permits early knee motion. Following wound healing and a period of knee motion and quadriceps exercises, a spica (see 9 a (3) (4)) is used for evacuation to the ZI.

IV - DISASTER MANAGEMENT IN FIXED HOSPITALS.

Any hospital in the theater, no matter how far removed from the Combat Zone suddenly may be called upon at any hour of the day or night to receive and care for large numbers of wounded or injured. It is essential, therefore,


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that plans for such an emergency be made in advance and be clearly understood by both administrative and professional staffs. The following principles are important:

1.  Early recognition of what may be termed the “pattern of trauma” so that appropriate treatment may be instituted without delay. This is established by a careful examination of a representative sample of time injured and supplemented by inquiry regarding the source and nature of injury, the time elapsed since injury and the possible number of casualties to be admitted. Serious secondary effects may be masked by obvious primary manifestations:  thus, the lethal effects of underwater blast may be masked by the effects of immersion; the inhalation of noxious fumes may pass unrecognized while superficial flash burns are treated. With explosions of ammunition ships or dumps in a theater of war, consideration must always be given to the possibility that agents of chemical warfare may have been released.

2.  Establishment of wards adjacent to the admitting ward for reception of patients is essential rather than distribution of the new patients throughout the hospital.

3.  Triage is established at the time of admission to sort three groups of patients:
  a.  Those in immediate need of resuscitation, close preoperative supervision and emergency operative procedures.
  b.  Those that require surgery but will be transportable if and when it is necessary to reduce the backlog of cases awaiting operation by transfer to other hospitals for treatment.
  c.  Lightly injured that will be discharged to duty after a short period.
Patients in group a. will be sent to a “shock” ward where treatment is carried out under close supervision. They receive first priority X-ray and laboratory service.
Group b. require ordinary ward supervision and second priority X-ray and laboratory service. Clinical records should be maintained and a tentative evacuation list prepared.
Group c. should be fed and made comfortable, but professional attention postponed during the emergency period unless special indications arise.

4. Surgical Management.
Patients in group a. are assigned to operative teams who direct the preoperative care, request necessary laboratory examinations and schedule the operation. One or more officers are assigned to the Shock Ward and remain on the ward. It is their duty to be familiar with the progress of each patient; what treatment has been ordered, and what examinations are in progress or have been completed. In addition they carry out resuscitation measures under surgical direction.
After operation, if the patient is in precarious condition he should be returned to the Shock Ward or to an adjacent Postoperative War-- but under no circumstances sent to some remote ward of the hospital.


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5.  Whole Blood Transfusion
Plans must include a well thought method of supplying whole blood in considerable quantity. Circular Letter No. 30 should be studied. Reliance cannot be based on securing blood from theater transfusion units, as the function of these installations is to supply blood to armies in combat. A supply of vacuum bottles, transfusion sets, refrigerator space and a donor list from the detachment will enable the laboratory to start a banked reserve. Immediate steps may be taken to supplement the donor list from organizations in the immediate vicinity. Type specific blood should be used as most economical of donors.

6.  Reserve Surgical Supplies.
Sufficient supplies must be kept on hand at all times to meet the demands of an emergency. Vaseline gauze, fine mesh gauze and other sterile supplies may be stored in sealed containers and resterilized as often as necessary.

7. X-ray Service.
Request for X-ray examinations should be based on the priority of the case, and the X-ray Department must not be flooded with examinations that can be postponed. Patients that may be transferred to another hospital for surgical operation need not be X-rayed unless necessary to the determination of transport ability or disposition.
A system for viewing wet films should be planned, and facilities made available for the films to accompany the patient to the operating theater.

8.  If doubt exists regarding the nature, source of circumstances surrounding the incident, examination of casualties dead on arrival or dying in hospital may be of importance not only for official record but for treatment of the survivors.

For the SURGEON:
  (S)  E. STANDLEE
E. STANDLEE, Colonel, M. C., Deputy Surgeon.

