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Chapter XVI - B

Contents

Section II. Clinical Considerations

EVOLUTION OF CLINICAL POLICIES

Principles of Surgical Care

    In the first weeks of the fighting in North Africa, there were few specified clinical policies. Surgeons chiefly employed the techniques which they had found satisfactory in clinical practice. The results, however, were often not as good as they should have been because (1) combat-incurred wounds differ


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in extent and, severity from most peacetime wounds and (2) the circumstances of military surgery differ materially from those of civilian surgery.

    The chief difference between military and civilian surgery is that in civilian surgery a single surgeon usually makes all the decisions for a single casualty while in military surgery the decisions are made by a number of surgeons. From the time a wounded soldier was tagged on the battlefield or in a battalion aid station of the Fifth U.S. Army until the completion of the cycle of treatment, evacuation, and disposition, he was cared for by a series of surgeons in a series of installations. The judgment and decisions of many medical officers were interwoven in the threads of his recovery. Every surgeon who treated him was called upon not only to evaluate the patient's status but also to estimate his own surgical capabilities and limitations and the facilities at hand to perform the necessary surgery. All decisions had to be made in the light of circumstances peculiar to a field army in combat.

    The whole system of medicomilitary care was based on the premises that medical care is accomplished in echelons; that the mission of each echelon is both specified and limited; and that all medical officers must not only perform the duties specified for them but must also limit themselves to the duties specified for that particular echelon.

    Fifth U.S. Army surgeons were allowed and expected to exercise resourcefulness and ingenuity. They had ample freedom to act in emergencies in the light of their professional experience and judgment. The system was flexible, but it remained a system, based upon general principles which surgeons were expected to apply to particular cases unless there was some very good reason indeed for not doing so. Furthermore, it was always essential that surgeons who had deviated from what was considered standard practice to make clear the extent of the deviation and the reason for it.

Establishment of Priorities

    On the basis of triage at the clearing station, casualties were divided into nontransportable patients, who made up about 10 percent of all casualties, and transportable patients. Categories could not always be defined with exactitude, but they served as useful guides. Once they had been established during the fighting in Sicily, as set forth in Circular Letter No.3, Office of the Surgeon, Headquarters, II Corps, dated 7 August 1943, 22 they remained substantially unaltered during the course of the war.

    First priority cases. - In this letter, first priority cases were specified as follows:

    1. Severe shock or continuing hemorrhage after temporary resuscitation in a clearing station.
    2. Compound fractures of long bones complicated by shock or hemorrhage, or fractures which had not been completely and comfortably immobilized.

22 See footnote 8, p.361.


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    3. Wounds of the extremities in which the blood supply was impaired or similar wounds in which it would be necessary to evacuate the casualty with a tourniquet in situ.
    4. Wounds characterized by extensive muscle damage, especially wounds of the shoulder girdle, thighs, or calves, in all of which clostridial myositis was a serious possibility.
    5. Traumatic amputations.
    6. Head injuries associated with deep coma or with signs of increased intracranial pressure.
    7. Maxillofacial wounds or wounds of the neck of special severity or associated with respiratory difficulties.
    8. Sucking chest wounds and any other chest wounds associated with respiratory difficulties.
    9. Thoracoabdominal wounds.
    10. Abdominal wounds and wounds of the buttocks which might have penetrated the abdomen or the rectum.

    Second priority cases. - Casualties with the following types of wounds were transferred directly from clearing stations to evacuation hospitals without passing through the field hospitals:

    1. Simple fractures and compound fractures of long bones in which the patients were transportable (that is, they were not in shock and had no other injuries which made them nontransportable) and in which satisfactory immobilization had been accomplished or could be accomplished in the clearing station.
    2. Peripheral nerve injuries, if not complicated by compound fractures or extensive muscle damage.
    3. Craniocerebral injuries which were not associated with coma or signs of intracranial pressure.
    4. Chest wounds which were not sucking and were not associated with respiratory difficulties.

    It is characteristic of the ubiquity of the disease even in wartime that it was specified that patients with early acute appendicitis or with possible appendicitis should be transferred to evacuation hospitals for surgery.

SHOCK AND HEMORRHAGE

Special Studies in Shock

    The steady decrease in the number of battle casualties who died in Fifth U.S. Army hospitals before they could be operated on or even anesthetized is a reflection of the steadily increased effectiveness of the management of shock during the fighting in Italy. A number of medical officers played a special part in this improvement. A discussion of their achievements follows.

    The first scientific appraisal of shock in the Fifth U.S. Army was begun by Captain Lalich on the Cassino front in December 1943. In March 1944, on


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the Anzio beachhead, he was provided with sufficient laboratory equipment by Colonel Cornell, Commanding Officer, 15th Medical General Laboratory, to make the detailed studies necessary to support his thesis that blood loss is the chief factor in shock. His laboratory investigations included determinations of the hematocrit, the plasma protein, the nonprotein nitrogen of the blood and blood chlorides, and the carbon dioxide combining power of the blood.

