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Appendix B

Contents

APPENDIX B

HEADQUARTERS SEVENTH ARMY

Office of the Surgeon

APO 758

US Army

18 JULY 1944

CIRCULAR LETTER NO. 2

SUBJECT:Surgery.

General............................................1

Echelons..........................................2

Morphine.........................................3

Tetanus............................................4

Surgical Procedures..........................5

Plaster Casts.....................................6

Plasma and Blood.............................7

Sulfonamides and Penicillin................8

Infections..........................................9

Burns...............................................10

The Patient.......................................11

 

1. The surgical policy that will be followed is a development of those principles and modes of Therapy that have been developed and established by NATOUSA throughout the past eighteen months. Full use will be made of a vigorous transfusion-resuscitation program by the establishment of blood banks within each hospital unit with the assistance of the Army Blood Bank (Sec.VII) and the mobile laboratories. Control of infection will be strengthened by the use of penicillin, which will be available in sufficient quantities so that treatment may be continuous from the Field Hospital to the Base. Treatment of the patient must be considered as a continuous unified effort with utmost cooperation and clarity of treatment and records by each echelon concerned. A combination of the saving of life and limb with early restoration of function and return to duty should be the aim of all installations.

    2. Surgical Echelons. Extract front NATOUSA Circular on Forward Surgery:

        "a. The welfare of the patient and the tactical necessity for rapid, yet safe, evacuation, demand a clear understanding of the function or mission of each unit of the Army Medical Department. This is best arrived at by dividing the treatment of a casualty into two stages--primary and definitive. Separate groups of units provide each stage of treatment. In general, the equipment of each group is designed for its particular purpose only.

        "b. Aid Stations, Collecting Stations, and Clearing Stations (First and Second Echelons) are equipped and staffed to render the primary phase of treatment. Arrest of hemorrhage, splinting, resuscitation measures needed to make the patient transportable, and administration of sulfonamides, are the prime functions of these stations. In addition, the treatment of minor injuries is carried out without evacuation. A Clearing Station is not designed to provide definitive treatment of battle casualties."

        "c. A proportion of admissions will be 'non-transportables. A nontransportable is a patient that cannot be evacuated farther without real danger to life and limb. (FM 8-10, par.65c.) These patients will be transferred immediately to the attached Field Hospital Unit in support of the Clearing Station. No surgery will be performed forward of the Field Hospital.

        "d. Third Echelon units, Field and Evacuation Hospitals, with attached Surgical Teams, are designed to initiate surgical treatment of battle casualties. Every effort should be made to deliver casualties requiring hospitalization to these units as quickly as possible so that lives may be saved, proper surgical care instituted, and convalescence shortened.

            (1) The Field Hospital Units supporting Division Clearing Stations are equipped to care for non-transportable casualties. These consist of two groups: First, those suffering from grave life endangering physiological disturbances, such as hemorrhage, severe shock, cardiorespiratory imbalance from wounds of the pericardium or large sucking wounds of the chest, intra-cranial pressure, and certain maxillo-facial or neck wounds in which there is obstruction to respiration. Second, there is the group of impending fulminating infections; this includes all thoracoabdominal and abdominal wounds or wounds in other areas that may have penetrated the abdomen, such as wounds of the buttocks and thighs; extremity wounds with severe vascular injuries or evidence of gas infection, major traumatic amputations, and compound fractures of the long bones with extensive soft part damage.

            (2) The Evacuation Hospitals are of two types: The semi-mobile 400-bed, and the 750-bed installations. To these are transported all cases not requiring the first priority urgent surgery of the Field Hospital units, and also medical and venereal patients. At times certain of these units may be used for specialized triage purposes.