DISTRIBUTION:
  Surgeon, Fifth Army 600
  Surgeon, Seventh Army 300
 Surgeon, SOS NATOUSA 800
 Surgeon, AAFSC/MTO   750
 Surgeon, Replacement Command  50
 Surgeon, NATOUSA 300


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HEADQUARTERS

MEDITERRANEAN THEATER OF OPERATIONS

UNITED STATES ARMY

Office of the Surgeon

APO 512

10 March 1945

CIRCULAR LETTER NO. 8

SUBJECT:  Notes on Care of Battle Casualties.

The contents of several previous circular letters pertaining to the surgical management of the wounded are consolidated and in certain instances extended or modified in the following recommendations.

1.  The care of the wounded must always be shaped by conditions and  circumstances that govern the tactical situation at the moment. It has been shown by this Theater that the surgery of war need not be molded by concessions to the need for haste and the confusion of caring for overwhelming numbers of patients. Military surgery is not a crude departure from accepted surgical standards, but a development of the science of surgery to carry out a specialized and highly significant mission. Modern surgical treatment employs many adjuvants to operative techniques, such as chemotherapy, fluid replacement therapy, the transfusion of whole blood and fractions of blood employed as substitutes, potent anesthetic agents and narcotics. These tools are as important to the military surgeon as his scalpel, but are equally dangerous to the patient if used without expert precision. One of the major responsibilities of the military surgeon is to make full use of these and similar measures and at the same time to avoid the dangers that may attend their usage.

The ever-present necessity for evacuation of the wounded to the rear is in fundamental conflict within ideal surgical management of the individual patient. To minimize this conflict, close coordination between the functions of administration and professional services is required. It is the responsibility of the medical officer charged with the surgical management of the patient to place technical procedures properly, both in time and in space, with due regard to the tactical situation on the one hand and to the welfare of the patient on the other. Unless the surgeon visualizes his position and the function of his hospital in relation to other surgeons and other hospitals, he may become confused in the mission he is to perform. Although some needed operation may be performed correctly, the military effort may be impeded and unforeseen harm done to the patient if the operation is done at the wrong time or in the wrong place.

It is the responsibility of administrative officers charged within the establishment of evacuation and hospitalization policies to adapt the schedules of movement of patients to the maintenance of highest standards of surgical treatment. Priority of movement must be accorded to patients with certain types of injuries just as the duration of hospitalization in a given zone must be differentially adjusted to the urgent surgical needs of the patients. The term “nontrans-


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portable” as relating to the unfitness of battle casualties for interhospital transfer must, when military necessity permits, be extended beyond actual danger to life by a consideration of the likelihood of deformity, ultimate disability, and delay of recovery when these hazards exist.

Just as the placement of various types of hospitals and consequently the provision of the facilities for surgery are determined by the geographic deployment of a military force, phases of surgical management exist that in general will conform with military echelons. These phases of surgical management are:  first aid measures, initial wound surgery, reparative wound surgery, reconstructive surgery, and rehabilitation measures.

First Aid Measures. Within the divisional area surgical management is limited to first aid measures and emergency resuscitation. Hemorrhage is controlled, splints and dressings applied, morphine administered for pain, plasma infused for resuscitation, a booster dose of tetanus toxoid is given, and chemotherapy initiated.

Initial Surgery. Actual conditions of warfare will determine both the facilities provided for emergency wound surgery and their location with reference to the combat area. In general, initial surgery is concerned with complete resuscitation so that surgery may be performed, and within surgical procedures designed to prevent or eradicate wound infection. Many of the seriously wounded casualties can be resuscitated only by a surgical operation in conjunction with transfusion and plasma therapy. For this reason, it is important that delays for the purpose of resuscitation ahead of an installation equipped for major surgery be kept at a minimum. Placement of the advance surgical hospital in physical proximity to the divisional clearing station accomplishes this end.

