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Chapter VIII



Plastic Surgery

Eugene M. Bricker, M.D.


In a description of the activities of a surgical specialty consultant in a theater of operations, the subject divides naturally into two main headings: Administrative and professional. While, in fact, the functions of administration and professional care were inseparably related, they were so completely different in nature that it appears justifiable to separate them in this account for purposes of clarity. Two admissions are readily made: (1) The history will be biased in that the author is convinced of the importance of plastic surgery in a theater of operations if the best care is to be available to all casualties; (2) any suggestions concerning the organization and use of personnel are made with an operation such as that in the European theater in mind, and with the realization that a future war may be entirely different.

At the beginning of World War II, plastic surgery could still be considered as a relatively new specialty. It was adolescent during World War I, when it was practiced by few surgeons who approached it from various other fields of primary interest, including dentistry, otorhinolaryngology, and general surgery. Following World War I, plastic surgery grew to maturity, as a well-defined specialty, in very few clinics throughout the country. Its function in a theater of operations was incompletely realized at the outbreak of World War II, though the need for adequate coverage in plastic surgery was recognized by Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA (European Theater of Operations, U.S. Army), and a full-time consultant in this specialty was present in the theater throughout the campaign. It could be said that the specialty, as applicable to a theater of operations, approached full maturity during the war in Europe.

In the development of the Professional Services Division, Office of the Chief Surgeon, ETOUSA, a consultant in plastic surgery was one of the first to be named. The value of adequate organization of this specialty had been impressed upon members of the U.S. Armed Forces in the British Isles by the great number of casualties resulting from the Battle of Britain that required reconstructive plastic surgery. Lt. Col. (later Col.) James B. Brown, MC (fig.182), arrived in England on 2 July 1942 in response to a specific request for a plastic surgery consultant. Colonel Brown was accompanied by Lt. Col. Eugene M. Bricker, MC (fig. 183), who succeeded him as Senior Consultant in


Plastic Surgery, ETOUSA, on 12 June 1943, after Colonel Brown had returned to the Zone of Interior to organize and direct a plastic surgery center at Valley Forge General Hospital, Phoenixville, Pa. Throughout the entire campaign until the dissolution of the Professional Services Division of the Chief Surgeon's Office in July 1945, the author worked in close cooperation with the consultants in the other surgical specialties. The work of the Senior Consultant in Plastic Surgery was closely associated with that of Col. Roy A. Stout, DC, Senior Consultant in Maxillofacial Surgery of the Dental Corps (fig. 184). This relationship was maintained on a completely cooperative basis, the function of the two specialties being determined by the fundamental consideration of surgical training and experience.

FIGURE 182.-Lt. Col. James B. Brown, MC.


The administrative duties of all consultants were concerned with the provision of a high standard of professional care for casualties at all echelons. This responsibility became intimately involved with tables of organization, tables of supply, professional qualifications of personnel, evacuation of casualties, and the establishment of professional policies. At the time of this writing, and for the purpose at hand, it seems best to cover the subjects briefly and in a general way as they concern the specialty of plastic surgery. The consultant found himself continually traveling from hospital center to hospital center and from hospital to hospital out of headquarters based successively in London, Cheltenham, Normandy, and Paris. This was a remarkable experience for a consultant out of civilian life. The enormity of the buildup in England for the invasion of Normandy will probably never be equaled in the future. Indeed, if future wars are to occur, it is doubtful that such an enormous land


force poised for invasion will be necessary. The magnitude of the Channel crossing and the problems presented in caring for and evacuating the wounded were unique in the annals of military medicine.

Tables of Organization

At the termination of the conflict, it was believed that the tables of organization should be brought abreast of the recent advances in the development of surgical specialties, and that they should particularly allow for the possible limitation of the number of qualified specialists. There was a constant conflict throughout the campaign between the location of plastic surgeons according to the tables of organization and the actual location of plastic surgeons in line with logical developments based on need. Thus, as a result of the size of this operation and the number of hospital units involved, it was never practical or possible to supply each 750-bed and 400-bed evacuation hospital with a qualified plastic surgeon as required by the tables of organization. The placing of plastic surgeons on field army unit tables of organization was founded on the principle that a very important period for surgery of maxillofacial wounds is early after injury. The progress of the campaign proved this con-

FIGURE 183.-Lt. Col. Eugene M. Bricker, MC.


cept to be correct, but the planning that called for an impossibly large number of plastic surgeons to be in army areas was in error.

Plastic surgery in a theater of operations plays its major role at two levels: (1) At the evacuation hospital level in army areas where definitive therapy is required for compound facial injuries, and (2) in the general hospitals of the communications zone where later definitive therapy can be given to massive soft-tissue wounds, burns, and definitive therapy can be continued for maxillofacial wounds. The placement of plastic surgeons in the communications zone general hospitals was accomplished without table of organization provision for them. This difficulty was not insurmountable, and it was one of the responsibilities of the consultant to overcome it. However, the problem seemed to be of some magnitude at the time, both to the consultant who was trying to manipulate hospitals and personnel, and to the personnel being manipulated into tables of organization with no provision for them. The simple human characteristic of desiring earned advance in rank was frequently thwarted as a result of these administrative difficulties. It is recognized that some of these difficulties were unique to the specialty which was still developing and the role of which in a theater of operations was still not clearly understood.

FIGURE 184.-Col. Roy A. Stout, DC.


As the preceding discussion suggests, the problems of personnel were chiefly precipitated by the tables of organization. During the 2-year preparation for the invasion of France, the need for qualified plastic surgeons to care for the injuries occurring among thousands of staging and training troops was repeat-


edly demonstrated. During part of this period, there were only two plastic surgeons in England who could be designated as qualified for the care of complicated cases. The situation was relieved in the latter part of 1943 by the arrival of several plastic surgeons with incoming general hospitals and by the return of army units from North Africa. During this long period before D-day, active combat was being carried on by the Eighth Air Force in East Anglia. The Eighth Air Force was served by a group of station hospitals, into certain ones of which specialist personnel were placed. The whole experience of providing specialist care for tremendous numbers of staging troops, and for an active air force based in the communications zone, demonstrated again and again the urgent need for highly qualified surgeons in all the specialties. In the specialties in which there was a shortage of qualified surgeons, it became imperative that those who were qualified be placed in such a position that they could cover a geographical area, and not have their activities confined entirely to the unit in which they were assigned.

At the end of the war, there were present in the theater 70 medical officers with the MOS (military occupational specialty) classification of Specialist in Plastic Surgery. As 9 of the 70 were in administrative or other types of positions, it was impossible to use them in active clinical work in plastic surgery. Of the remaining 61 surgeons, 24 had a "D" classification; the majority of the 24 were general surgeons or specialists in some other branch of surgery. A much more accurate appreciation of the supply of plastic surgeons in the theater than is afforded by a survey of the 70 so listed can be obtained by realization of the fact that only 15 of the 70 were classified as "B" or above, and only 8 of the 15 were available for use in clinical plastic surgery. The total number of plastic surgeons available for clinical use with classifications of "C" or above was only 27. It seemed obvious that the place for the more experienced plastic surgeons was in the hospitals located to the rear where a large number of patients could be funneled to them, where the holding period was longer, and where they would have an opportunity to cover a broader field of surgery than was possible in the forward units. Accordingly, insofar as possible, the more capable surgeons were retained in the rear, and the excessive demands of army unit tables of organization were met with the surgeons in the lower classifications. Of the 24 surgeons in the "D" category, 13 were with evacuation hospitals. This consultant received wonderful cooperation from these men along with the remarkable patience and courtesy with which they accepted his own limitations.

The training of additional plastic surgeons within the theater proved to be a completely impractical task. The very nature of the work made it mandatory that a relatively long period be devoted completely to the specialty before any degree of proficiency could be attained. During the long, quiet period in England, there were not enough casualties accumulated in any one area or location to offer training material of any value. The medical officers who would benefit most from short periods of training were those who already had an extensive background in surgery. Such officers in most instances were


loath to give up their chosen field of surgery which, in many instances, would have resulted in forfeiture of chance for advancement in rank. There were a multitude of officers who were anxious to get into plastic surgery, but almost invariably the meager surgical background of these men eliminated them from being anything other than assistants. Advantage was taken of the presence of established British plastic surgery centers for training of U.S. Army surgeons during the long periods of relative inactivity. The surgeons ordered to these units were those with previous training in plastic surgery who would be most benefited. The most extensively used British unit was that at the Queen Victoria Cottage Hospital, East Grinstead, Sussex East. Approximately 50 officers were sent there for 10 days of lectures and demonstrations by Mr. Archibald McIndoe (later knighted). Other units at which American officers were placed on temporary duty were the Hill End Hospital at St. Albans under Mr. Rainsford Mowlem and the Emergency Medical Service Hospital at Park Prewett, Basingstoke, under Sir Harold Gillies. These British surgeons and many others showed a marked degree of cooperation and courtesy throughout the period of close association in England.

It would be impossible to pay individual tribute to the various surgeons who did so much in this specialty during this phrase of the war in Britain and Europe. To mention a few would be unfair to others. Much of the clinical work was quite outstanding, and many of the surgeons had an opportunity to demonstrate originality and imagination in their approach to the various complicated clinical problems. Furthermore, the administrative ability that, of necessity, accompanied the clinical work of setting up a plastic surgery service in a hospital and hospital center was enough to deserve special recognition.


Problems of supply were a rather minor but a constant source of concern for each consultant. The Supply Division of the Chief Surgeon's Office was always found to be very cooperative in the procurement and distribution of nonstandard items. Tables of equipment and basic allowances were found to be inadequate for the needs of the hospitals for special treatment that were developed as the campaign progressed. The items concerned pertained to the specialized types of surgery on large volumes of casualties. Detailed comments regarding deficiencies of supply were made in a report to The Surgeon General completed shortly after the war. It was believed that, since the use of hospitals for special treatment had reached such a degree of development and recognition in the European theater, in addition to the changes in organization aimed at facilitating the establishment of these hospitals, consideration should be given to the need for supplementary tables of equipment to furnish such units. The items concerned were such things as suction apparatus, needles and suture material, needle holders, tissue forceps, skin hooks, small hemostatic forceps, cotton-waste dressing material, dental arch bars, and dental elevators, all of which, it can be seen, are instruments of a specialty nature.


The complete absence of photographic equipment as an item of medical supply to both communications zone and combat zone hospitals was keenly felt as a handicap throughout the campaign. The need for such equipment was partially relieved by procurement from the British. "Photographic units" were placed with most of the hospital centers. In most instances, the equipment was placed in a hospital performing plastic surgery. It was found that reliance on the Signal Corps for clinical photography was completely unsatisfactory. There always seemed to be plenty of photographs of British nobility visiting the hospitals, but, when an overworked operating surgeon wanted a photograph of some important clinical condition at an irregular hour or on an offday, it was often next to impossible to get it. Clinical photography in the U.S. Army Medical Department was a sorely neglected field that cannot adequately be discussed here. A single detachment of artists and photographers from the Army Medical Museum, such as was supplied in the European theater, was not a satisfactory solution.