    3. Morphine. An initial dosage of morphine sulfate, gr. 1/4 (0.015 gms.) is sufficient. Doses of gr. 1/2 (0.030 gms.) are too large: such dosage causes too great respiratory depression, is definitely bad for intra-cranial and maxillo-facial lesions, and accomplishes no more than the smaller dose in abdominal and chest casualties. Whenever morphine is administered, the amount and time will be clearly recorded. Morphine, when given subcutaneously, is poorly and slowly absorbed in patients who are in shock; therefore, repeated administration in such cases is fraught with real hazard, for, as recovery from shock ensues, absorption of the accumulated amounts may be rapid and morphine poisoning result. This danger may be avoided in such patients in shock by a single dose of gr. 1/6 (0.010 gms.) to gr. 1/4 (0.015 gms.) given intravenously, nevermore.

4. Tetanus. A stimulating dose, 1cc., of tetanus toxoid will be given to all casualties In first or second echelon units. This dose will be recorded in the EMT Tag. To date there has been only one (1) case of tetanus in the U.S. Army in this Theater.

    5. Surgical Procedures.

        a. Dressings. After initial application, dressings will not be disturbed until the Field or Evacuation hospital is reached, except for hemorrhage. They are inspected at each stop along the line of evacuation, however, and splints readjusted or dressings rearranged when necessary. Frequent and unnecessary change of dressings increases the risk of hemorrhage and infection and also increases time-lag from wounding to initial surgery. "Innumerable sufferers in every war have been bandaged into their graves at the hands of over-enthusiastic dressers." (Jolly)

        b. Tourniquets. Tourniquets are seldom necessary and frequently misused. When applied properly for otherwise uncontrollable hemorrhage, a tourniquet may be a lifesaving measure. When improperly applied, however, bleeding is increased and complete exsanguination may occur. The sole indication for their use is active spurting hemorrhage from a major artery. For hemorrhage from veins and lesser arteries a small pack and bulky pad bandaged snugly over the bleeding point will almost always suffice. To date the tourniquet has been used with good judgment by Aid Men and Battalion Surgeons. In applying the tourniquet, if rubber tube or bandage is employed, 2 or 3 turns are made about the limb stretching the rubber between each application. The knot or ends are then to be made fast so as to prevent any slipping. The limb is observed for a few moments to be sure that hemorrhage has ceased. If not, the tourniquet must be readjusted and tightened. Unless the tourniquet is so applied as to accomplish its purpose of stopping hemorrhage, it is not only useless, but harmful, and may well cost a life rather than save one. When non-elastic material and Spanish windlass mechanism is used, a firm pad or roll of bandage is placed over the course of the artery, one turn of the tourniquet made about the limb, and the tourniquet tightened until all bleeding stops. The windlass is secured so that no relaxation occurs, and the limb observed for a few minutes. Do not apply a tourniquet directly over the skin, if possible. Leave a layer of clothing or towel in place. Whenever a tourniquet has been applied, this will be so noted in CAPITALS on the EMT Tag and the reason therefore stated as a guide to all stations to the Field Hospital.

        c. Amputations. The policy on amputations is one of conservatism. Every effort will be made to save and give the limb a chance. The prompt administration of penicillin, meticulous debridement, and possible paravertebral sympathetic block will help. Amputations will always be performed at the lowest possible level. They will be circular, the incision passing through each tissue layer at the level of retraction of the next most superficial layer; i.e., skin, deep fascia, muscles, bone, no primary suture. A loose covering of fine mesh dry or [petrolatum-impregnated] gauze will be placed over the surface and skin traction down to the skin edge applied immediately. 5-10 pounds are used. When applied evenly this has the beneficial effect of an even pressure dressing. Packing will Not be used. In lower leg amputations some type of posterior splint from midthigh to beyond the stump is provided to prevent contracture at the knee. A Thomas splint or plaster cuff with wire cage may be used for attachment of traction. No skin grafting or secondary suture will be performed in army installations. The object of amputation for trauma is the saving of life and as much limb length as possible. Every inch saved is of great value in forming the final useful stumps. This, however, must be left to Base and ZI Units.

        d. Debridement of Wounds. Careful attention will be given to Circular Letter, No. 26, Office of the Surgeon, NATOUSA, 19 April 1944, Subject: Wound Management. "The keystone of successful wound management is the initial surgical operation. When this is performed correctly the complications of infection are absent or minimal and secondary suture may be carried out promptly and successfully." Chemotherapy is an adjunct and can never be substituted for meticulous, complete, proper initial surgery. Good light and wide incision to provide ample exposure are necessary to permit adequate removal of damaged underlying tissues. A team of two is far superior to the single operator. All foreign matter, loose and unattached bone fragments, damaged muscles, and fascia must be removed at the initial procedure. An absolute minimum of skin is removed and wounds are never circumcised. No primary suture, except of cranial wounds and some wounds of the face.

