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Preface

Contents

Preface

In World War II, as in all previous wars, wounds of the extremities, a great number of which involved the bones and joints, constituted the bulk of the surgical load. In the Mediterranean (previously the North African) Theater of Operations, of 111,125 wounded or injured in action it is estimated that 79,000, more than 71 percent of the total number, sustained wounds of the extremities. A significant proportion of these required orthopedic management. Incidentally, the number of wounds of the extremities in this theater approximately equaled the total number of wounded or injured in action (79,526) in the entire Korean conflict

'These figures are not surprising. In the Mediterranean theater, United States Army ground forces experienced the longest period of continuous ground combat which they had known since the War Between the States. With only very brief interludes, in the early and late summer of 1943, they were in constant contact with the enemy from 8 November 1942 until 2 May 1945. They fought from the shores of Casablanca across North Africa to Bizerte. After a short respite, they conquered Sicily. After another interlude, they invaded Italy and fought to the Swiss border.

The medical history of the Mediterranean theater parallels the tactical history. The steady flow of battle casualties through forward and fixed hospitals from November 1942 until May 1945 provided a concentrated experience in military surgery, unusual opportunities for the observation of results, and, on indications changes in both concepts and methods. These changes are described in detail in the chapters of this volume. In brief, the management of compound skeletal injuries in the early days of this experience was based upon the concepts of plasma for shock, sulfonamide drugs for the prevention of infection, and the closed plaster method for the management of fractures and wounds. As the result of continuing observation of the results obtained in the theater, each of these concepts was discarded

Long before the fall of Rome on 5 June 1944, the prevailing concepts were that the most important preventive measure against wound infection was adequate debridement at initial wound surgery; that whole blood was crucial in the management of wounded men; that penicillin, used systemically, was an important measure in impending or established infection; and that wounds left open at initial surgery need not heal by granulation but, instead, that it was surgically feasible to perform delayed closure of clinically clean wounds over fractures, following which good results could be anticipated.

The delayed primary closure of soft-tissue wounds by suture, including wounds associated with compound fractures, was not, of course, an entirely new concept It had been practiced to some extent in World War I. In that war, however, the criterion of low bacterial count on repeated cultures of the wound before delayed closure was undertaken not only made the method impractical for general use but also, because of the repeated dressings necessary, was an invitation to secondary infection. In World War II, closure was predicated upon only a clean clinical appearance of the wound several days after the initial surgery. The method was, therefore, more widely applicable.

The lessons of World War I had, in large measure, to be learned again in World War II. Lives and limbs will be saved, and countless extended periods of morbidity will be avoided, if the lessons derived from the Mediterranean-theater experience with musculoskeletal injuries as set forth in this volume are put into practice without delay in any future war.

OSCAR P. HAMPTON, Jr., M. D.