Careful supervision of the policies regarding evacuation and constant observation of the flow of casualties to insure that those which were an exception to the general rule were promptly and adequately provided for proved to be among the most important duties and responsibilities of a consultant. The general picture of evacuation varied from day to day and was influenced by the tactical situation, the number of casualties, and the weather. Maxillofacial injuries were considered to travel well. Their early evacuation from army areas was urged, and provisions had to be made in the communications zone to insure against their being lost and not being transferred promptly into the hospitals for special treatment. Burn casualties were also evacuated into specialty hospitals as soon as possible. No special provision was made for the large number of extremity wounds which would require plastic surgery. These cases were picked out of the hospitals in the communications zone and transferred to hospitals providing plastic surgery service as soon as the need for this type of surgery was recognized. Transit and holding hospitals played a very important part of the evacuation of specialty type casualties. The following paragraphs from the Semi-Annual Report, Plastic and Maxillofacial Sections, Professional Services Division, Office of the Chief Surgeon, U.S. Forces European Theater, for the period 1 January-30 June 1945, indicate the main features of the evacuation problem presented by casualties with severe facial injuries:

The care of maxillofacial casualties is directly related to the efficiency and speed of evacuation, since continuity of treatment must be maintained. Throughout the campaign, one of the chief duties of the Senior Consultants in Plastic and Maxillofacial Surgery has been to enforce priority of evacuation for maxillofacial casualties, to brief air holding units in the preparation of casualties for air evacuation, and to see that patients were properly dispersed from landing areas in which a high concentration of cases accumulated. Train and boat evacuation also presented the problem of making Hospital Train crews and Hospital Ship Platoons aware of the special problems involved in caring for and feeding


the severe maxillofacial casualties. Arrangements were finally made with Evacuation Divisions of the various Commands to have those maxillofacial casualties going to the Zone of Interior by water to go only on Hospital Ships, where care by properly instructed medical personnel could be depended upon.

1. Air Evacuation:    a. Front to Paris: Maxillofacial casualties were given a high priority of evacuation directly from the front to Paris, where they were accumulated in the 108th and the 1st General Hospitals. This relieved the load on the forward transit general hospitals and placed the casualties early in the hands of specialists, where they could remain until ready for evacuation to the Zone of Interior.

b. Front to England: Any available air lift to England was taken advantage of by priority maxillofacial casualties. There were periods when casualties were admitted to the special hospitals in England within 36 to 48 hours of the time of injury. This proved to be a tremendous advantage in securing the quality of specialist care desired at an early date and making it unnecessary for the case to go through repeated stages of evacuation.

c. Liége to England: The 15th General Hospital at Liége, Belgium, functioned as a special maxillofacial hospital for the 820th Hospital Center and as a holding transit unit for air evacuation to England. This arrangement functioned very well during the heavy Ardennes fighting and served to decrease the load arriving in the Paris area, as well as to keep the casualties in the hands of specialists. Major Carroll Stuart, MC, and Major Leo La Dage's team of the 5th Auxiliary Surgical Group did a very commendable job at this unit while the casualties were heavy and Liége was being bombed. In England the air evacuated casualties were passed through the 154th General Hospital near Swindon. Personnel were added to this unit to care for the load of casualties. From the 154th General Hospital, the cases were dispersed to the 117th, the 91st, the 192nd, and the 158th General Hospitals by ambulance, and to other hospitals by train or hospital car.

d. Paris to Zone of Interior: Maxillofacial casualties were given first priority for air evacuation to the Zone of the Interior. Paris was the departure point from the Continent. The 1st General Hospital functioned as air holding unit where the adequacy of preparation for air evacuation was checked.

e. England to Zone of Interior: From all special hospitals in England cases were evacuated to the Zone of the Interior by air as air lift was available.

2. Train and Boat: Insofar as possible, all maxillofacial casualties were evacuated by air. Evacuation to the Zone of the Interior by boat was confined to Hospital Ships during the latter part of the campaign.

3. Function of Transit Hospitals at Liége and Swindon: The designation of such specialty transit hospitals was found to be a very necessary step to control the direction of evacuation and to insure patients falling to the hands of surgeons and dentists with special training and interest. Approximately 3,000 maxillofacial casualties passed through the 154th General Hospital at Swindon from D-day to V-E Day.

Plastic or Maxillofacial Surgery Centers

The establishment of hospitals for special treatment, or "plastic and maxillofacial surgery centers" presented problems that were inseparable from those described in preceding paragraphs on tables of organization and personnel. As a matter of fact, the establishment of these specialty hospitals was the solution to the tables of organization and personnel problems. On 30 March 1943, in a letter on the subject of patients requiring plastic surgery, the Office of the Chief Surgeon, ETOUSA, designated the 298th General Hospital, at Bristol, and the 30th General Hospital, at Mansfield, as centers for plastic surgery. During the following year eight more specialty hospitals for plastic surgery were developed in England. On 10 June 1944, Circular Letter No. 81,


concerning hospitals with facilities for specialized treatment, was issued by the Office of the Chief Surgeon, ETOUSA, and designated hospitals for special treatment and plastic surgery, neurosurgery, thoracic surgery, and urological surgery. Thus 10 hospitals, scattered geographically to cover all areas of hospitalization in England, were designated as plastic and maxillofacial surgery centers. Subsequently, one more general hospital was so designated in England. This arrangement provided one plastic surgeon to approximately 10,000 hospital beds. If specialist care was to be made available to all casualties arriving in England, it would be necessary to scatter the available surgeons geographically rather than to place them in a smaller number of hospitals and thus allow each hospital a larger staff. Previous experience warned, and it was later vividly demonstrated, that during the heavy flow of casualties long ambulance hauls of patients to specialized hospitals would not be possible. Plastic surgery could not have served the mass of casualties in England through two or three ideally setup and ideally staffed plastic surgery services.

Preparation for the designation of a hospital as a so-called specialty center usually consisted of moving a qualified specialist into the hospital chosen. This move was preceded in eight of the centers by the installation of additional facilities in the hospital plant for the late treatment of burns by saline baths. From here on, development of the specialty section became largely the responsibility of the specialist himself. In the case of plastic surgery in 1,000-bed communications zone general hospitals, the difficulties encountered resulted directly from the tables of organization. A new surgical section requiring nurses, ward officers, trained technicians, and some items of special equipment had to be fitted into a hospital which was considered to be already organizationally complete. In some instances, weeks or months transpired before a section could be sufficiently developed to be considered possibly to be running efficiently. The plastic surgeon became all integral part of the hospital to which he was assigned. This was an advantage so far as cooperation from other members of the hospital was concerned, but it proved to be a great disadvantage when movement of the surgeons became necessary. Replacements were always necessary or wanted when a surgeon was to be moved. The finding of a replacement and the prolonged administrative details of changing the surgeon's assignment from one hospital to another resulted, in some instances, in defeating the object of getting the surgeon quickly transferred to a place in which he was more urgently needed.

In England, the plastic surgery centers had the most favorable opportunities to develop and to work efficiently. The administrative decentralization that started very early after the influx of large numbers of troops favored the efficient function of specialty hospitals. The breaking up of England into base sections made it possible for certain hospitals to be designated for the coverage of a base section. The desires and recommendations of the Chief Surgeon's senior consultants were enforced through a base section directive, and the base section consultants were of inestimable value in seeing that such directives were followed. Later, when England became designated as the United Kingdom


Base Section, the division of the hospitals into hospital groups again facilitated the use of special hospitals. The most efficient organization prevailed at the end of the campaign when all hospitals in England were included administratively under seven hospital center headquarters. The areas covered by the hospital centers were smaller, the hospitals were usually fairly well concentrated, and the contact between the surgeon of the hospital center and the commanding officers of various hospitals was direct. By the time this administrative organization had developed, the plastic surgery centers were established and their functions understood. Transfer of patients from other hospitals to the plastic surgery centers was carried out with a satisfactory degree of efficiency. The plastic surgeons in the designated hospitals acted as consultants for the hospital centers, thereby furthering the good relationship between the various hospitals and the specialty surgical services.

The situation as it existed in England during the terminal months of the campaign could be considered as being almost ideal, with one exception: The plastic surgery services in the individual chosen hospitals still had to be developed on an entirely improvised basis. The additional help that was necessary was not provided in the hospital organization. It was necessary to beg, borrow, or steal it. The same often was true of adequate ward, dressing room, and operation room space. In addition, with the shortage of qualified plastic surgeons, it eventually seemed advisable to close a service in one of the hospitals and to depend for coverage of the area on transfer of patients to a hospital in an adjoining hospital center. Withdrawal of the specialist from a hospital nearly always met with opposition from the commanding officer of the hospital as well as from the commanding officer of the hospital center involved. This opposition was understandable, since it was the duty of the hospital center commanding officer to insure adequate professional coverage for his command. Nevertheless, it was often difficult to fit the supply of plastic surgeons to the obvious needs and at the same time supply the supposed needs of individual administrative subdivisions that were not acquainted with the overall picture of supply and demand in surgical specialists. These difficulties are enumerated not because they were insurmountable administrative obstacles but because they appeared to be unnecessary; that is, they could have been avoided by better planning for the distribution of specialist personnel.

Professional Policies

Professional policies for the theater emanated from the consultants in the Professional Services Division of the Office of the Chief Surgeon. The formulation of professional policies was influenced by many factors that required serious consideration in planning for the care of casualties falling into a surgical specialty. The factors of greatest significance were (1) the expected numerical flow of casualties, (2) the average professional ability of the personnel that were to handle the casualties, (3) the specific needs of the particular types of injuries, and (4) the hospitalization policy for the theater (which was


gradually shortened as the reserve of hospital beds decreased). Policies were made known from the Office of the Chief Surgeon by circular letters, administrative memorandum, subject letters, and contact of the Chief Surgeon's consultants with the medical personnel in the various hospitals. The Manual of Therapy, ETOUSA, compiled by the consultants and published in May 1944, served as a guide to the general medical and surgical officers and to the various specialists. With the reception of large numbers of casualties, certain policies were changed and the changes made known in subsequent circular letters on professional care.

The very close contact it was possible for the Senior Consultant in Plastic Surgery to maintain with the plastic surgeons throughout the various centers in England and France proved to be of enormous value. Current professional problems could be discussed in this way and ideas of the various surgeons interchanged. In addition, frequent visits between the surgeons of the different plastic surgery centers were encouraged. It was thus possible to define the limits of plastic surgery to be carried out in the theater and to see that these policies were uniformly adhered to. It was always the aim to do only what was urgently indicated and to prepare the patients for evacuation to the Zone of Interior as soon as possible. The Medical Bulletin, ETOUSA, published monthly, served as a very valuable unofficial means of getting information to medical officers throughout the theater. This publication was used to advertise the specialty centers, to explain their function, and to encourage the transfer of patients to these hospitals. The administrative professional policies pertaining to the various types of casualties falling to plastic surgery are discussed in subsequent paragraphs devoted to professional care.