Reparative Surgery. The general hospitals of the communications zone receive casualties from the hospitals of the forward area for further surgical management. As the initial wound operation is by definition a limited procedure, nearly every case requires further treatment. Soft part wounds, purposely left unsutured at the initial operation, are closed by suture, usually at the time of the first dressing on or after the fourth day. Fractures are accurately reduced and immobilized until bony union takes place.

Designed to prevent or cut short wound infection either before it is established or at the time of its inception, this phase in the surgical care of the wounded is concerned with shortening the period of wound healing and seeks as its objectives the early restoration of function and the return of a soldier to duty with a minimum number of days lost. In addition, it affords the return of patients to the United States at an earlier date and in better condition and minimizes the ultimate disability and deformity in the seriously wounded.

The success of this important phase of surgery depends on the provision of an adequate period of hospitalization in addition to competent surgical care, particularly in specialized fields. It is not to be confused with the reconstructive phase of surgery, which may be postponed until return to the Zone of the


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Interior. The ideal time for the procedures of reparative surgery will be found between the fourth and tenth days after wounding. The patient then becomes “non-transportable” for a period of time which, in the case of fractures, may extend to eight or ten weeks. Transfer of patients between fixed hospitals within the zone of communications must be regulated with these considerations in mind, otherwise the objectives of this phase of surgical management may be sacrificed. The establishment of special centers within general hospitals for certain types of surgery during this phase is highly desirable, as the procedures are oftentimes of considerable magnitude and call for mature and experienced professional judgment. Advancement of general hospitals in close support of Army or utilization of air evacuation from Army to more remote fixed installations are two measures that further the establishment of a program of reparative surgery.

Reconstructive Surgery. Early evacuation to the United States is desirable for patients whose return to duty cannot be anticipated within the limits of the hospitalization policy of an overseas theater. The phases of reconstructive surgery and rehabilitation may then be integrated.

2.  Wound Management.
  a.  Initial Wound Surgery.
(1)  X-ray. In the preoperative examination of a battle casualty X-ray examination is essential.
(2)  Adequate assistance and instruments, a good light, and access to the wound that is unhampered by faulty position of the patient are basic requirements. Ample preparation of a wide field by shaving the skin will allow for extension of the incision or counterincision.
(3)  Bold incision is the first essential step in an operation on a wound. Adequate exposure is necessary to carry out excision of devitalized tissues. On the extremity the line of the incision is placed parallel within the long axis of the limb; elsewhere it follows the natural lines of skin structure. Only the devitalized skin of the margins of the wound is excised in a strip rarely wider than 2 to 3 mm. The creation of circular skin defects is avoided.
(4)  Incision and excision of the fascial layers is performed in the same manner to give free access to devitalized muscle. Unrestricted exposure of successive anatomic layers permits the complete excision of devitalized muscle and the removal of foreign bodies.
(5)  The surgeon must be familiar within the blood supply of muscles, particularly large groups like the gastrocnemius-soleus muscles of the calf and respect these vessels in his dissection. Deep recesses of the wound containing foreign bodies may be approached by counterincisions planned anatomically rather than by sacrificing normal muscle structures.
(6)  Use fine hemostats. Use the finest ligature compatible with the procedure. Include the smallest possible amount of tissue in ligating a bleeding point. Do not repeatedly bite the wound with tissue forceps. Sponge gently with pressure instead of wiping. Remaining devitalized tissue produced by