            (1) Head wounds are to be transferred promptly to an Evacuation Hospital unless there are signs of intracranial pressure or uncontrollable hemorrhage, when they will go direct to a Field Hospital.

            (2) Eyes. One (1) percent atropine is to be instilled, an anesthetic bland ointment, such as butyn metaphen smeared liberally in the eye, and across the lids, and a pressure dressing held snugly in place with overlapping strips of adhesive applied. The patient is then sent to an Evacuation Hospital. Here a conservative policy will be pursued and every effort made to preserve the eye. There is no danger of sympathetic ophthalmia within the first 3 weeks after injury. Therefore, unless there is danger from infection or hemorrhage, great conservatism will be practiced.

            (3) Maxillo-facial. Ensure an adequate airway and transfer sitting or semiprone to an Evacuation Hospital. Occasionally it may be necessary to send such a casualty directly to a Field Hospital.

            (4) Chest. These patients are to be sent as No. 1 priority to a Field Hospital when there is continuing hemorrhage, signs of cardiorespiratory failure, or suspicion of abdominal involvement. Otherwise, transfer to an Evacuation Hospital.

            (5) Abdomen and Thoracoabdominal cases are all sent direct to the hospital nearest the Clearing Station, usually a Field Hospital. Wounds of the rectum are included in this group. Wounds of the buttocks and upper thighs are frequently in this group. A rectal examination wil1 be done on all cases. Blood on the examining finger indicates rectal involvement. A colostomy is performed for all wounds of the rectum, preferably of the simple loop type. In all wounds of the colon, the damaged part is exteriorized, or if the wound is in a fixed portion of the colon, a proximal colostomy is performed. The abdomen is always closed with through and through sutures; the peritoneum and posterior and anterior sheaths may be closed in addition.

            (6) Joints will be widely opened, meticulously debrided of all foreign matter, dead tissue, loose and ragged fragments of bone and cartilage, and blood clot, and then thoroughly irrigated with saline. The synovia is then closed, a flap of fascia or skin being utilized to close defects when necessary, and 10,000 units of penicillin (250 units per cc. in saline) are injected into the joint. The skin is not to be sutured and no drains are to be used into the joint. The limb is then immobilized in plaster. For the knee, the most common and important joint affected, a hip spica is applied. Under periods of great stress a circular upper thigh to lower leg cast may be substituted. For immobilization of the knee this is not as good as the hip spica, but is far superior to the usual lower leg mid-thigh cast, which permits rocking of the joint. The cast will be split.

            (7) Compound Fractures. Many casualties with compound fractures of the long bones or traumatic amputations are in severe shock or have lost much blood so that prompt resuscitation is necessary. These are transferred direct to the Field Hospitals. The purpose of the forward hospital is not to treat the fracture but to make such casualties transportable to the rear as rapidly as possible where treatment of the fracture will be undertaken. For this reason, only thorough debridement and plaster immobilization of these cases will be carried out in forward hospitals, and parenteral administration of penicillin begun (Sec. VIII). Internal fixation will be used only when it is evident that the circulation will be jeopardized by impingement of the bone ends. Pins incorporated into casts will not be used. They do not transport well. The transportation cast is the safest and most practical and comfortable means for transporting such patients to the rear. These casualties will be given first priority evacuations. Such casts will also be used for extensive soft part injuries without bone or joint damage.

            (8) Nerve Injuries. Nerves will not be sutured in hospitals of the first three echelons. There are no exceptions.