It was the responsibility of a surgical consultant to see that, so far as possible, each casualty was directed to the hands of a physician qualified to provide the necessary care as rapidly as this could be accomplished after injury. As indicated in the foregoing discussion of administration, this responsibility concerned the consultant with all phases of the tactical situation, but chiefly with the evacuation of casualties and the placement of professional personnel. Since plastic surgery was coming of age and was represented by a consultant in the Office of the Chief Surgeon, it seemed advisable to establish a definition of what plastic surgery should entail. Accordingly, plastic surgery was defined, in Circular Letter No. 5, Office of the Chief Surgeon, Headquarters, ETOUSA, by the Chief Surgeon on 12 January 1943, while Colonel Brown was still in the theater, as follows:

1. Definition: Plastic surgery includes maxillofacial surgery and is defined as the care and treatment, in all stages of:

a. Injuries of the face and jaws that may alter the shape of the bony structure or leave disfiguring scars.

b. Injuries of any part of the body which require skin grafts or flaps, scar adjustments or surface tissue readjustment.


c. Serious burns which may not be regarded initially as falling within the classes in subparagraphs a and b above.

2. Technical Supervision: The Senior Consultant in Plastic Surgery is the adviser of the Chief Surgeon and will, under the direction of the latter, exercise technical supervision of all plastic surgery in ETOUSA, regardless of echelon.

The definition was a good one and served a very useful purpose in clarifying responsibility in matters of professional policy. The inclusion of maxillofacial surgery under plastic surgery is difficult to justify completely since the fundamental sources of training are quite different for each, and the two fields, though closely associated in many ways, are quite divergent in others. Except in the case of a few surgeons, qualified in both surgery and dentistry, it was always necessary for the two specialists to work as a team if the highest standard of care was to be maintained. Patients were admitted to hospitals on the surgical service under the responsibility of the chief of surgical service. The dental officers were used to the fullest extent and furnished constant and invaluable assistance in caring for all cases of fractures and injuries about the mouth. Without the dental officers to help with such cases, the surgical services would have been crippled. Subsequent comments on the treatment of maxillofacial casualties in this chapter step considerably unto the field of the dental officer with maxillofacial training. Colonel Stout, Senior Consultant in Maxillofacial Surgery, worked side by side with the Senior Consultant in Plastic Surgery in the care and supervision of maxillofacial injuries, and many of the views expressed on this subject stem directly from him.

This author, having been drafted into the position of Senior Consultant in Plastic Surgery, has long had mixed feelings about the advisability of a man who is basically a general surgeon acting as consultant in such a specialty. However, the professional policies and decisions that were required in this theater of operations were of such basic commonsense and general surgical nature that the situation was not as incongruous as it might have been. It was found that, in addition to bedside consultation, the consultant could provide an important professional service by the rapid word-of-mouth dissemination of information during his travels. He was in excellent position to observe and to utilize the knowledge and experience of many first-class surgeons and thus crystallize ideas and policies that were generally beneficial. It was most important that the natural process of learning by experience be speeded up as much as possible in order that the good in professional policies be separated from the bad and promptly put into general practice. The consultant was in a key position to facilitate this process and to appreciate the necessity for altering professional policies in accordance with the dictates of the tactical situation.

Maxillofacial Injuries

Before World War II, the only definite knowledge available concerning treatment of the severe facial wounds of war was that which resulted from World War I. The basic principle of treatment of severe facial wounds ema-


nating from World War I was that such wounds should be closed, or partially closed, and that massive displacements of tissue were to be replaced as soon as possible, with primary healing as the aim. The basic principle had been supplemented because of two very important factors by the time the active phase of World War II approached: (1) Twenty years of civilian experience had been acquired in handling the severe injuries resulting from the speedup and increase in motor transportation; (2) chemotherapy had established an important place as a method of prophylaxis and treatment of infections. It was believed that these two factors would allow aggressive extension of the basic principles emanating from World War I. Thus, it was concluded that the time for complete definitive surgery was immediately in the hands of the first qualified specialist who received the patient, providing that the procedure was feasible and not complicated by such loss of tissue as to make it impossible. Even the latter cases should be treated definitively as far as possible, leaving only replacement and reconstructive procedures to be done at a later date. The object was to produce definitive treatment that would make it necessary, in many cases, for later surgery to consist only of superficial wound revision or excision. The proper treatment of fractures was an integral part of the procedure. In order to approach as nearly as possible the theoretical ideal, definitive surgery at the evacuation hospital level was urged to the limit of the professional talent available there. So far as possible, the most highly qualified plastic surgeons were retained in the rear medical installations where they could handle a greater volume of casualties through triage and where their talents could be used on a broader scope of surgery than at the front. The system produced results that were quite gratifying, considering the tremendous geographical area covered and the mass of casualties handled.

A section of the Manual of Therapy, ETOUSA (app. F, p. 989), indicates the policies pertaining to the treatment of maxillofacial injuries that were in effect at the time of the Normandy invasion.

The sources of severe facial injuries were multiple. Civilian-type injuries resulting from vehicle accidents and fist fights were always common, and, during the period before the invasion of France, provided the majority of maxillofacial injuries. Casualties from the Air Forces presented no notably characteristic features. Landing and takeoff accidents resulted in a number of blunt-force facial injuries, many of them complicated by associated burns. Flak wounds varied from massive shearing injuries caused by large shell fragments to small perforating ones resulting from small missiles. Some of the small missiles from flak were of exceedingly high velocity and produced considerable comminution and "blowing out" of the face. During the hedgerow fighting in Normandy, there was an unusually high incidence of maxillofacial injuries resulting from the close type of combat and the necessity for the men to expose their heads to see the enemy. These wounds were predominantly caused by small arms fire and were characterized by being exceedingly severe and not


FIGURE 185.-Anterior and lateral views of very extensive injury, associated with extensive loss of tissue. Note the tracheostomy which was absolutely essential for the survival of this patient. Such casualties also presented extremely difficult feeding problems, and a gastrostomy was occasionally justified. Little of a truly restorative or a reconstructive nature can be done for such an injury during the early phase of care. The problem is one of keeping the patient alive and getting him ready for evacuation to the Zone of Interior.

being associated with wounds elsewhere in the body (fig. 185). This is the type of injury that lends itself to extensive early definitive treatment since associated wounds do not influence the patient's condition or have to be considered.

Also, during certain periods of the Normandy campaign, there was a high incidence of a virulent type of wound from "tree bursts" of mortar fire and high-explosive shellfire. In wooded sections, the shells would explode in the air upon striking a tree. This not only decreased the time in which a soldier could drop to the ground for protection but changed the dispersion of the smell fragments so that dropping to the ground gave no added protection. These wounds were very often associated with other wounds of the trunk or extremity which complicated treatment of the maxillofacial injury. Landmines produced a characteristic injury that often was extremely severe. During the fighting around Aachen and the crossing of the Siegfried Line, landmine casualties were especially numerous. They were usually accompanied by shattered feet or legs which made the patient's general condition so critical that little could be done for the face. The facial injury consisted of "tattooing" with multiple


FIGURE 186.-Powder "tattooing" as illustrated by this casualty was almost invariably associated with blindness in one or both eyes. The aftereffects of this "tattooing" could be greatly lessened by vigorous early treatment. It was possible in some instances for the anesthesiologist to scrub and debride the powder marks of the face while the surgical team was taking care of other injuries. It was unfortunate that the insignificance of this particular phase of the patient's injury understandably led to its early neglect in so many instances.

small perforating wounds which usually involved both eyes (figs. 186 and 187).

Evacuation hospital - Planning for the management of facial injuries was based on the belief that the time for the most effective definitive treatment was at the evacuation hospital level. This concept was proved to be correct, particularly for those casualties without massive soft-tissue loss. Maxillofacial surgical teams of the auxiliary surgical units were effectively used by being placed in evacuation hospitals. At this level, the casualty was treated for shock, all bleeding was controlled, the airway was insured, the extent of the injury was surveyed, and the patient was rested and prepared for operation. If the condition of the patient permitted and the tactical situation allowed, a complete definitive operation was then done (fig. 188). The bony skeleton


FIGURE 187.-A blast injury, resulting from a mine explosion, somewhat different from the usual in that the foreign particles were larger and were easily removed. Blast "tattooing" as illustrated by this case could be greatly benefited by prolonged and fastidious curettage and soap and water cleaning of the thousands of small punctate wounds. (Case of Maj. Byron C. Smith, MC, 1st General Hospital.)


was reduced and the initial fixation applied. The wound was debrided and, if advisable, closed in layers. The patient was continued on penicillin, which was started upon arrival at the hospital, and held until he had passed the critical period before being evacuated. Tracheotomized patients were held for a minimum of 4 days to become accustomed to the tracheotomy and to develop some degree of self-reliance in case of emergency. Feeding problems were held at least until the more acute problem of maintaining fluid intake had subsided. The object was to get these casualties back as quickly as possible to a specialty center in the communications zone as soon as they could be transported safely (fig. 189).

General hospital - In the United Kingdom Base Section, there were 10 general hospitals, staffed and equipped as treatment centers for patients with maxillofacial injuries as well as for burn casualties and casualties with massive soft-tissue loss of the trunk or extremities. These specialty hospitals were geographically dispersed over England, one such hospital being designated in each hospital center. From the evacuation hospital where the initial definitive treatment had been given, the casualty was transferred to the communications zone and, if it was severe enough to warrant it, directly into one of the specialty hospitals. The severe facial injuries were continued on a logical regimen aimed at anatomical replacement of tissues, the promotion of healing as rapidly as possible, the reduction and fixation of skeletal derangements and through it all, the maintenance of morale and the nutritional state.

It is obvious that this effort involved many more people than those primarily concerned with plastic surgery or the treatment of maxillofacial injuries. Consultation with the general surgeons, the ophthalmologist, and the otorhinolaryngologist was an integral part of the conduct of such a service. Dental officers of the hospital staff became a part of the plastic and maxillofacial team. The Senior Consultant in Plastic Surgery was almost invariably accompanied by Colonel Stout of the Dental Corps during his inspection of these centers. The suggestions of Colonel Stout concerning the management of complicated jaw and facial fractures furnished an invaluable and indispensible supplement to the author's own inadequate experience in this field. However, it was found that the application of basic surgical principles and commonsense would usually point the way to a solution for most of the complicated injuries.