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the missile or by the surgeon must slough before the wound can be closed by secondary suture.
(7)  Large wounds in regions of heavy muscles, particularly when complicated by comminuted fracture, require especial care. The depths of these wounds must be opened by a long incision with counterincision if necessary to allow free dependent drainage.
(8)  Only enough dry, fine, mesh gauze is used to separate the surfaces of the wound. It should be smoothly laid in the wound--not “packed”.
(9)  Ether, white soap, and benzene, have slight but definite necrotizing effects on living muscles. Green soap and various other substances used as detergents have greater necrotizing effects. Physiological saline solution is relatively innocuous. In general, progress in wound management points away from the introduction of any agent unto a wound, either for its supposed mechanical or antiseptic effect.
(10)  Old wounds (48 hours or longer) are managed in accord within the same principles, except that in selected cases of established pyogenic infection and anaerobic cellulitis within toxicity the general condition of the patient to withstand radical surgery may be improved by immobilization, penicillin and repeated blood transfusions until an optimum time is selected for intervention. In postponement of surgery the advantage that accrues from the immediate drainage of septic hematomas, large masses of dead muscle, and fascial plane abscesses is not to be forgotten. Postponement of surgery is not justified if clostridial myositis (gas gangrene) may be present.
(11)  Proper transportation splinting is provided for skeletal and joint injuries. Soft part wounds are supported by firm pressure dressings and may, if extensive, be advantageously enclosed in a light plaster. Care is taken to avoid any constricting action of a pressure dressing placed on an extremity. Plaster casts must always be padded and split or bivalved before the patient is returned to the ward.
  b.  Reparative Wound Surgery.
(1)  0n arrival at a hospital where bed care can be assured for a period of at least fifteen days (soft part wounds) the original dressing is removed in the operating room under aseptic precautions. X-ray films should be at hand.  If the primary wound operation has been complete and has been properly done, all superficial wounds and many deep wounds may be closed by secondary suture at this time (4 to 10 days). Foreign bodies in soft parts adjacent to the wound are removed. Following suture, the part is immobilized, preferably by a light plaster, or if this is impractical, by bed rest.
(2)  The presence of residual dead tissue or established infection manifested by profuse discharge of pus, reddening and edema of the wound margins, persistent fever or toxicity is an indication for delay in secondary suture. When these manifestations are present but minimal, the wound is allowed to “clean up”. This process can be hastened by moist dressings or by additional surgical excision of devitalized fragments. Secondary suture


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can then be performed in a few days. If established infection is severe, or if the patient is toxic and anemic from deep seated sepsis, a course of penicillin therapy and blood transfusions is instituted and followed by radical wound revision, and staged closure.
(3)  Wounds that have been laid open properly at the initial operation tend to gape widely and give the impression of extensive skin loss. This appearance is actually due to loss of support of the deep fascia. Skin defects are more apparent than real in the majority of cases and closure of a defect is made from local tissue within suture in a straight line when possible. Undermining with advancement or rotation of flaps provides sufficient skin in nearly all instances and is preferable to grafting.
(4)  Technical considerations that are important to the success of secondary wound closures are:
  (a)  Atraumatic handling of tissue.
  (b)  Avoidance of tension sutures.
  (c)  Accurate approximation of skin margins. The epithelial bridge is the main support of the wound for a considerable period of time.
  (d)  Obliteration of dead spaces by pressure dressings and immobilization. Stab wound drainage may be instituted when desired and is preferable to drainage through the suture line.
  (e)  Leaving sutures in place for twelve days if stitch infection does not develop.
  (f)  Suture in straight lines rather than the creation of sharp angles.
(5)  Preliminary bacteriologic analysis of the flora of a wound does not provide information pertinent to making the decision to perform secondary suture or allow the prediction of the result. If the suture is not successful because of infection, appropriate studies and corrective therapy is instituted before resuture is attempted.
(6)  The conditions that most often jeopardize results are:
  (a)  Suture of a wound that is discharging pus. This usually means dead tissue in the depths.
  (b)  Too early motion. (Wounds breaking down for this reason should be immediately resutured.)
  (c)  Unrecognized foreign bodies adjacent to the wound.
  c.  Closed Plaster Treatment.
(1)  The regimen of closed plaster management of war wounds is not considered as satisfactory as the method described above when field conditions permit the use of the latter.
(2)  While the necessity for the rapid turnover of large numbers of casualties might justify an adoption of the closed plaster method of management of compound fractures, a high penalty in the form of skeletal deformity would be the inevitable result. Results obtained by secondary suture do not justify the use of closed plaster for soft part wounds.
(3)  When it is desired to allow granulations to cover exposed bone in deep irregular wounds, the wound may be encased in plaster subject to in-


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frequent changes. This is also an accepted method of management for established infection of bone, particularly when the wound has caused an extensive loss of overlying soft parts or there is a large bone defect. Before application of the plaster, all devitalized tissue and loose bone fragments are excised. There should be no pocketing or pooling of pus in the fracture site or adjacent fascial compartments. Small surfaces of bare cortical bone may be removed surgically when this permits closure of the defect by suture or skin graft.