    On the basis of clinical observations alone, Captain Lalich had already advocated that battle casualties who were in shock be divided into three categories, according to the following criteria:

    1. The patient has a normal blood pressure, with no significant abnormalities in pulse volume or pulse rate, but his wounds are sufficiently numerous, and of sufficient gravity, to make expectation of circulatory failure reasonable. Replacement therapy in the amount of 500 cc. of plasma and 500 cc. of blood should therefore be instituted before surgery.
    2. The blood pressure ranges from 90 mm. Hg down to the lowest level at which it can be demonstrated. Resuscitation requires 1,000 to 2,000 cc. of blood.
    3. The blood pressure cannot be determined by auscultation. The patient should receive, immediately and rapidly, 500 to 1,500 cc. of blood, the precise amount depending upon how much is needed to raise the systolic pressure to about 100 mm. Hg. After this level has been reached, an additional 500 to 1,000 cc. of blood should be given before the patient is put on the operating table. If the systolic pressure fails to rise to at least 50 mm. Hg after 1,500 cc. of blood has been given over a period of 15 to 30 minutes, operation should be resorted to without further delay, for continuing hemorrhage or factors other than blood loss are probably contributing to the continuing shock. Among these factors are gross contamination and infection of the pleural or peritoneal cavities and toxemia from clostridial myositis. Even when these conditions are chiefly responsible, blood loss may also play some part in the patient's state of shock.

    The second study on shock was conducted by Lt. Col. John D. Stewart, MC, and Lt. (later Capt.) Frank B. Warner, Jr., MC. It was begun in January 1944, when Mobile Unit No. 3, 2d Medical Laboratory, was set up at Cassino, beside the 3d Platoon of the 11th Field Hospital. This hospital was doing first priority surgery, and the objective of the investigation was to study the response of seriously wounded men from the standpoint of shock, hemorrhage, and dehydration.

    In the preliminary report of this study to the Surgeon, NATOUSA, through the Surgeon, Fifth U.S. Army, dated 17 March 1944, the following findings were listed as characteristic of shock:

    1. Absence of hemoconcentration.
    2. Reduction in the blood volume.


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    3. A greater reduction of red cell concentration than of plasma protein concentration immediately after wounding.
    4. A later lowering of both red cell and plasma protein concentration.
    5. Frequent delayed dehydration.

    Attention was called in this report to the variability of both vasomotor and cardiovascular responses to wounding and to the fact that the reactions to shock and hemorrhage were much less stereotyped than had usually been supposed.

    The original observations of Major Stewart and Lieutenant Warner were based on a study of 35 desperately wounded casualties operated on at the 11th Field Hospital as well as of several patients with gas gangrene. Studies had also been made on blood specimens provided by other hospitals nearby. The surgical staff was kept informed of all laboratory findings and was able to use the information in the management of its cases.

    In their final report on 2 January 1945, Colonel Stewart and Captain Warner discussed observations on 100 patients, of whom 48 had penetrating abdominal wounds, 32 had penetrating thoracic wounds, and 55 had compound fractures (the figures are overlapping); 17 had died during the period of the investigation. In addition to the studies already listed, special studies on the urine were included in this report.

    Conclusions from the total study were as follows:

    1. The syndrome of wound shock was notable for its variability.
    2. Reduction in blood volume was characteristic of untreated shock.
    3. Hemoconcentration was not encountered, but decreases in plasma protein concentration and hematocrit readings were evident from the outset.
    4. Dehydration and azotemia were common in the early recovery period.
    5. The urinary reactions were indicative of a rather mild base deficiency.
    6. No evidence of excessive use of plasma or whole blood was detected.

    A third study of shock was made at Cassino and on the Anzio beachhead by Henry K. Beecher, MC, Consultant in Resuscitation and Anesthesia, NATOUSA, and Capt. (later Maj.) Charles H. Burnett, MC. Most medical officers who had studied shock believed that it was wiser to resuscitate the patient as completely as possible before placing him on the operating table unless there was evidence that continuing blood loss or some one of the other factors just listed was responsible for his condition. As a result of this study, Major Beecher and Captain Burnett took the contrary position. Their concept was that surgery be considered a phase of the program of resuscitation and given an earlier place in it. This meant that, when the systolic blood pressure had reached 80 mm. Hg and the patient was warm and had a good color, he should be placed on the operating table without further delay. Whatever additional blood replacement might be necessary could be accomplished during the operation. Some medical officers agreed with this concept and put it into practice, but it did not win general acceptance.