The degree to which early facial reconstruction and repair could be accomplished was a continual source of amazement and stemmed directly from the availability of antibiotics coupled with good surgical care. An effort was made to take full advantage of the opportunity afforded to obtain early tissue replacement and healing. Much of this was definitive plastic surgery at its best. However, the majority of the surgery in the European theater was aimed at preparing the facial casualty for evacuation to the Zone of Interior in the very best condition for travel with the wound in the very best condition for a continuation of whatever subsequent reconstruction might be necessary (fig. 190). Many things were learned, only a few of the most important and obvious of


FIGURE 188.-The treatment of a compound facial wound at the evacuation hospital level. The wound illustrated is associated with fracture of the maxilla and loss of tissue about the nose. The maxilla was supported by an arch bar to which wires were attached and brought out through the wound for superior traction. The wound was then closed as much as possible after conservative debridement. No attempt was made to reconstruct features associated with loss of tissue. These areas were left open for later reconstructive surgery. (Case of Maj. Vilray P. Blair, Jr., MC, 45th Evacuation Hospital.)


FIGURE 189.-A casualty with a severe wound of the chin and mandible as he arrived in the communications zone. Note the nasal feeding tube which had been of vital importance. In this case, superior traction and support was supplied to the mandible and tongue through elastic bands and a circumferential head bandage. The circumferential head bandage was found to be just about as reliable during evacuation as was the plastic head cap.

which can be mentioned in the following paragraphs. To discuss the treatment of maxillofacial injuries of war in detail would require a separate volume.

Hemorrhage - When active intervention for the control of hemorrhage became necessary, it was found preferable, and in the majority of cases possible, to expose the bleeding point and ligate the vessel. Remarkably few cases were seen in which trunk vessels had been ligated for uncontrollable hemorrhage. The majority of these cases were secondary hemorrhage associated with infection, and the results of trunk vessel ligation was not the most satisfactory.

Airway -By the end of the war, it was realized that tracheotomy was a much more vitally important procedure than had been anticipated. It was found to have a place for the critical patient who was near suffocation. In addition, it was found useful for the patient who had an adequate airway, but whose wounds made breathing difficult, messy, and a cause of continued anxiety


FIGURE 190.-A major facial wound with loss of nose, maxilla, and mandible, representing a composite of the problems presented by these casualties. The problem at first seems to be almost an insurmountable one of maintaining the patient's airway, nutritional state, and morale. A. The patient during his critical stage in an evacuation hospital. B. The man ready for evacuation to the Zone of Interior. The posterior mandibular fragments are stabilized by metal cap splints and a connecting bar. (Case of Maj. Leo H. La Dage, MC, 5th Auxiliary Surgical Group.)

on the part of the patient and his attendants (fig. 185). In such cases, tracheotomy relieved the anxiety, put both the patient and the wound at rest, and simplified nursing care, subsequent anesthesia, and operative procedures.

Debridement - In the preparation of facial wounds for closure, the procedure of debridement was found to be as important as it was for wounds elsewhere in the body. However, it was completely different  because it was necessary that it be conservative and at the same time thorough. Debridement and closure had to be judiciously associated with adequate dependent drainage for wounds involving the buccal mucosa, the floor of mouth, and the paranasal sinuses. Debridement and closure could not be practiced on facial wounds with massive soft-tissue loss. In such cases, the procedure was altered to provide for as early healing as possible without gross displacement of features (fig. 188). The suture of skin to buccal mucosa was a procedure frequently practiced (fig. 191).

Primary closure - The success of primary closure of facial wounds was directly dependent upon the skill with which the debridement and closure were done and upon the extent and location of the wound. A surprising percentage


FIGURE 191.-This compound injury is associated with fracture and loss of bone and loss of overlying soft tissue. The skin to buccal mucosa suture provides early healing and at the same time simplifies the care of the fracture and floor of the mouth by making these areas more accessible. Any attempt at early closure and reconstruction of this facial defect would have been a serious error. Notice the multiple wire loops for control of the bone fragments by elastic traction. (Case of Lt. Col. B. Eugene Boyer, MC, 53d General Hospital.)

of them were successful (fig. 192). Those that were unsuccessful were subjected to secondary closure in the communications zone hospitals after the wounds had been cleaned up and the associated skeletal derangements stabilized.

Infection.-Routine antibiotic therapy had a definite role in the low incidence of spreading infections. It is of great interest that, in his travels, the Senior Consultant in Plastic Surgery did not see one case of Ludwig's angina. Spreading cellulitis and erysipeloid infections were practically nonexistent. The infections observed were localized and, for the most part, due to poor debridement or lack of provision for adequate drainage of wounds in which drainage was indicated (fig. 193).

Reduction and fixation of fractures - Before a compound facial wound was closed, the initial reduction and fixation of fractures was accomplished with the following ends in mind: (1) Restoration of normal anatomical position and contour, (2) restoration of normal occlusal relationship between the maxilla and mandible, (3) maintenance of the dental arch and prevention of collapse


FIGURE 192.-This case admirably illustrates the results of the early definitive treatment of compound facial injuries. Most closures of this nature were done in evacuation hospitals. However, the case illustrated here was closed at the 1st General Hospital in Paris, having been evacuated by air. Primary closure was most effectively applied to soft-tissue wounds without associated skeletal injury and without soft-tissue loss. The case illustrated shows the result of minute tissue replacement followed by primary healing. The transverse maxillary fracture was supported through a plastic head cap attached to an arched bar. (Case of Maj. Byron C. Smith, MC, 1st General Hospital.)

(figs. 191 and 194). The multiplicity of means of fixation of facial and jaw fractures cannot be discussed in detail here. Suffice it to say that the problem was chiefly a mechanical one and was influenced by many factors. If the patient was seen early enough and if the anesthesia was adequate, reduction could usually be accomplished manually. If impaction or swelling and fixation prevented manual reduction, a plan for traction reduction had to be formulated.


FIGURE 193.-This case illustrates a penetrating wound of the antrum with infection. Most infections observed were due to inadequate debridement or lack of provision for adequate drainage. Infection in the above case could have been prevented by debridement of the maxillary antrum and the provision of adequate drainage through the buccal fornix.

The mechanical means were multiple and those used would vary with the individual surgeon and the individual case. Certain principles, however, were considered in the application of these mechanical means. These principles were: (1) To strive for simplicity; (2) to take advantage of every favorable factor offered by the peculiarities of the case (that is, the presence of key teeth for application of apparatus, the holding of one fragment in place by impacting it against another, or the holding of a posterior mandibular fragment in position by a retained molar); and (3) to avoid external applications and plaster head caps when possible. It was in this phase of care that the "multiple loop" wiring method of Colonel Stout was used most extensively (fig. 191). Intermaxillary rubberband fixation, applied to multiple loop wires, served a great purpose in the European theater both for the early care of maxillofacial casualties and for the later definitive support of mandibular and maxillary fractures during the final healing phase.


FIGURE 194.-Compound facial wound associated with loss of the maxillary alveolus and overlying soft tissue and a fracture of the mandible. Good early care with an acrylic resin splint to mandible and stabilization of the remaining maxillary fragments.

Drainage.-At the time of closure, the indications for establishing adequate drainage had always to be kept in mind. This was a principle that was well understood during World War I when infection after closure was much more likely to be a critical complication than at the time of the present conflict when spreading infection could, to a great extent, be controlled by sulfonamide or penicillin therapy. Failure to provide adequate drainage was a not uncommon error in the treatment of the first casualties following the invasion of Normandy. It was believed that drainage should be instituted routinely for the following types of wounds:

1. Wounds involving the floor of the mouth. The floor of the mouth should be closed, and dependent external drainage provided. This could usually be done through an external portion of the wound.

2. Severe wounds associated with the comminuted fracture of the mandible. The drained area should include the fracture site.

3. Deep wounds of the upper neck. Such wounds were subject to accumulation of blood and serum because of the unavoidable motion following swallowing and breathing.

4. Wounds involving the maxillary sinus were drained into the nose or buccal fornix.


5. Wounds which resulted in the turning of a large flap. Accumulation of serum and blood was guarded against by the insertion of a small drain after replacing the flap.

6. Compound wounds of the frontal sinus were drained externally (provided the wound did not involve the posterior wall and dura).

7. Extensive comminuted fractures of the mandible, compounded into the mouth, but not associated with external wounds through which drainage could easily occur. Such wounds were treated by a properly placed incision and the insertion of a drain.

Delayed primary and secondary closure - Primary closure of facial wounds at the evacuation hospital was the general practice when possible. However, there were cases that for various reasons were found inadvisable to close in the evacuation hospitals. For instance, an evacuation hospital group swamped with casualties might be in a position to bypass maxillofacial injuries that were considered transportable through an air evacuation unit directly to hospital centers in England where they would arrive in only a few hours (fig. 192). Many facial injuries were then subjected to debridement and closure with successful results from a few hours to as long as 72 hours following injury. Without question, penicillin therapy had an important bearing on the fact that comparatively late, radical, definitive procedures were possible. The absence of invasive infection was the clinical finding supporting the rationale of late closure. Technically, delayed primary closure did not differ from early closure.

The cases requiring secondary closure might be classified in two categories, as follows: (1) Those that had previously been closed with unsuccessful results; (2) those that were not closed previously and in which delayed primary closure had been advisable. Both of these types became characterized by surface infection, sloughing of devitalized tissue, and abscess formation if drainage was inadequate. The problem resolved itself into one of nursing care, care of the wound, maintenance of the nutritional state, and control of infection in preparation for secondary closure. Reduction and fixation of skeletal parts proceeded concomitantly, and in these cases the procedure frequently became one of gradual traction reduction.

Secondary closure was done judiciously, with the realization that the results could not be accepted as final and with the understanding that the procedure was never strongly indicated unless it would increase the comfort of the patient or result in producing a healed wound that would terminate pathological processes detrimental if allowed to proceed (fig. 195). An effort was made not to lose sight of the fact that the normal healing process of an open wound produces results that are frequently difficult to surpass by surgical intervention. If the wound was not resulting in loss of bone or important loss of function, it was realized that closure or revision by experienced hands many weeks later, after the tissues had healed and softened, might be expected to offer the best results (figs. 196 and 197).


FIGURE 195.-This case illustrates the secondary closure of a compound facial wound. Some casualties were so severely injured and the circumstances of their treatment so complicated that early definitive care could not be accomplished before evacuation became necessary. The case illustrated here shows the condition of a casualty upon arriving at a general hospital 5 or 6 days following injury. There is an extensive defect of the maxilla. In such cases in which there was no extensive loss of tissue, the soft-tissue parts could be replaced as soon as possible. This case illustrates the results of such an early secondary closure. (Case of Maj. Douglas W. Macomber, MC, 91st General Hospital.)