 *   *   * * * *
 
  h.  Amputations.
(1)  The most important phase in the management of amputations is the functional rehabilitation of the patient by the fitting of a prosthesis. Amputation centers have been established in the Zone of the Interior for this purpose. It is the expressed desire of The Surgeon General that the early management of amputations in overseas theaters conform within policies that have been set forth in numerous Bulletins and Circular Letters and which are summarized below.
(2)  In the forward area., amputations will be performed at the lowest possible level except that a proximal amputation will be done in preference to a disarticulation. The technique for the performance of amputations is as follows: A circular incision is made through the skin at the lowest level compatible within viable tissue and the skin allowed to retract; the fascia is then incised at the level to which the skin has retracted. The superficial layer of muscle is then cut at the end of the fascia and permitted to retract. At its point of retraction, the deep layers of muscle are cut through to the bone. After the deep muscles have retracted, the periosteum of the bone is cleanly incised and the bone sawed through flush with the muscles. No cuff of periosteum is removed as in a closed amputation. Bone denuded of periosteum will sequestrate if infection is present and a ring sequestrum often results when the periosteum has been removed. It is important also that no periosteum be elevated or torn from the bone in the stump by rough handling. The properly performed Hapless guillotine stump exhibits a slightly concave open cross section of the extremity.
(3)  The proper dressing of the stump is important. The end of the stump is dressed with  fine mesh gauze in such a manner that it does not overlap the skin edges. Skin traction is applied immediately. This may either be by a stockinette cuff attached within ace adherent or by adhesive tape. Traction is obtained preferably by a light plaster cast within a wire ladder banjo. The cast always incorporates the joint above the amputation, e. g., a spica for an amputated thigh. The Army Hinged Half-Ring splint may be utilized as an alternative. Medical Supply Item No. 36614, Cord, Elastic, for Traction. is available and is preferable to plasma tubing for the elastic traction. Before evacuation, the traction is examined and if doubt exists as to its effectiveness it is reapplied.
(4)  At the base areas, secondary closure of a circular guillotine amputation stump is not indicated, as it is impossible to suture the inelastic fascia


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without wasteful shortening of the bone. Bone length can be saved by continuing the skin traction for an additional period of time 4 to 6 weeks. Closure of stumps by sliding flaps, plastic resection within sacrifice of bone length, or formal reamputation are procedures to be carried out in the Zone of the Interior rather than in an overseas theater. Skin grafting is not indicated. Vertical incisions in the stump made for control of infection or as part of the initial debridement should be closed by secondary suture while skin traction is being maintained to cover the defect at the end.
(5)  In the Communications Zone continuous skin traction is maintained in all cases. After removal of the cast or splint, maintenance of 4 to 6 pounds in below-knee and 6 to 8 pounds in thigh stumps of traction over a pulley at the foot of the bed is indicated. Traction is continued until the wound is healed. Priority air evacuation to the Zone of Interior should be available for amputation cases as soon as they are able to be transported. Traction during evacuation is provided for by stockinette and a banjo plaster.
  i.  Fractures.
(1)  The management of a compound fracture is divided into the following phases: first aid splinting in the field; debridement and the application of transportation splinting in a mobile hospital; final correction of the deformity and attainment of wound healing and bony union at a fixed hospital (reparative phase); reconstructive or corrective surgery (bone grafting, osteotomy, sequestrectomy, etc.) in the Zone of the Interior. In every phase attention is directed to the ultimate function of the extremity which is dependent on muscles, nerves, blood vessels and joints as well as on skeletal integrity.
(2)  Transportation Splinting applied subsequent to initial wound surgery for evacuation from mobile to fixed hospitals is not designed to provide anatomic reduction or prolonged fixation in suitable reduction. Except in rare instances it is by plaster of Paris. Plaster bandages are adequately padded and bivalved or split through all layers to the skin. Skeletal fixation by the incorporation of pins or wires into the plaster is not recommended. The only indication for the use of internal fixation in the forward area is to preserve the vascular integrity of the extremity.