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    The Board for the Study of the Severely Wounded made great contributions to the study of shock, crush injuries, and nephropathies.23

    Captain Lalich's investigations constituted the first scientific study of shock in battle casualties in World War II. His studies, together with those conducted by Major Stewart and Captain Warner, showed that blood loss, with a resultant decrease in the circulating blood volume, is the most important cause of shock in battle casualties. These observations were confirmed by the work of Major Beecher and Captain Burnett and by the Board for the Study of the Severely Wounded. The practical application of their observations placed the management of shock upon a rational basis and was responsible for the saving of many lives.

Principles of Resuscitation

    Rapid, complete examination of the casualty in shock was an immediate necessity, to determine the conditions present which might be contributing to his status, so that immediate steps could be taken to correct or control them. Among the shock-producing conditions likely to be found were the following:

    1. Cardiorespiratory embarrassment from painful wounds of the chest wall; sucking wounds; hemothorax; pneumothorax and tension pneumothorax; cardiac tamponade; paradoxical respiration; accumulation of blood, mucus, or both in the tracheobronchial tree; and anoxia from any of these causes.
    2. Continuing hemorrhage.
    3. Large soft-tissue wounds and inadequately immobilized fractures.
    4. Wound sepsis, including clostridial myositis.
    5. Gross contamination of the peritoneal cavity in abdominal wounds.

    The measures to control and correct these conditions included maintenance of a patent airway; postural or suction drainage of tracheobronchial secretions; closure of sucking chest wounds; relief of hemothorax or tension pneumothorax; oxygen therapy; and conservation of body heat.

    Whatever the contributory cause, however, the underlying cause of shock in most cases was blood loss, either alone on associated with one or more of the factors just listed. The regimen of resuscitation was a complex affair, but the keystone of the arch was the administration of whole blood.

    Resuscitation was not an end in itself. It was a means to an end. The end was the operation, which was imperative in the control of hemorrhage, peritoneal contamination, and numerous other conditions and which was an essential part of the management of all cases. Timing was important. When the patient had reached an optimum stage of recovery, it was essential to take advantage of the moment and operate at once, for the status of a wounded casualty was never static, and deterioration was the rule if surgery was too long deferred. Once the patient had slipped back into shock, secondary

23See footnote 18, p.398.


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resuscitation was more difficult than primary resuscitation, and many experiences suggested that it was never as satisfactory.

DEVELOPMENT OF THE BLOOD PROGRAM

North Africa

    U.S. medical officers found, as soon as they began to care for casualties in North Africa, how essential whole blood was both for freshly wounded casualties and for those whose wounds were older. When U.S. Army hospitals landed and began to operate the hospitals in Oran, plasma was available to them in large quantities, but most of them had come overseas with limited equipment for transfusion or none at all. In the 77th Evacuation Hospital, in which Major Snyder was in charge of chest surgery, the only equipment available for transfusion was that which Captain Lalich, who headed the shock team, had secured from the British blood bank in England. The hospital had neither citrate nor distilled water and had no facilities to make the latter. Sodium citrate was obtained from a French pharmacy, a still was borrowed from the French, blood was obtained from the hospital detachment, and the casualties cared for in this hospital received more whole blood than plasma.

    The need for whole blood transfusions in the management of combat casualties and the extreme inadequacy of the equipment for transfusions were reported to the Surgeon, II Corps, early in December by the chief of surgery of the 77th Evacuation Hospital through channels. Major Snyder also emphasized the importance of whole blood in his critique of surgery in clearing stations in North Africa for the Surgeon, II Corps, in March 1943 (p.372). In his report, he stated that (1) a shock team should be part of the personnel assigned from an auxiliary surgical group to a clearing station, (2) a more convenient method of blood transfusion should be made available, and (3) a source of blood other than clearing station personnel should be provided.

Sicily

    When Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, was published on 7 August 1943 (p.361), plasma was still considered to be the most effective weapon for combating shock, though it was noted that, when hemorrhage was a major factor in the patient's status, whole blood should be used as soon as crossmatching could be completed. It was also directed that both blood and plasma be used without delay and in sufficient quantities to accomplish resuscitation, even if this took large amounts. Finally, it was emphasized that, once the patient had been satisfactorily resuscitated, he must not be allowed to slip back into shock, since secondary resuscitation was less effective and more difficult than primary resuscitation.


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    During the fighting in Sicily, blood donors, as in North Africa had to be secured from the personnel of hospital units or from neighboring service units. Transfusion sets, also as in North Africa, had to be prepared, cleaned, and sterilized by hospital personnel. The frequency of malaria reduced the list of available donors, but volunteers, on the whole, responded generously, and the hospital chaplains rendered effective aid in keeping donors continuously available.