Rotation flaps, pedicle grafts, free skin grafts.-With the exception of the free skin graft, none of the procedures listed in the title of this paragraph were considered to have a role in the early treatment of maxillofacial wounds. If there was massive loss of tissue requiring replacement, it was believed that this was better done at a later stage in the Zone of Interior. An occasional wound lent itself to free skin graft as a means of promoting a healed surface, though it was rather surprising how infrequently such wounds were encountered.

Feeding and maintenance of nutritional state - In any hospital in which maxillofacial casualties were accumulated, the problem of their feeding soon became an acute one. In the specialty hospital in the European theater, it became the habit, as soon as the load of patients warranted it, of setting up special feeding facilities for these casualties. The American soldier, almost regardless of the handicap, will get enough to eat if he is given the opportunity. A few of the casualties were definitely reticent about feeding themselves before


FIGURE 196.-This case illustrates a poorly advised secondary closure of a soft-tissue wound of the face. This wound obviously needed skin replacement rather than secondary closure since the wound was not causing disability and nothing was to be gained by closing it. If free skin-grafting was inadvisable at the time, such wounds were much better left for secondary healing and subsequent plastic revision.

others when this procedure involved the messy use of fingers or feeding tubes. If they were segregated with other patients suffering from the same handicap, this embarrassment disappeared, and a spirit of rivalry could be stimulated to see which could get the most food down and gain the most weight. Feeding of severe maxillofacial casualties in the late stage became a matter of simply supplying the soldier with suitable food in the right environment. Feeding in the earlier stages of care of such casualties provided a much more serious problem and frequently had to be solved by the insertion of a nasogastric tube for this purpose (fig. 190). Gastrostomy was not infrequently indicated in those severe types of casualties which could be expected to experience great difficulty in the ingestion of food over a long period of time and in whom a nasal tube could not be expected to be tolerated sufficiently long.

Blast injuries.-Blast injuries from landmines presented a most distressing problem. It was seldom the case that these patients were in good condition and without other associated severe injuries. Had this not been the case, it would have been possible to have given more of the blast injuries complete definitive treatment at an early hour. When it could be done, this treatment consisted of very careful, complete, meticulous cleansing of the face with removal of all embedded particles (fig. 187). Obviously, if thoroughly done, the procedure could be expected to require hours of operating time, and for this


FIGURE 197.-This case illustrates a major facial defect at the time the patient arrived at a general hospital in England. Buccal mucosa to skin suture often is not possible in the extensive cheek defects. All efforts should be bent toward promoting bony replacement and union, in controlling sepsis, and in maintaining the patient's nutritional state. This type of patient is one requiring extensive nursing care and oral hygiene. Reparative or reconstructive surgery is not feasible at an early date. It is possible that an occasional wound of this nature might be speeded in healing by an early free skin graft, although occasions when this procedure could be used are not frequent.

reason it was frequently impractical because of other priority casualties or because of other associated more severe injuries. The condition resulted in very disfiguring scarring and "tattooing," and, when possible, complete early care was administered.

Summary - The concept that certain types of injuries could best be managed by triage and evacuation to specialty centers in the communications zone was amply verified during World War II. The time and effort expended in establishing plastic and maxillofacial centers certainly proved to be justified. The same could be said for the specialties of neurosurgery and thoracic surgery. So far as facial reconstruction was concerned, it was of the greatest importance that proper judgment be exercised in determining just what and how much should be done in a communications zone. The policy of providing skeletal replacement and stabilization plus soft-tissue healing in as good an anatomical position as possible was a sound one. Such a policy made it possible to evacuate the casualties to the plastic surgery centers in the Zone of Interior in the best possible condition for final definitive surgical correction. The advent of the chemotherapeutic drugs and antibiotics had a profound impact upon the successful management of maxillofacial casualties as well as of all others.



By direction of the Chief Surgeon, ETOUSA, the treatment of burns that might require skin-grafting was made the responsibility of the Senior Consultant in Plastic Surgery. In view of the fact that so many burn casualties were expected to fall into this category, the Chief Surgeon and Col. Elliott C. Cutler, MC, Chief Consultant in Surgery, ETOUSA, asked the Senior Consultant in Plastic Surgery to formulate the policies for the treatment and evacuation of all burn casualties. At the time Colonel Brown, the first Senior Consultant in Plastic Surgery, ETOUSA, and this author arrived overseas in July 1942, there was still considerable debate within the National Research Council and the Surgeon General's Office over the problem of "closed" and "open" treatment of burns. At this time, "closed" and "open" methods referred to treatment by eschar-forming protein precipitants such as tannic acid, and non-eschar-forming dressings such as bland ointment or plain gauze.

Since Colonel Brown had always been an advocate of open methods of treatment, there was never any question in the European theater about which would be used. At the outbreak of the war, the use of tannic acid for the surface treatment of burns was still the official policy of the Army. By late 1942, this policy was changed by directives from the Surgeon General's Office, and 5 percent sulfadiazine in a water soluble cream base was advised. Tannic acid was taken off the tables of supply, and 5-percent-sulfadiazine cream was inserted. Early in 1943, the Cocoanut Grove disaster occurred in Boston and the voluminous writing following the treatment and study of these burn casualties, along with further studies by the National Research Council, led to the withdrawal of sulfadiazine for local treatment of burns by the Office of The Surgeon General because of the danger of toxic absorption of the drug from the burn surface. These various occurrences led to complete confusion in the minds of the individual medical officers who were to have the responsibility of treating burn casualties under combat conditions. Studies emanating from treatment of the Cocoanut Grove fire casualties led to the widespread belief that not only should treatment of the burn surface be restricted to the application of a bland ointment but any preliminary cleansing and debridement of the burn could be dispensed with.

The Senior Consultant in Plastic Surgery disagreed with both of these concepts in the treatment of war burns. A program was then instituted in the European theater to brief all incoming medical units concerning a standardized method of treating burns and to insure that each hospital unit had a well-defined plan of admitting, sorting, and treating these casualties if they should arrive in large numbers. In all planning at that time, thought had to be given to the possibility of mass civilian as well as military casualties. It was believed to be possible that many civilian casualties might result from enemy bombing, as in the Battle of Britain. It was believed mandatory that some semblance of standardization of treatment of burn casualties be established. This was not accomplished without some difficulty. Many first


aid kits, particularly those kits supplied to the armored divisions, were still arriving in the theater containing tannic acid jelly. It was also of interest that, during the height of this educational program, a prominent visiting surgeon from the United States gave several very important lectures in which he not only deprecated the use of local antibacterial agents and of local cleansing and debridement but also created doubt and confusion concerning the efficacy of plasma replacement therapy in resuscitation. With the endorsement of Colonel Cutler, Senior Consultant in Surgery, and General Hawley, the Chief Surgeon, the policy was established in the European theater that burns would be treated by gentle and careful debridement and cleansing when possible, and the burn surface would be covered with a thin layer of fine-mesh gauze impregnated with 5-percent-sulfadiazine cream over which would be placed a pressure dressing. The policies concerning the treatment of burns, as crystallized in the Manual of Therapy, ETOUSA, appear in appendix G (p. 993) of this volume.

An interesting facet of this story was precipitated by the withdrawal from the tables of supply of the 5-percent-sulfadiazine cream by direction of the Office of The Surgeon General and upon the advice of the National Research Council. Again, with the backing of the senior medical officers of the European theater, it remained the policy that sulfadiazine cream would be used, and an attempt was made to procure the drug from local British sources. Unfortunately, the British could not produce sulfadiazine in adequate quantities at that time. A substantial quantity of sulfadiazine powder was therefore ordered from the United States, and arrangements were made for its incorporation in a cream base by British drug firms. However, when the sulfadiazine powder arrived (almost 2 years later) it was well past D-day, and the matter of local chemotherapy in the treatment of burns had faded into insignificance with the advent of unexpectedly adequate supplies of penicillin. It was suggested by the Senior Consultant in Plastic Surgery that the sulfadiazine powder residing in a warehouse in London be turned over to the British on reverse lend-lease. Two weeks after this was accomplished, the Eighth Air Force had traced this supply of the drug and requested it for use on their bomber crew personnel as a prophylactic to reduce the incidence of upper respiratory infections and otitis media which were exacting such a toll from the crew members. What became of the ton of sulfadiazine powder is not known, but this consultant was immensely relieved to have heard no more about it.

In retrospect, the advocacy of 5-percent-sulfadiazine cream in fine-mesh gauze for the treatment of all burns was probably poorly advised. It was used extensively during the early part of the war and, so far as this author is aware, there were no deaths directly attributable to overdosage from absorption of the drug from the burned surface. However, it was recognized that this danger did exist. There is no doubt in this author's mind that this was an effective way of controlling infection of the burned surface in the early postburn period. However, when penicillin became available in adequate amounts, it was quite logical to dispense with local chemotherapy and whatever hazard it may have


entailed. It was this consultant's strong clinical impression that sulfadiazine cream was most effectively used in the treatment of hand burns. Here, there was no danger of overabsorption, and surface infection seemed to be better controlled than by other methods. It is unfortunate that there were no reliable controlled studies made on this subject.

Etiology.-Accidents accounted for a large portion of the burn casualties, and, as might be expected, they occurred most frequently in the wintertime. Command directives were issued forbidding the use of gasoline and other flammable materials for starting fires, for cleaning clothes, and for cleaning garage floors. In spite of these efforts, high octane gasoline continued to be used for such purposes, and some of the most severe burns occurred as a result. Because of the experiences of the British during the Battle of Britain, a high incidence of burns from the Eighth Air Force was expected. However, burn casualties from this source were never received in the numbers anticipated. It was believed that the low incidence of Air Force burns in the early days resulted from the fact that active air combat was carried out only across the Channel. Fighter pilots fell in France or Germany; and bomber crews most likely to have been subjected to burns did not get back to the bases in England. Burns from the Air Force as a result of active combat were limited almost completely to those received during takeoff and landing accidents in England. After the liberation of prisoners at the end of the war, a large number of the Air Force casualties were found to have suffered from burns and had been treated in enemy prisoner-of-war hospitals.

The landing on the shores of Normandy did not produce the large number of burns that might have been expected from closely packed troops in flammable vessels landing on a hostile shore. The incidence of burn casualties increased after the breakthrough at Saint-Lô when troops practically lived in traveling tanks and armored vehicles. These vehicles almost invariably burned upon being hit, and, in the case of the tanks which were hard to get out of, the resulting burns among the crew were very severe. Flash burns from bazooka fire were occasionally seen but were not common. Burns from white phosphorus and chemicals were comparatively rare. An unexpected and not infrequent type of burn was that occurring in paratroopers when they struck high tension wires during descent, with resulting limited but deep electrical burns.