Methods of transportation splinting that have proved safe and comfortable are:

Femur:  A low waisted “one and one half” plaster spica within the knee slightly flexed and minimal abduction.
The Tobruk plaster and the Army leg splint within skin traction do not provide as adequate immobilization and should only be used as emergency measures when large numbers of casualties or multiple wounds in a single casualty demand concessions to operating time or for special indications such as the presence of a colostomy or suprapubic cystostomy. When restricted to lower third femoral fractures and knee joint injuries the Tobruk splint provides adequate immobilization.

Humerus
: A thoracobrachial plaster with the arm forward in internal rotation.


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A plaster Velpeau bandage binding the arm to the trunk within the forearm flexed at a right angle and placed across the chest.
The Army humerus splint designed for field (first aid) use is not suitable for postoperative transportation splinting.
A hanging cast is both uncomfortable and ineffective as a method of transportation splinting.

Forearm
:
A circular plaster bandage that extends to the midbrachial region within flexion of the elbow and extending only to the proximal palmar crease.
Plaster slabs in the form of “sugar-tongs.”

Tibia and Fibula
:
A circular plaster bandage from toes to groin. The knee is slightly (15 degrees) flexed and the foot held in neutral position at 90 degrees to the axis of the limb. A plantar slab may extend beyond the toes to afford protection, but hyperextension is to be avoided.
(3)  Reparative Surgery of Compound Fractures. (See Wound Management, par. 2 c on Closed Plaster Treatment.)
Reparative surgery in compound fractures is made necessary by leaving unsutured the large incisions made for debridement and the recognized fact that splinting suitable for transportation is inadequate for complete reduction and fixation of the fracture. The goal is functional restoration of the extremity and demands treatment of muscle and nerve injury as well as skeletal damage. Observance of certain basic principles are important to the success of this phase of management.

Preoperative correction of anemia by whole blood transfusion. Despite whole blood transfusion for resuscitation in the forward area, a high percentage of compound fracture cases will arrive at a fixed hospital in the Communications Zone with low red cell volume (hematocrit) and hemoglobin. An approximate estimate of the quantity of whole blood needed to restore red cell volume may be deduced from the rough rule of 500 cc blood for each 3 points of the hematocrit or 0.9 grams of hemoglobin. In the use of whole blood transfusion for correction of secondary anemia or hypoproteinemia the total volume administered in a 24 hour period should not exceed 1000 cc except to replace blood lost at operative procedures. Thus is in contrast within the larger volumes that are administered for resuscitation when the total circulating blood volume may be greatly reduced. No correlation exists between the hematocrit or hemoglobin levels and circulating blood volume and care must be taken not to precipitate pulmonary edema by overtransfusion of a patient in whom the blood volume has been restored by dilution but who still shows a greatly reduced cell volume (hematocrit) and hemoglobin.

The surgical elimination of residual necrotic tissue. No available chemotherapeutic agent can “sterilize” an open wound containing devitalized tissue or blood clot. A properly managed clean wound requires no local antiseptic.

The control of invasive infection by systemic chemotherapy. Systemic penicillin therapy in a dosage of 25,000 units every three hours is recommended


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as a routine adjuvant for secondary operations on compound fractures. Treatment is continued postoperatively until the likelihood of invasive infection is passed.