Fifth U.S. Army

    By the end of 1944, most hospitals in the Fifth U.S. Army had established their own small blood banks, in which type-specific blood was held for 24 hours, or, occasionally, a little longer. In a few hospitals, the administration of blood at this time averaged 0.5 to 0.8 pint per casualty, but as a rule the rate was far below this. As Major Snyder went from hospital to hospital, it was easy for him to tell from the appearance of the patients after operation whether they had received sufficient blood; if they had not, they looked white and bled out. In almost all hospitals in the winter of 1943-44, it was necessary to urge medical officers to use blood more liberally.

    In February 1944, a central blood bank, designed to supply whole blood to the Fifth U.S. Army, was organized to supply whole blood for Fifth U.S. Army installations, chiefly through the work of Maj. (later Lt. Col.) Eugene R. Sullivan, MC. Field and evacuation hospitals were thus relieved of the difficult task of drawing their own blood in the quantities then being used in forward surgery, and the always undesirable practice of bleeding line and service troops in forward areas was also ended. This organization, officially designated as time 6713th Blood Transfusion Unit (Provisional), was attached to the 15th Medical General Laboratory in Naples, under the command of Colonel Cornell.

    In April 1944, a program was set up by which a medical officer from each army hospital and a technician from each hospital laboratory were sent to Naples for 3 days of intensive instruction at the blood bank. Handling of the banked blood at the individual hospitals was much improved as a result of these courses.

    Anzio beachhead. - The first blood provided by the blood bank at Naples went to the Anzio beachhead, on 25 February 1944. Up to this time, whole blood had been provided to both British and U.S. Army hospital units by the British l2th Field Transfusion Unit. The initial 200 pints of blood brought in on the day of the landing, 22 January, had been used up by 27 January. Thereafter, an average of 100 pints a day was brought in, usually by LST's, occasionally by small planes which could land on the airstrip without drawing German fire. It was the responsibility of the two enlisted men who checked all incoming supplies to watch for the shipments and to arrange for their immediate dispatch by truck to the medical dump. The blood was held there until it was called for by the British transfusion unit, which con-


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tinued to store the blood and distribute it to the hospitals. The performance of this unit was highly efficient.

    Before the breakout at Anzio, it had become evident that the 6713th Blood Transfusion Unit would not be able to supply as much blood as would be needed for the casualties expected. With General Martin's approval, Major Snyder discussed the problem with Lt. Col. (later Col.) Kenneth F. Ernst, MC, Commanding Officer, 2d Medical Laboratory (a Fifth U.S. Army unit). He agreed to supply an additional 100 pints of blood daily. He was able to secure the necessary equipment and supplies, and on 26 May 1944, to the surprise and gratification of the surgeons on the beachhead, he delivered the first 100 pints. The same supplement was received daily until the need for it no longer existed. This laboratory could have supplied whole blood if it had had more donor sets. As it was, it had to stop in the middle of the day to resterilize its equipment.

    Between 22 January and 4 June 1944, 10,624 pints of blood were used in U.S. Army hospitals on the beachhead, an average of 1 pint for each 2.01 battle casualties, and 3,685 pints were used in British hospitals, an average of 1 pint for each 2.95 casualties.

Use of Blood

    From the time the Naples blood bank began to operate, field hospitals were always supplied with all the blood they required. Evacuation hospitals, for a time, continued to operate their own blood banks when the casualty load was not heavy. When it was, their supplies were augmented with blood from the base bank. Later, these hospitals were also supplied with all the blood they needed from the blood bank. In July 1944, when the advance up the peninsula was rapid, forward hospitals sometimes ran out of blood; when they did, a supply was promptly flown in by cub plane.

    As a rule, clearing stations were not supplied with blood. On a few occasions, however, as when the advance was particularly rapid after the breakout from Anzio, blood was used in some of the clearing stations which were well ahead of field hospitals. There were no untoward results, but when field hospitals were abreast of clearing stations there was no real need for this practice.

    Blood was used with more and more liberality as the months passed, and its value was increasingly appreciated. This was true in all echelons of medical care. In the last 4 months of 1944, 9,903 pints of blood were given to 15,553 casualties admitted to Fifth U.S. Army hospitals--0.63 pint per casualty. In 1945, before the fighting in Italy ended, the ratio was 1 pint per casualty.

    Blood was used with equal liberality in general hospitals. Colonel Hampton and Major Lyons, for instance, in their demonstration of correct surgery of the extremities at the 21st General Hospital in the fall of 1944, reported the daily use of 1,000 cc. or more in septic patients, in order to bring the hematocrit and plasma protein to normal levels.