An estimated 90 percent of all burns involved only the hands and face. A majority of the hand and face burns were superficial and could have been completely eliminated by the slightest degree of protection. In spite of continued efforts, it was impossible to get air force personnel to wear gloves as a precautionary measure against burns. The attitude of the young flier was that, while flying in combat, protection against burns was the least of his worries. He would not hamper himself by wearing gloves, nor would he consider any face protection that would restrict motion or limit the field of vision. Essentially the same philosophy was characteristic of the tank crewmen. Ordinary clothing was adequate protection against flash burns elsewhere on the body.


Evacuation hospital - During combat, the evacuation hospital provided the first opportunity for the effective treatment of burn casualties. For resuscitation, reliance was placed on plasma and on saline and glucose solutions in adequate amounts. After resuscitation, the burn casualty was taken to the operating room and the burn surface was cleansed of dirt, clothing, and hanging devitalized skin. The dirt and filth that covered many of these wounds made it seem inadvisable to apply dressings without some effort at cleansing and debridement. Frequently, a mild soap or detergent was used gently on the burn if the condition of the patient permitted it. A good many burns were of limited surface extent and were not associated with other injuries. Under these circumstances, a meticulous debridement and cleansing seemed advisable. Burn surfaces were covered with 5-percent-sulfadiazine cream, petrolatum-impregnated gauze, or boric acid ointment gauze, and a pressure dressing was applied. Often, plaster splints would be added for immobilization. The casualty was then held, and resuscitation therapy was continued until his condition was considered satisfactory for evacuation. Patients with severe burns traveled poorly and often had to be held for several days before they could be safely moved. Evacuation was through regular channels by hospital train or air.

General hospital - Upon reaching the communications zone, the bad burns were transported to hospitals designated for their care within a hospital center. In the United Kingdom Base Section, there were always hospitals that had been designated for plastic and maxillofacial surgery and had been prepared with adequate physical facilities for the management of complicated burn casualties. The plastic surgeon and his team in these hospitals worked with members of the general surgical service and medical service in preparing the burn casualties for the necessary skin-grafting operations. The 10 specialty hospitals in England treated the great majority of burn casualties occurring in the European theater, and the standard of professional management was uniformly high. The casualties were cared for by nurses, orderlies, and medical officers with a special and detailed appreciation of their needs. Saline bath units had been provided in eight of the specialty hospitals in England, and they were used extensively to make the changes of dressing as painless as possible and to promote hygiene of the wound (fig. 198). During the period of preparation of the wound for grafting, the general care of the patient was of utmost importance. His feeding and his state of morale were factors demanding constant attention. Corpsmen placed in charge of these patients were often combat soldiers on limited duty after having been burned in combat and having gone through treatment similar to that which they were now overseeing. The morale factor provided by these corpsmen as well as the enormous physical effort they expended in caring for the casualties in these burn centers was tremendous and cannot be acknowledged adequately. During the heaviest phase of the war, the burn centers were uniformly filled to capacity, and several


FIGURE 198.-There were 10 burn centers in England, scattered from the south coast to Liverpool and Nottingham. These centers proved invaluable for the accumulation of severe burn casualties requiring prolonged dressings and grafting. Large porcelain tubs for saline baths were provided in these centers and were used practically around the clock for the changing of dressings, debridement, exercise of extremities, and so on. The personnel of these centers, in addition to the doctors and nurses, consisted of corpsmen, many of whom were combat soldiers who themselves had suffered from burns. These men were trained to handle the patients in the baths and to do the debridement and dressings, and they proved to be ideal for the job.


of them worked on a 24-hour basis in keeping up with the resuscitation, dressing, debridement, saline tubing, and skin-grafting of these badly injured soldiers.

The saline bath units consisted of from one to four large tubs placed in rooms provided with adequate heat in the hospital selected and designated for the handling of burn cases. Some of these hospitals were selected before and during construction, and the burn units were incorporated in the hospital plan. In other completed hospital plants, or in those taken over from the British, an existing ward was modified and the saline bath units were added. The tubs were obtained from a firm in Scotland and were large and of cast iron with a thick, high-grade porcelain that would permit satisfactory cleansing and sterilization. The units were used during the late stages of treatment of burns and were considered particularly necessary for those burns involving the trunk, buttocks, and lower extremities. The first burn dressing in the general hospital was usually done in the operating room under light general anesthesia. This first dressing was usually from 2 to 6 days, or longer, after the initial application of the dressing in an evacuation hospital. Subsequent dressings were usually done in the saline bath units, at which time debridement of sloughing, devitalized tissue could be done most advantageously. This procedure greatly decreased the pain of dressings and facilitated the rapid healing of the wound surface and its preparation for grafting if this was going to be necessary. The bathrooms were supervised by medical officers and nurses.

Much of the actual work was done by corpsmen who were trained to do the dressing, cleansing, and debridement of wounds and the filling, emptying, and cleaning of the tubs. These were the enlisted men, a good many of whom had suffered severe burns themselves and had been through one of the treatment centers. The possibility of cross infection received careful study and consideration. Casualties with active hemolytic streptococcal infections were either not subjected to saline baths or were submitted to the procedure in a bath reserved for their use. Other organisms presented no difficulty from cross infection if the tubs were properly cleansed. Cleansing of the tubs was done with hot water and soap, followed by an antiseptic detergent. Cetyltrimethylammonium bromide, a British preparation, was the detergent most frequently used. This detergent was also found to be very good for the primary cleansing of the burned surfaces and for the subsequent cleansing of the wound and the surrounding skin. Submission of patients to saline baths had to be done with some caution. Reactions were not uncommon, and occasionally a sick patient had to have the baths discontinued. An effort was made to keep the temperature constant at about 105° F. and to keep the degree of salinity at normal by manual manipulation of the inflow of water and the addition of salt. It was not believed to be of great importance that these factors be absolutely controlled so long as the patient was comfortable and the solution was not allowed to become hypertonic. The baths offered an excellent opportunity for exercise of muscles and joints, and, with the minimum of effort,


it was possible to prevent the marked deformities that so often have a tendency to occur before skin-grafting can be done. The baths were a very great factor in maintaining the morale of the patient, particularly if the patient had been unfortunate enough to have undergone a series of changes of dressings without baths before admission to the specialty hospital.

With the professional talent available and the physical facilities provided, it seemed advisable to establish the policy that all burns would be held until they were healed or grafted. These same intensive efforts that were aimed at getting the burn wound ready for grafting were equally effective in promoting healing. Care had to be exercised not to graft unnecessarily. It was to the credit of the medical officers taking care of these patients that hundreds of them were successfully grafted at an early date with resultant restriction in disability and loss of function. Immediate burn excision and grafting was not practiced except in an occasional case of electrical burn. The general practice was that of repeated debridement and dressings until the wound was clean enough for graft. If, by that time, the remaining third-degree loss was great enough and appeared to warrant it, a split graft was applied. The advent of penicillin to help control infection contributed greatly to the success of early grafting. The manually operated Padgett dermatome was available in the theater but was not an unmixed blessing. Good blades were available for those surgeons capable of cutting free hand grafts. So-called stamp grafts and pinch grafts were used occasionally in special situations.

Burns of various parts of the body presented different problems, but two areas in particular warrant special comment. Eyelid burns were very frequently observed. If these were severe enough, the problem of management in a communications zone hospital in preparation for evacuation to the Zone of Interior was a very trying one. The concern was primarily one of protection of the globe and preservation of sight. Almost invariably, patients with severe eyelid burns would have severe burns of the hands and could not be depended upon to take care of themselves during evacuation. In those cases in which lid eversion made it evident that the cornea was endangered, it seemed advisable to make some effort to decrease the danger by promoting lid adhesions or by grafting the lids (fig. 199). A decision as to just what to do for an individual casualty was frequently very difficult. It is beyond the scope of this presentation to go into this matter in detail. Suffice it to say, grafting of lids should not be done in a theater of operations if it can be avoided without endangering the cornea (fig. 200). It can be said also that the promotion of lid adhesions is not an entirely effective method of protecting the cornea since, in the severely burned lid, the contracting force is great enough to cause the adhesions to stretch and reexpose the cornea to ulceration (fig. 201). The situation is one demanding the most stringent nursing care and the closest collaboration between ophthalmologist and plastic surgeon.


FIGURE 199.-This case illustrates ectropion from burns and is the type of case which, it is believed, urgently required correction by grafting before evacuation from the theater of operations. The danger of resulting corneal ulceration was considered to be too great to allow such patients to go through the chain of evacuation without being able to close their eyes. This case illustrates an extreme situation in which an early graft was done with very acceptable results. (Case of Maj. Dean W. Tanner, MC, 158th General Hospital.)


FIGURE 200.-This case is an excellent example of a needlessly applied eyelid graft. Obviously, there would have been no ectropion if the lids had been left to heal spontaneously. It was sometimes extremely difficult to determine whether grafting was indicated or not. Usually, if there was any question about it, it was better to postpone the procedure until it could be done by competent plastic surgeons in the Zone of Interior.


FIGURE 201.-Illustration of the futility of controlling lid contraction after burns by formation of interpalpebral adhesions. If adhesions appeared effective they were not necessary. Where protection was most needed because of contraction, the adhesions usually stretched and required protection did not result. This patient probably required grafting before evacuation. A satisfactory result was obtained. A and B. Views of eyelids, with eyes open and closed, before grafting.


FIGURE 201.-Continued. C and D. Views, with eyes open and closed, after eyelid grafts were applied. (Case of Maj. Dean W. Tanner, MC, 158th General Hospital.)


Burns of hands were obviously of very great importance from both the numerical and functional standpoint. It was with hand burns that the prevention of edema and early control of infection were found to be of such great practical value, since the ultimate loss of full thickness of skin was as dependent on these factors as on the initial thermal injury. A burned hand allowed to develop uncontrolled edema not only resulted in embarrassing the circulation of the tightly stretched skin of the dorsum but made this skin more susceptible to infection. In this way, large areas of skin that were not destroyed by the initial thermal injury could be converted into third-degree burns. Therefore, it was the aim to make hands surgically clean as early as possible and to control edema by effective pressure dressings and elevation. The position of the hand and fingers during this period of immobilization was, of course, considered to be of great importance. The initial hand dressing was left on for from 6 to 8 days, following which exercise of the hand in saline baths and careful daily debridement was started. From this time on, supervised active exercise was emphasized in maintaining flexibility of the joint capsules. The burn was made clean and debrided of eschar as rapidly as possible. When the hand was clean enough for graft, it was carefully evaluated to determine whether the overall function of the hand could be more benefited by grafting with its attendant period of immobilization, or by continued exercises while spontaneous healing progressed (figs. 202 and 203). A decision was made upon the merit of each individual case, with the realization that preservation of function depended upon early grafting when it was really necessary but that function could be lost by unnecessary grafting and its associated period of immobilization.