Reduction or closure of soft tissue defects. Exposed cortex of bone, nerves and tendons are vulnerable to the necrotizing effect. of wound suppuration and are protected by the apposition of adjacent soft parts.  Transversely divided important muscle groups are united by suture. Fascial compartments are restored to minimize scarring and improve muscle function. Certain of these procedures may be staged operations. Emphasis should not be placed on early or complete skin closure, as in most cases any remaining cutaneous defect will heal before bony union occurs.

Provision of drainage for residual exudate. Severely comminuted fractures may require dependent drainage in association with the apposition of soft parts over exposed bone. Exteriorizing fascial plane incisions have proven superior to stab wounds or rubber drains. Upper extremity fractures rarely present a drainage problem. The thigh may be drained by a posterolateral incision between the vastus lateralis and the biceps. An adequate posterior drainage route for the shaft of the tibia does not exist and such an injury may necessitate a period of "on the face" nursing.

Internal fixation of battle fractures is not feasible commonly because of extensive comminution. Further, the method demands further periosteal stripping and surgical trauma to the wound. Limitation of the use of this method to cases carefully selected by specialists fully experienced in the techniques and  hazards of its usage is strongly advised. An example of sound usage is the employment of screws for restoration of the anticular surface of a major joint. Reduction of the fracture is the goal of reparative surgery--not the use of internal fixation.

Use of suspension traction. The application of suspension traction in the treatment of fractures, particularly those of the femur, is the safest and most satisfactory method of management.  In fixed hospitals fractures of the femur should be treated by skeletal traction for ten to twelve weeks until enough union has been obtained to permit safe transportation to the Zone of the Interior in a plaster spica. The use of suspension traction promotes the maintenance of joint and muscle function and prevents angulation or over-riding deformity.

Overpull and resulting distraction must be avoided at all times, particularly in cases associated with injury or division of the thigh muscles. Certain cases of this type require very expert attention and delay in the application of traction until firm fibrous union of muscles has been attained by suture.

  j.  Joints.
Early complete debridement is the keystone of success in the management of wounds that compound a joint. The wound of the soft part is excised and the bone and cartilage damage assessed through incisions that provide complete exposure. Comminuted fragments of bone and cartilage are removed from the joint and a careful search made for foreign material. Badly comminuted frac-


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tures of the patella are excised completely as a step in the debridement of a knee joint wound.

Every effort is made, after cleansing the joint cavity, to close the capsule. The skin is left unsutured. Closure of the joint is especially  difficult the face of extensive loss of soft parts. When it is impossible to close a joint by suture of synovia or capsule, an occlusive dressing is applied. On arrival at a fixed hospital, effort is directed toward closing the defect by advancement of a skin flap or other plastic procedure.

Adequate exposure of the hip joint is a specialized procedure that requires precise anatomical orientation. The same principle of management must be applied to improve the results of this particular lesion.

Penicillin is inserted into a joint at the end of the operation. In joints that are accessible to needle aspiration, accumulating exudate may be withdrawn and penicillin injected during the postoperative period.

Wounds of the ankle joint within comminution of the os calcis or astragalus are peculiarly liable to sepsis. Initial debridement of comminuted bone fragments must be minimal if function is to be preserved and early efforts are made in the reparative surgical phase to reduce or close the skin defect with split thickness graft when necessary. When sepsis is established, subperiosteal excision of necrotic bone fragments followed by wound closure by graft or suture should not be delayed.

For the SURGEON:
  (S)  E. STANDLEE
E. STANDLEE, Colonel, M. C., Deputy Surgeon.

DISTRIBUTION:
 Surgeon, PENBASE  300
 Surgeon, NORBS 20
 Hq. A/G of S 10
 Surgeon, Adriatic Base Command  100
 Surgeon, Fifth Army 600
 Surgeon, AAFSC/MTO 700
 Surgeon, Replacement Command 50
 Surgeon, Rome Area Command 25
 Surgeon, Hq. Command, AF 30
 Surgeon, MTOUSA 300