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    Colonel Snyder and Captain Culbertson, in their study of combat fatalities in Fifth U.S. Army hospitals, provided the following data on the use of blood and plasma:

    1. Of all wounded patients treated in field hospitals, about 70 percent required blood transfusions and about 63 percent required plasma. An average of 3 pints of blood was given to each patient who required blood and an average of 2.5 units of plasma to each patient who required plasma.
    2. In evacuation hospitals, about 20 percent of the patients required blood transfusions. Each of them received an average of 2 pints. About 15 percent of the patients required plasma, and each of them received an average of 2.5 units.

    The superior management of the blood bank established at Naples and the unlimited quantities of blood which it supplied contributed greatly to the improved results of combat surgery in the Mediterranean theater in the last year of fighting. The medical officers who headed shock teams and supervised resuscitation of shocked patients developed great skill and judgment in the preparation of battle casualties for surgery, and the saving of many lives can be attributed to their fine work.

BLOOD REPLACEMENT THERAPY

Techniques

    Once it was realized that shock was chiefly due to loss of blood, restitution of the depleted blood volume was recognized as the principal component of resuscitation. Plasma was used from the battlefield through the clearing station, in sufficient quantities to render the patients transportable to hospital installations. Thereafter, whole blood was chiefly used except in burns, in which, logically, plasma was employed in large quantities, particularly immediately after injury.

    When the patient was in severe shock, 1,000 cc. of whole blood was given rapidly into two veins, under positive pressure. In extremely urgent cases, when the blood pressure could not be obtained at all, the first 1,000 cc. of blood was administered without crossmatching; since all blood used was low titer group O blood (p. 420), this expedient was regarded as safe, at least under the circumstances. After the systolic blood pressure had reached 80 mm. Hg, the rate of the transfusion was reduced. When the pressure approximated normal (100 mm. Hg or higher), an additional 500 cc. of blood was administered unless there was some urgent reason for operating immediately. The rationale of this practice was that a systolic blood pressure in the neighborhood of normal was often attained before the depleted blood volume had reached a satisfactory level.

    Blood replacement was frequently continued during operation unless exploration of an abdominal wound revealed that peritoneal contamination was


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the principal factor responsible for shock; in these circumstances, if there had not been a considerable loss of blood, plasma could be used.

    Long before the end of the war, copper sulfate solutions were in universal use for the determination of hemoglobin, hematocrit, and plasma protein values in battle casualties. The procedure was standard in both field hospitals and evacuation hospitals and proved extremely valuable in estimating the nutritional state of patients after operation. This useful development grew out of the work of Captain Lalich on the Anzio beachhead (p. 412).

Reactions

    The blood sent from the Naples blood bank to the Anzio beachhead was all type O. One set of recipient tubing was furnished with each two bottles of blood. There were no serious reactions, but a few patients had mild attacks of shivering or slight chills. When this happened, the transfusion was continued from another bottle of blood, the partially used bottle being employed for another casualty.

    In April 1944, anuria was reported in a number of casualties who had been transfused with untitered group O blood. Shortly afterward, a serious reaction was reported in a group A recipient who had received 2,500 cc. of group O blood. Major Snyder at once initiated discussions with Major Beecher, Captain Burnett, Captain Lalich, and others who had made special studies of shock and resuscitation. Captain Lalich reported the development of urinary difficulties in a number of individuals with cases of shock which he had investigated. They were by no means universal, but they had occurred, and some of them had been serious. He did not think, however, that sufficient evidence had yet been accumulated to inculpate group O blood or to ask that the blood bank furnish type specific blood. Others in the group thought that this request should be made immediately. These reactions were also discussed with officers at the 15th Medical General Laboratory.

    It was agreed, as the result of the conferences, that low titer group O blood should be given a further trial before any change in the present policies was instituted. As a precaution, all blood with an anti-A or anti-B titer over 1:250 was to be marked "For group O recipients only."

    On 1 May 1944, when Major Snyder visited time 33d Field Hospital on the Anzio beachhead, he received reports of two deaths in group A recipients who had received group O blood. Most medical officers were now convinced that the use of group O blood in group A recipients was unsafe and should not be continued. Major Beecher returned to Naples, to discuss the matter further with officers in the blood bank there, and it was agreed that sufficient evidence was now at hand to warrant a change in policy and the supplying of group A blood for A recipients. It was also agreed that a circular letter should be prepared to accompany the shipments of group A blood.

    Before these arrangements could be consummated, the decision was reversed; and the Surgeon, Fifth U.S. Army, was informed by radiogram from


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the Commanding General, NATOUSA, that thereafter the base collecting section of Blood Transfusion Unit 6713 would furnish the Fifth U.S. Army installations with only one type of blood, group O, with an agglutinin below 1:64. It was indicated that this radiogram was for action by the Commanding Officer, 15th Medical General Laboratory.