Summary.-During the buildup phase before the invasion of Normandy, this author had rather grandiose plans for detailed study of burn casualties. He was even successful in having the Chief Surgeon's Office approve certain directives and statistical forms and charts which he hoped to accumulate by the thousands and from which it was anticipated valuable information might be secured. Needless to say, from D-day until the end of the war, this type of research was out of the question and all efforts were simply bent toward adequate care of the injured and the maintenance of lines of medical evacuation. The author had a feeling of guilt that more positive information did not result from this tremendous experience. At the same time, he had a feeling of admiration and respect for the medical officers who performed the terrific task of taking care of the burn casualties in the various centers. In retrospect, it can be stated without equivocation that the establishment of the burn centers was good planning and paid off tremendously in the results which were achieved. Regardless of later concepts of burn treatment and cross infection, the saline baths, as used, were effective in the handling of mass casualties during


World War II, and the writer would still want such facilities. The European theater was well supplied with highly qualified personnel and, after combat began, they were utilized to the very highest degree possible. Some perfectly superb work was done by various medical officers in the management of burn casualties, particularly in the management of the severely burned hands, and it is to be regretted that the patients involved were not subsequently followed and the results of this experience properly recorded. For those readers who may wish to be critical, the foregoing account is admitted to be an extremely superficial exposition of the management of this important type of casualty during World War II in the European theater.

Wounds Other Than Head Wounds

If one examines the medical history of World War I, it will be found that the possibility of delayed primary and secondary closure of wounds was recognized and practiced to a limited extent near the termination of that conflict. However, the chief impression left by the First World War was that wounds should be debrided and left open for secondary healing. This impression was strengthened by the intervening experience of the Spanish Civil War and the widely publicized plaster immobilization of wounds after debridement. The wounds treated by this manner were those of the extremities, and after adequate debridement the wound was dressed open, usually with petrolatum-impregnated gauze pack, and a plaster encasement dressing was applied. The plaster was not changed for many days. The wounds did well and, if debridement had been adequate, usually at the time of first inspection of the wound the base was found to be covered by healthy granulations and there was no evidence of invasive infection. The transportation of casualties was simplified by this procedure as was the nursing care. The disabling effects of prolonged immobilization and healing by secondary intention were minimized.

World War II was entered not only with the background of knowledge from World War I and the Spanish Civil War, but also with more of an appreciation of the methods whereby function of an extremity could be preserved after a severe wound. Furthermore, the day of the wonder drugs had arrived and the sulfonamides and antibiotics were ready for exploitation. Another factor of very great importance was that surgeons interested in reconstructive and plastic surgery had been demonstrating for the past several years what could be accomplished with various types of grafts in the healing of wounds, and the importance of healing extensive burn wounds by early grafts was generally recognized. It was natural that these background factors led immediately to a more aggressive method of war wound management as soon as the medical officers had an opportunity to start taking care of casualties.


FIGURE 202.-This case ideally illustrates the principle of active motion and early grafting for the burned hand. Active motion can only be accomplished with all dressings removed. It was found to be most easily accomplished with the patient reclining in a saline bath so that the hands could be held in elevation and submerged at intervals as the exercise progressed. Smaller arm saline baths proved to be more practical when the burn was limited to the hand and arm.


FIGURE 202.-Continued. The left hand, in the case illustrated, shows extensive persistent deep epithelial islands surrounding small areas of third-degree skin loss. This type of hand should not be grafted; instead, motion should be maintained and spontaneous healing encouraged. If grafting is indicated, eventually it may be done as a late, clean definitive operation. The right hand in this case obviously presents a deep third-degree burn with sloughing tissue and is the type of burn that should be grafted at the earliest possible date. The result of early grafting of the right hand in this patient was excellent. Some of the grafts were placed over small areas of exposed tendon. This type of work had to be done in the theater of operations. If the patient had been returned to the Zone of Interior, in spite of air evacuation, 1 or 2 weeks' time would have been lost before graft could be applied. (Case of Maj. Dean W. Tanner, MC, 158th General Hospital.)

Early in 1943, this consultant was attached to the 298th General Hospital from the University of Michigan Medical School which was stationed just outside Bristol, England. Shortly after he joined the hospital, it was filled with a boatload of casualties from the North African invasion. These patients had received what amounted to evacuation hospital care and arrived in England 2 or 3 weeks after having been injured. A remarkable opportunity was provided to study war wounds of varied extent and to crystallize opinions


FIGURE 203.-This case illustrates the result that can be obtained by early radical graft to the dorsum of severely burned hands. The entire dorsum of each hand has been covered by an early graft. The flexibility and motion of the fingers are a direct result of the early application of skin covering. (Case of Maj. Byron C. Smith, MC, 1st General Hospital.)


regarding their treatment. It was perfectly obvious that the provision of early healing by secondary closure would limit scarring, fibrosis, edema, and disability. It was also perfectly obvious that the same results could be achieved with much larger and more extensive wounds, not amenable to secondary closure, by healing the wound with split graft. Many such wounds were grafted very soon after the patients arrived in the hospital. The results of these procedures were most gratifying. The plastic surgery service at the 298th General Hospital pushed the principles of early closure and grafting. This principle was extended subsequently to include pedicle grafting for compound injuries with exposed joints, tendon, and bone. At the first ETOUSA Medical Society meeting held at the 298th General Hospital in June 1943, the results of an extensive grafting and secondary closure of war wounds were demonstrated, and it was predicted that such surgical procedures would play a very great role in the treatment of war casualties to be expected when the Continent was invaded. The conception of excluding infection from the body by making the body surface intact was promulgated. Just exactly when and on what type of casualties this conception could be successfully practiced was not completely realized at that time. Early in 1943, a soldier was admitted to the 298th General Hospital after receiving an accidental explosive wound of the hand with exposure of bone and tendon. This man was successfully treated with an immediate undelayed pedicle graft 24 hours following his injury. In the light of this success and of the experience gained in treating casualties from North Africa, it was believed that secondary closure and free and pedicle grafting would be possible of application to war casualties on a large scale during the approaching invasion. The plastic surgery centers throughout England were set up with this as one of the important functions in mind. It later proved to be a very major portion of the work done in these hospitals.

The wounds under discussion were almost all confined to the extremities. A few of them were wounds of the shoulders and buttocks (fig. 204). They were the result of small arms fire or shell fragments which had been treated by debridement at the evacuation hospital level. The condition which had to be treated at the general hospital could be considered as due to the primary missile wound and its resultant necessary debridement. When received in the general hospital, these wounds varied in age from 3 days to 2 weeks. Many of them were associated with compound fractures. Since secondary closure of such wounds can be considered as a general surgical procedure, the subject is not discussed in detail in this presentation. However, the role played by the plastic surgery centers in the treatment of the complicated soft tissue and extremity wounds is briefly outlined.


FIGURE 204.-This case illustrates the possibility of secondary closure of large, soft-tissue defects by extensive undermining and direct wound approximation. It was important that a proper balance be maintained between the possibility of closure by this method and the need for tissue surface replacement in the form of a free graft. (Case of Lt. Col. Thomas O. Otto, MC, 305th Station Hospital.)

Free skin grafts.-The type of wounds most frequently suitable for healing by the use of free grafts was those which presented extensive loss of skin with exposed muscle or fascia which could be expected to take a graft. If bone or tendon presented themselves within the depth of the wound, free graft was usually unsuitable, a pedicle graft being indicated if simple secondary closure was impossible. Wounds suitable for free graft were usually confined to the massive fleshy part of the extremities or of the trunk (fig. 205). Extensive wounds of the feet, ankles, lower leg, knee, and corresponding areas in the upper extremity usually required covering by use of the pedicle graft.

The wound was prepared for free skin graft in essentially the same manner that it was prepared for secondary closure. It was necessary that it be free of sloughing tissue and free of localized collections of pus. It was not necessary to wait until a granulation tissue bed had developed. It was found that a free graft could be applied satisfactorily at any time interval after debridement, provided the wound fulfilled the qualifications of being free of sloughing tissue and growth of surface organism. Repeated debridement and wet dressings played an important role in the preparation of the "dirty" wound. Dakin's solution was very prominent by its almost complete absence from the surgical armamentarium.


FIGURE 205.-The extensive disability that would have resulted from secondary healing of this wound is obvious. The postoperative illustration shows the admirable result obtained by closure of the large defect by mobilizing the skin edges and by free skin-grafting that portion of the wound which could not be closed. (Case of Maj. Douglas W. Macomber, MC, 91st General Hospital.)


The free grafts were applied in a fairly standardized manner which usually involved immobilization of the extremity and some type of pressure dressing. It was of some importance that proper judgment be exercised and that insignificant wounds not be grafted. Many wounds which appeared almost certainly to need a graft were found to be not worthy of a graft by the time they were clean enough for this procedure. Needless to say, a few instances were seen in which a small wound had been successfully grafted but the soldier remained disabled as a result of an unhealed donor area. It has been mentioned previously that the dermatome was not an unmixed blessing.

Pedicle grafts - The wounds suitable for covering by use of a pedicle graft were those of the extremities in which important structures (bone, tendon, and nerve) are normally covered by a relatively thin layer of superficial tissue and skin. This situation exists in the feet, ankles, anterior portion of the lower legs, knees, hands, wrists, forearms, and elbows. These are all vitally important functional areas. A good many wounds involving these parts were of the avulsed type which, following adequate debridement, presented exposed bone and tendon and often open joints, impossible of closure by any other means than the use of a pedicle graft. If these important exposed structures were to be preserved, the pedicle graft must be applied at an early date. This was considered to be one condition in which a definitive plastic surgery procedure in a theater of operations was urgently indicated. If the procedure was postponed until the casualty arrived in the Zone of Interior, important function and structures would be lost. The recognition of the need for the procedure of pedicle grafting and its effective application in a theater of operations was a new development in war surgery. By effective application it is meant that the conditions requiring pedicle grafts were widely recognized and the casualties were accumulated into plastic surgery centers where the procedure could be properly controlled and well done. There were recorded 700 pedicle grafts of this nature, done in the plastic surgery centers in England alone. During the tour of the Senior Consultant in Plastic Surgery through the plastic surgery centers in the Zone of Interior in March of 1945, the evaluation of the procedure of pedicle graft by the Zone of Interior's surgeons was carefully sought. It was found to be held in very high regard and to be considered in many cases to have greatly simplified later reconstructive procedures.

The preparation of the wound for pedicle graft differed slightly from the preparation of a wound for secondary closure, or for covering by skin graft, in that it did not have to be nearly so complete. All gross sloughing tissue obviously needed to be removed. However, the covering of a wound by tissue


which was viable, and which did not have to rely for continued viability on nourishment from the wound itself, offered possibilities which had never been exploited to the fullest. Not only was this covering self-sustaining in that it carried nourishing blood supply, but it served as a viable vascular dressing for the surface of the wound where it could actually contribute to the natural processes of overcoming infection and healing. It was felt that pedicle grafting to accomplish secondary covering of the wound was even more physiologically sound than was secondary closure in that there was no embarrassment of the circulation of the wound margin by tension or deep sutures, and the wound, always a contaminated one, was not closed in the true sense of the word, since complete drainage was afforded the entire wound through the wide margin to which the graft was not sutured.