            (9) Blood Vessels. Rarely it may be possible to repair wounds of major arteries. If not, they are to be doubly ligated and the damaged portion excised. Never ligate in continuity. The accompanying vein is ligated and divided, adjacent nerve trunks are injected with 1 percent procaine and paravertebral block of the sympathetic chain with 1 percent procaine is performed. This may be repeated at 12-24 hour intervals or sympathectomy decided upon. Cases of major vascular injury will be sent to the nearest unit, generally a Field Hospital.

            (10) Evacuation. As far as possible, no abdominal, thoracoabdominal, head, or major vascular casualties will be evacuated before the 10th or 12th post-operative day. The same applies to the more serious chest cases. Such patients do not tolerate transportation. Fractures will have first priority.

            (11) Records. The need for careful, accurate, legible, records is emphasized. A concise, clear description of what is done in each installation is essential for the best uninterrupted and continued care of the patient. The "how, when, and where" of a wound or injury are the first items to be noted. The "when" includes the hour as well as the date of occurrence, and the same applies to the time of arrival in different installations. The type of missile is also noted. It is particularly important to note on the record, and also on the cast, the presence and size of skin defect, the type of fracture, nerve and vessel lesions, and the type of colostomy formed and length of spur when present. Sulfonamide and penicillin therapy as to amount given and whether or not continuance is desired will be stated.

6. Plaster Casts. When plaster of paris is used, no circular adhesive or bandage will be applied underneath the cast. All casts are to be padded, and all are to be split throughout their entire length immediately. This splitting must include all layers of circular padding or dressings down to the skin. Unpadded or unsplit casts have no place in forward installations. The foot is to be at right angles to the leg, the knee and hip flexed very slightly, and the toes free. The plantar surface of the cast will extend beyond the toes or a loop beyond the toes made so as to withstand the weight of the bed clothes. In arm cases, the arm is in neutral position. slightly forward, with the wrist and hand supported in neutral position, or in cock-up. Flexion at the wrist is not to be used. Casts with the arm in full abduction or hanging casts, will not be used, as these are very poor for transportation. in third echelon installations, casts are used for transportation purposes as well as for the underlying injury--soft part, or fracture; hence, transportability becomes an important consideration, and the cast applied accordingly. Diagrams, dates of wound and casting, and notes will be written on casts with an indelible pencil.

    7. Plasma and Blood. Plasma is used in all places from the battlefield itself to the ZI. As a measure of resuscitation, its value rests chiefly in supporting time hemorrhage or shock casualty until he arrives at a station where whole blood is available. It is in no way a substitute for whole blood. Up to 750 ccs. may be given rapidly. After that there is the danger of further diluting an already grave hemodilution. Careful perusal of Circular Letter No. 30, Office of the Surgeon, NATOUSA, 12 May 1944, Subject: Blood Transfusions, is recommended, and its instructions will be followed. An Army Blood Bank Unit will furnish low titre "O" blood to the Field Hospitals. Depending on the demand here, some may be available for the Evacuation Hospitals. This blood may be used for all patients in amounts up to 1,000 or 1,500 ccs. After this, specific type blood should be used. high titre "O" blood will also be available but the use of this must be restricted to "O" recipients. All recipients and donors will be crossmatched. This may be rapidly performed (3-5 mm.) by the centrifuge method and doubtful cases checked by the longer slide technic.

        a. It is essential that the Evacuation and rear units maintain their own blood banks as outlined in Circular Letter No. 30. Only in this way can adequate supplies of whole blood be assured. Blood will be used judiciously and not wasted. Only the amount needed to bring about adequate resuscitation and carry the patient through his surgery and post-operative period is to be given, for the risk of fatal anuria is not negligible. There will be adequate blood available at first, but the various units will organize their own blood banks as rapidly as possible.