    There were two reasons for this decision. One was the fear that more deaths might be caused by errors in crossmatching if both group A and group B bloods were supplied than would occur if group O blood titered for anti-A and anti-B agglutinogens continued to be used. The second was the possibility that group A blood might be administered through tubing through which plasma was running, with resultant serious reactions.

    In a return radiogram, the commanding officer of the 15th Medical General Laboratory made the following points:

    1. Rigid compliance with the order received might necessitate discarding half the O blood drawn. In the past, O blood with an anti-A titer of 1: 250 or over had been marked "For group O recipients only." These bloods had comprised only about 15 percent of all bloods drawn. The order in the wire from NATOUSA precluded the use of O blood with a titer of over 1:64 for anyone. Immediate authority was requested to use group O blood for O recipients, regardless of titer.
    2. Four histologically proved cases of fatal hemoglobinuric nephropathy were known to have followed the use of group O blood for A recipients. In two of these fatalities, only low titer blood had been used. Major Beecher had information of other clinical cases in which the circumstances were similar, and he had ceased to use group O blood for group A recipients.

    An immediate investigation by Colonel Churchill was requested, with authority to modify or revoke the order of 13 May from theater headquarters. The matter was finally resolved by continuing, as in the past, to use group O blood of any titer for O recipients and to mark all blood with an anti-A or anti-B agglutinogen titer of 1:250 or more "For group O recipients only."

CHEMOTHERAPY AND ANTIBIOTIC THERAPY

The Sulfonamides

    Because penicillin was not available during the fighting in North Africa and was available only in limited quantities and for strictly limited use in Sicily and in the first months of the fighting in Italy, sulfonamide therapy was used both locally and systemically during this period.

    The studies of Major Stewart and his associates on shock (p. 413) included determinations of the sulfonamide levels in the blood. In both the preliminary and the final reports, these observers called attention to the erratic and uncertain blood sulfonamide levels. They warned that this unpredictability should be kept in mind in any appraisal of the presumed benefits of routine sulfonamide


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therapy in severely wounded men. If both overdosage and ineffective levels were to be avoided, sulfonamide therapy must be controlled by blood determinations.

    The local use of the sulfonamides became more infrequent as the war progressed. Opinions concerning the value of this route had differed widely. A few surgeons considered local sulfonamide therapy of great value, a number considered it harmful, and the majority believed that it made no difference whether or not it was used.

    The possible implication of sulfonamide therapy in lower nephon nephrosis is discussed under "Complications, Anuria and Nephropathy."

Penicillin

    When penicillin first became available in Sicily in the summer of 1943, its use was limited to the treatment of clostridial myositis. It was also used only on this indication in the first months in Italy. The routine of securing it was quite complicated. It was distributed by the 15th Medical General Laboratory in Naples, which served as a depository for it, and it had to be secured by requisition from certain designated hospitals in the army area. When it was needed at the 15th Evacuation Hospital on the Anzio beachhead, for instance, it was necessary for the chief of surgery there to call Lt. Col. (later Col.) Phillip W. Mallory, MC, Executive Officer, the 56th Evacuation Hospital, each time he needed a supply.

    By the spring of 1944, penicillin had become available in sufficient quantities to be used in all wounds in which it was indicated. Meantime, at the 21st General Hospital, Major Lyons, consultant in penicillin therapy, and Major Hampton had set up a septic ward in which they were demonstrating a threefold program in the surgery of the extremities, consisting of adequate debridement, liberal blood transfusion, and penicillin therapy (p. 359). Penicillin was given in dosages of 200,000 Florey units daily (25,000 units every 3 hours) by the intramuscular route. At the suggestion of these observers, this regimen was instituted in all field and evacuation hospitals as soon as the casualty was admitted. The operating surgeon decided whether to continue the use of penicillin after operation.

    Penicillin was sometimes used intraperitoneally in abdominal injuries, occasionally in combination with the local implantation of sulfanilamide powder or crystals. Opinions concerning its value by this route differed as widely as opinions concerning the local use of sulfanilamide. There was general agreement, however, that penicillin was of great value when used locally in the pleura and the joints.

    Penicillin was introduced at about the time forward surgery was greatly improved, particularly in respect to more adequate debridement, with greater emphasis upon the removal of all devitalized tissue. This was also the period in which blood began to be used in generous quantities and in which delayed


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primary wound closure was generally employed in base hospitals. The policy of wound closure, which was highly successful, was possible because most of the wounds looked and were healthy and clostridial myositis had ceased to be the threat it had been earlier. Penicillin was given, and deserved, a considerable share of the credit for these achievements. Knowledgeable surgeons continued to insist, however, that good surgery was the basic reason for the improvement in results, and there is no doubt that their emphasis upon it was entirely justified.