Since the only reason for holding a casualty long enough in a theater of operations for the application of a pedicle graft was the early performance of the procedure to preserve function, the technique had to be developed for this purpose. If the peculiarities of the case were such that the graft could not be applied to the wound for 2 or 3 weeks or longer, there was no point in holding the patient in the European theater for the procedure. It was presumed that the medical organization in the Zone of Interior would be able to accomplish the procedure within that period of time. If the case was such that important structures and function would not be lost if a temporary free skin graft was applied, it was better that the free graft be done and the patient be evacuated to the Zone of Interior. The procedure was, therefore, reserved for those cases in which the graft could be applied without delay and in which early application was mandatory. The technique of application of the pedicle graft was consequently modified in order that it might be extended to as large a number of cases falling into this category as possible.

The great majority of pedicle grafts were done as direct undelayed flap grafts, elevated and attached to the recipient area at one sitting. The direct abdominal wall (fig. 206) and thoracic (figs. 207 and 208) flap grafts were the simplest to use. In the beginning, direct grafts from the lower leg were done with some trepidation. As experience and ingenuity increased, it was discovered that there were few wounds from the knee down that could not be covered with a direct graft from the other leg. It can be stated that the direct crossed leg pedicle grafts proved to be much better than attempts to close lower leg defects by the use of local rotation flaps. When the defect required coverage by skin and subcutaneous tissue, the results of pedicle grafts early in the war surpassed those of local methods of closure and the latter were discarded.


FIGURE 206.-This case is an ideal illustration of the type of injury in which pedicle grafting should be done without delay. All flexor tendons were exposed. The soldier was wounded on 6 September 1944. Eight days later, the wound was completely covered by an abdominal pedicle graft. The last photograph shows the arm 6 weeks following injury. The value of an early pedicle graft in an injury such as this cannot be exaggerated.


FIGURE 206.-Continued. It was estimated at the time of discharge of this soldier that he would get about 85 percent return of function of the hand. Without the pedicle graft, there would have been complete loss of function. (Case of Capt. William W. L. Glenn, MC, and Lt. Col. Eugene M. Bricker, MC, 22d General Hospital.)


FIGURE 207.-This case illustrates the end result of replacement of a large soft-tissue loss of the upper arm by use of an undelayed pedicle graft from the chest wall. In planning all undelayed flat grafts, the size and position of the base is obviously of very great importance. The size of the base in this case demonstrates the extreme which sometimes may be necessary if a graft is to be successful. (Case of Maj. Clifford LaV. Kiehn, MC, 117th General Hospital.)

One factor that accounted for the use of the lower leg so frequently as a means of accomplishing crossed leg pedicle grafts was that many of these wounds were complicated by associated fractures (fig. 209). It was a frequent occurrence that a pedicle graft might be urgently needed, but its application was almost impossible because of an accompanying fracture. A great deal of ingenuity was exercised in solving these problems. In some cases, it was justifiable to consider applications of the graft as being more important than primary consideration of the fracture. Properly applied plaster splints could sometimes be made to hold the fracture in position during application of the graft. The use of Anderson splints was resurrected to help solve these problems, and they were found to be of distinct value in some cases for maintenance of position during the period of preparation of the wound and application of the graft


(fig. 210). The splint was left in place only until the graft was completed, a matter of 3 or 4 weeks, after which it was removed and the generally accepted methods of treating fractures were instituted from this point on.

Very few delayed flap grafts were done. Obviously, if delay was necessary, the job might just as well be done in the Zone of Interior. However, there were a few instances in which the procedure could be simplified and the certainty of a satisfactory outcome increased by delaying the pedicle graft. This would often be done while the wound was being prepared to receive the graft.

Tubed pedicle grafts were found to have very little application in solving the needs of early grafting in a theater of operations. Even when the time element was of no importance, tubing of the graft was considered to be a superfluous procedure.

Pedicle grafting was not used for facial reconstruction in the communications zone. It was felt that this was a procedure better done in the plastic surgery centers in the Zone of Interior.

Summary.-The opportunity of using pedicle grafts in the treatment of complicated war wounds on such a scale as was done in the European theater was a unique experience. There is no doubt that it served a great purpose in the preservation of function in many extremities.

Treatment of Hand Injuries

Plastic surgeons had long been interested in the problems presented by the injured hand. Long before the invasion of Normandy, burned hands and the severe wounds of hands received accidentally in combat training were recognized as acute problems. After the Normandy invasion, it was discovered early that hands were going to form an unexpectedly high percentage of casualties and that the principles involved in treating hand injuries were not generally recognized. The plastic surgeons were then interested primarily in replacing the soft-tissue loss in the avulsed type of injury (figs. 211 and 212). This had been practiced as an early procedure previously at the 298th General Hospital in England. This problem having been recognized, cases were searched for throughout the hospital centers in England and those requiring pedicle grafts were transferred to the hospitals designated for plastic surgery. This accumulation of the severely injured hands in the plastic surgery hospitals led to the logical conclusion that the best method for handling all hand injuries was to place them in special services under interested, qualified personnel.

On 4 September 1944, a memorandum on the subject of development of hand centers (app. H, p. 999) was submitted to the Chief Consultant in Surgery and referred to hand centers in both the communications zone and the Zone of


FIGURE 208.-A complicated compound fracture with extensive loss of overlying tissue is converted into a simple fracture by the use of an undelayed pedicle graft. It was found that these grafts could be applied to wounds that far from fulfilled our original concept of how a wound should appear before a graft could be applied.


FIGURE 208.-Continued. A vascular type of graft cannot be compared with a free graft that depends on the wound for its own sustenance. A well-planned pedicle graft is a viable vascular dressing that can be considered as carrying sustenance to a wound. (Case of Maj. Clifford LaV. Kiehn, MC, 117th General Hospital.)


FIGURE 209.-This soldier was wounded by machinegun fire on 5 August 1944 in France. He was evacuated to a hospital center in England where a split graft was attempted on 8 October. It was not until 21 October that the patient was transferred to a plastic surgery center and the pedicle graft applied. 


FIGURE 209.-Continued. Ideally, the pedicle graft could have been applied from 7 to 14 days after injury. (Case of Lt. Col. Malvin F. White, MC, 129th General Hospital.)


FIGURE 210.-This case illustrates the technique of immediate undelayed cross leg pedicle graft covering a compound defect of the tibia. The Anderson splint was occasionally used in these complicated cases. The splint was dispensed with as soon as a graft was applied. Large, undelayed flap grafts such as that illustrated were possible. The fact that the leg grafts were done with such a low incidence of failures was undoubtedly due, in large part, to the youth of the patients. (Case of Lt. Col. Malvin F. White, MC, 129th General Hospital.)


Interior. Following this, hand centers were developed both in England and on the Continent. It was the aim to have each center under the supervision of both a qualified orthopedic surgeon and a plastic surgeon. With the cooperation of Col. Mather Cleveland, MC,1 Senior Consultant in Orthopedic Surgery, most of the hand centers were located in the hospitals designated for plastic surgery. Although this was a very definite step forward, it by no means solved the problem of adequate care for hand injuries.

With the start that was made, it is believed that, had the war progressed, the organization would have resulted in a standard of care for hand injuries never before equaled. Unfortunately, this state of affairs was far from being reached by the end of the war. The difficulty resided in the fact that the plastic and orthopedic surgeons themselves had much to learn, and the respective consultants were slow in recognizing the need for fundamental changes in overall policies. The surgeons in the hand centers believed at an early stage that they had reached an impasse because they were not receiving the casualties early enough after the injury. This led to the idea that possibly more definitive surgery should be done at the evacuation hospital level. The standard of care at the evacuation hospital level previously had not been high. Although it may be understandable that the surgeons at the evacuation hospitals were more concerned with injuries of a more serious nature, it hardly justifies the delegation of injured hands to surgeons of the least experience, as was frequently done. In March 1945, a directive was issued stating that hand injuries should be closed after they were debrided in the evacuation hospitals. The results of this policy could never be determined with certainty because the war ended soon after it was put into effect. It is, indeed, doubtful that much would have been accomplished by this change in policy.

Hand wounds with such loss of soft tissue that important underlying structures were exposed fell into the category of those amenable to pedicle grafting. The procedure of pedicle grafting of such wounds had certain shortcomings and limitations, the most notable of which was the unavoidable limitation of motion and poor position often necessary during application of the pedicle graft. With proper care, these objectionable features could, to a large extent, be avoided. It was possible to have good position and active motion maintained during the time the graft was being applied in most, but not all, cases. It took fine judgment to weigh the disadvantages afforded by these objectionable features against the need for pedicle graft and to decide whether the procedure should or should not be done. This author's views at the time on the treatment of hand injuries were set forth in a memorandum, dated 5 March 1945, to Colonel Cleveland, Senior Consultant in Orthopedic Surgery, ETOUSA, (app. I, p. 1001).

1Cleveland, Mather: Chapter IV, Hand Injuries in the European Theater of Operations. In Medical Department, United States Army. Surgery in World War II. Hand Surgery. Washington: U.S. Government Printing Office, 1955.


FIGURE 211.-The illustration of a large, soft-tissue loss from the dorsum of the hand, associated with underlying bone injury. Such a wound might conceivably be covered by a split graft. However, the possibilities of return of function and subsequent reconstructive surgery are greatly increased if a pedicle graft is used.


FIGURE 211.-Continued

Summary -When one considers all the thought and planning devoted to the preparation for treatment of maxillofacial injuries, burns, and massive soft-tissue injuries, it is surprising that more definitive plans for the treatment of injured hands were not formulated earlier in the course of the war. It was never anticipated that severe hand injuries would form such an important segment of the casualty list. It is perfectly obvious that an anatomical structure as delicate and complicated as the hand requires the most detailed and skilled care if function is to be maintained. Although the late phase of care of injured hands has been developed to a very fine degree, there is no doubt that the very early care could be of equal importance in the preservation of function. Until very late in the war, our overall efficiency in the early care of hand injuries might be compared to that of a plumber trying to service a Swiss watch. This should not obscure that fact that there were two or three surgeons in the European theater who were extremely expert at hand care and who were, to a large extent, responsible for stimulating more interest in this type of injury.


FIGURE 212.-The provision of surface covering through and beneath which subsequent reconstructive surgery would be possible was of primary importance in the rehabilitation of the injured hand. However, it had to be applied with a proper perspective and with consideration of total hand function. In the case illustrated here, the urgent demand for palm covering in relation to subsequent function is perfectly obvious. (Case of Lt. Col. B. Eugene Boyer, MC, 53d General Hospital.)