    8. Sulfonamides and Penicillin. Sulfonamides will be used both locally and orally at the original dressing of the wounded casualty. No further local application will be made until the patient reaches the Field or Evacuation Hospital, though oral administration will be continued. When admitted to these installations all except the certainly trivially wounded will receive an initial injection of 25,000 units of penicillin intramuscularly, which is to be continued on a 3-hour schedule until stopped by the Surgeon. At the first dressing or operation he will decide whether to continue penicillin or sulfonamide. Both will not be used. Instructions given in Circular Letter, NATOUSA, Subject: Penicillin, will be carefully followed.

    9. Infections. The Clostridial infections comprise the important group that is encountered in forward surgery. Early, careful, thorough surgery, combined with adequate blood replacement and penicillin is the best preventive. Sulfonamide Therapy is of no demonstrable value, either as a preventive or therapeutic measure. Certain facts relating to the incidence should be borne in mind. About three-quarters of the cases are in wounds of the lower extremities. One-half are complicated by fractures, and one-third by vascular injuries. Yet the mortality is lower in these two groups than when only soft parts are injured. Apparently less concern is felt over the possibility of "gas" in this type of wound and these cases are not recognized early. Jergesen has described the early symptoms as: 1. pain, 2. mental changes, either hyperactive or drowsy and apathetic, 3. rapid pulse out of proportion to temperature, 4. temperature. To these may be added loss of appetite. The most important and common of these is pain, often with strikingly sudden onset. This should call for immediate re-examination of the wound and not just a "dose of morphine and drop around later" policy. Inspection of the wound will show swelling, sometimes skin discoloration, muscle changes, possibly the presence of gas, and possibly a putrefactive odor. Early diagnosis may be greatly facilitated by proper training of the nursing and ward personnel, and supervision of this problem by one or two officers in a unit. In this way any change in a patient's condition will be noted early and brought to the attention of the surgeon, and many valuable hours saved. True clostridial myositis should be differentiated from anaerobic cellulitis. In the former, the infection is in the muscles or muscle groups, in the latter it is in the fascial planes, and the muscles are uninvolved. Anaerobic cellulitis responds readily to wide incision, excision of damaged tissues, and penicillin. With the use of penicillin, blood, and perhaps antigas serum, the surgery of true clostridial myositis may be more conservative than formerly. If the infection is limited to one or only a few muscle groups, these alone may be completely excised and a wide fasciotomy performed. No amputation will be performed merely for the control of the infection. If the limb is so badly impaired that it will be of no functional use, or if after excision of the involved muscles the limb would be useless, then amputation is indicated. It should be performed at the lowest level consistent with a healthy useful limb. It need not be completely above the limit of the infection for such infected muscle as may be left can be excised and an extended fasciotomy performed. The patient may then be carried along on penicillin therapy and other adjuncts.

    10. Burns. Burns will be treated by application of boric ointment gauze and pressure dressings. The use of a snug fitting stockinet over the dressings is recommended. This provides even pressure. Unless the burn is grossly dirty no initial cleansing will be done. Blisters are left undisturbed or aspirated with sterile precautions. When cleansing is necessary, simple non-irritating detergents such as white soap are employed. Loose tags and shreds of tissue are snipped off. No further debridement is carried out. Full aseptic technic in caring for burns, with all personnel masked, is employed. Tannic acid or other escharotics will not be used. In severe burns a secondary anaemia develops, hence, whole blood, as well as plasma will be necessary. The employment of these will be governed by the plasma protein, hematocrit, and hemoglobin levels, as well as by the clinical condition of the patient. Adequate plasma, blood, and fluid replacement is essential, but one must be careful not to drown the patient with an over-enthusiastic program.

    11. The Patient. From start to finish, from the Aid Man until the final completion, one way or the other, of the case, all those having care of and contact with the wounded, injured, or ill, must constantly bear in mind that he is one of themselves--a human being. Carelessness, neglect, and rough or harsh treatment will never be tolerated. The patient must always be cared for as one would like himself to be treated. Thus, kindness and consideration go hand in hand with therapy.

M. P. RUDOLPH

Colonel, MC

Surgeon