SPECIAL TYPES OF WOUNDS AND INJURIES

Soft Tissue Injuries and Fractures

    Initial wound surgery. - The principles of initial wound surgery, particularly the importance of adequate debridement, had been thoroughly taught before the war and were fully appreciated from the beginning of the fighting in North Africa. Certain practices were introduced, and others were modified, but the fundamental principles remained unchanged. As the war progressed, however, these principles were more generally and more correctly applied.

    Circular Letter No.3, Office of the Surgeon, Headquarters, II Corps, dated 7 August 1943,24 gave the following directions for the management of wounds produced by high explosive shell fragments:

    1. All foreign bodies should be localized by fluoroscopy before operation.
    2. Devitalized and contaminated skin should be excised, but healthy skin should not be sacrificed.
    3. The skin wound should be enlarged by appropriate incision to permit exposure and excision of all underlying devitalized and contaminated tissue and to provide adequate drainage to the depths of the wound. This required similar incision of the fascial plane.
    4. Foreign bodies, which frequently carried in bits of clothing, dirt, and other foreign material, should be removed.
    5. When debridement had been completed, raw surfaces should be dusted with sulfanilamide powder, and fine-mesh petrolatum-impregnated gauze should be placed loosely in the wound.
    6. The wound should never be sutured primarily.

    Changes in this technique were as follows:

    1. Fasciotomy proved a very useful method in hematomas of the leg and in wounds associated with swelling and with impairment of the blood supply. It was performed at initial wound surgery or later according to the indications of the special case.
    2. The type of incision based on the Z-plasty incision employed in plastic surgery proved very useful in extensive injuries in areas in which there was

24 See footnote 8, p. 361.


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little excess of skin. Each limb of the incision was begun at the opposite corner of the traumatic incision. Delayed primary wound closure was greatly facilitated when this incision was employed in the types of wounds mentioned.
    3. After January 1944, fine-mesh dry gauze began to be used in wounds instead of petrolatum-impregnated gauze.

    The circular letter published in August 1943 stated that little or no debridement was necessary in through-and-through wounds produced by high-velocity bullets. This did not prove a satisfactory policy. Later, it became the practice to make a sufficiently long incision through the skin and fascia in this type of wound to permit a search for possible muscle damage. If no damage was found, nothing further was done. If damage was found, debridement was proceeded with according to the usual technique.

    The principles of adequate debridement of high explosive wounds of the extremity were, as already mentioned, known before the war, and they were emphasized throughout the war. They never changed. The problem was not the management of these wounds. It was teaching inexperienced surgeons and staffs of newly arrived hospitals to follow these principles and practices. That these principles and practices be followed was essential, for the whole program of reparative surgery (delayed primary wound closure) was based upon the adequacy of initial wound surgery.

    Fracture management. - The management of compound fractures at initial wound surgery was limited to the correction of gross malposition. Definitive reduction was not the function of an army hospital. Roentgenologic controls were not feasible in a forward hospital, and, even if precise reduction could have been maintained during the application of transportation splinting, it would probably have been lost when the cast was split or bivalved, as was the fixed rule in forward areas, to guard against circulatory impairment during transportation. Definitive reduction, by whatever method was indicated, was the function of the general hospital, at reparative surgery.

    Removal of totally detached bone fragments was part of initial wound surgery. All large fragments whose removal would have created a segmental bony defect were left in situ, as were all small fragments which had any attachment at all.

    Delayed primary wound closure. - Closure of the wound was the function of general hospitals in the base but was occasionally completed on minor wounds in convalescent hospitals in the army area. The wound was inspected in the operating room, and if it looked clean and healthy it was closed by interrupted sutures. Contraindications to closure included infection; the presence of necrotic tissue in more than minimum amounts (small fragments of necrotic tissue were excised) ; and inability to secure closure without tension unless a skin graft was employed. Wound healing was usually prompt and satisfactory if initial wound surgery had been adequate.


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    Most surgeons preferred to perform delayed primary wound closure within 4 to 10 days after wounding. As experience was accumulated, the earlier timing came to be considered more desirable.

    When Dr. Allen Whipple visited North Africa in the fall of 1943 (p.368), he had just returned from observing British surgery in the Far East. British surgeons ascribed their success in delayed primary wound closure to the local use of penicillin. Under Colonel Churchill's direction, a number of U.S. Army surgeons at the Bizerte medical center had been trying out this technique, but without using local antibiotic or other therapy. After Dr. Whipple had observed the outcome of these cases, he concluded that penicillin had nothing whatever to do with the results he had observed in British hospitals and agreed with U.S. Army surgeons that their good results were due to good surgery alone.

    Splinting and casting. - The primary splinting applied in fractures of the extremities was, like the first dressings, intended to serve until the patient reached a hospital in which surgery could be performed. This was not always practical; improvised splinting frequently had to be employed to remove the patient from the battlefield to the battalion aid station. In any event, whatever splinting had been applied on the battlefield was inspected in the battalion aid station and in subsequent division installations, but it was not disturbed if it was adequate.

    The hinged full-ring arm splint was found unsatisfactory in southern Tunisia, and its use was discouraged in Sicily.25 It was entirely abandoned during 1944. This splint was poorly adapted to fractures of the elbow, and patients were seldom comfortable in it. A few cases of gangrene were reported as the result of pressure of the ring on the blood supply in the axilla.

    Fractures of the shoulder, arm, and elbow were best immobilized by placing the arm in a sling and then binding it to the chest, with the elbow in 90 flexion, with another triangular bandage. An axillary pad was always used. Some surgeons preferred to use padded wire splints for these injuries.

    The Army half-ring hinged splint remained the most satisfactory transportation splint available during the war in the first echelon of medical care for fractures of the thigh, knee, and upper and middle leg. As time passed, surgeons learned to apply it more competently. For one thing, they learned to use it merely to immobilize the limb, without attempting to reduce the fracture. They also learned to avoid excessive and harmful traction.

    In fractures involving the knee and the lower and upper thirds of the femur, the half-ring splint was so bent as to provide for from 20 to 30 knee flexion. At least five muslin slings were used to support the thigh and leg and additional slings were employed for the foot. The litter bar used to secure the splint to the litter added to its effectiveness.

25 See footnote 8, p.361.


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    Fractures of the lower third of the leg and of the ankle and foot were usually immobilized in wire ladder splints. One splint was applied to the posterior surface of the leg and the plantar surface of the foot, and a second was used as a U or stirrup splint to support the sides of the leg and the foot-piece of the first splint. The splints were well padded and were held in place by bandages.

    Transportation splinting after surgery was accomplished with well-padded plaster casts. Circular casts were split or bivalved down to the skin while the patient was still on the operating table. There were no exceptions to this regulation.

    The plaster Velpeau was preferred for transportation splinting in fractures of the shoulder, arm, and elbow. The most satisfactory immobilization of compound fractures of the femur was secured by a plaster spica applied to include the intact thigh, with the upper part of the cast extending to just above the iliac crest.

    The Tobruk splint required less plaster and less water than other plaster casts, and it was sometimes, of necessity, used when these commodities were in short supply, as not infrequently happened in desert fighting in North Africa. It was occasionally used in extensive soft-tissue wounds of the lower extremity. Otherwise, this splint, which British surgeons favored highly, never won popularity with U.S. surgeons. They used the plaster spica, as just described, except in occasional cases in which there was a concomitant wound of the abdomen. Then the Tobruk splint was useful. This splint was sometimes used in fractures of the knee joint and, less often, in fractures of the leg. More often, a long-leg plaster cast was used for injuries of the leg and a single plaster spica for injuries of the knee joint.

Joint Injuries

    The evolution of the management of joint injuries followed the same general pattern as for soft-tissue wounds and fractures. Early in 1944, it was directed that arthrotomy be performed in all joint wounds, to permit wide excision of devitalized cartilage and removal of all foreign bodies. After irrigations with physiologic salt solution, the synovia or capsule was closed, and penicillin solution was instilled. Aspiration of the joint and reinstillation of penicillin were carried out at 24-hour intervals after operation for as long as seemed necessary.

    The application of these principles to injuries of the knee joint led to a greatly reduced incidence of infection and much better functional results. A similarly bold approach was recommended in injuries of the hip joint, but it could be applied much less universally. This is an inaccessible joint, and the number of orthopedic surgeons in the theater who had sufficient knowledge of surgery in this area to perform the radical surgery required was always limited.


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    Resection was practiced in injuries of the knee joint but was not employed in injuries of other joints.

Vascular Injuries

    Considerable improvement was effected in the management of wounds of the major vessels of the extremities as the war progressed, but these wounds remained a serious problem throughout.

    The use of tourniquets. - Originally, the use of tourniquets was both confused and unsatisfactory. Early in the war, they were used far too frequently and removed far too often. After a tourniquet had been applied by a corpsman on the battlefield, it was examined by the first medical officer who saw the casualty and frequently was removed by this medical officer. If the tourniquet was not removed, it was the policy to loosen it routinely every 30 minutes. In some cases, death occurred from the cumulative effects of the bleeding which ensued each time the tourniquet was loosened. These fatalities usually took place during evacuation by ambulance, on trips lasting several hours, when the medical corpsman loosened the tourniquet every 30 minutes as he had been instructed to do. Many deaths which could have been avoided were thus precipitated because no facilities were at hand to control the hemorrhage which frequently followed the removal of the tourniquet.

    Later, the policy was reversed, and, once a tourniquet had been applied, it was not loosened or removed, particularly if the casualty was in shock, until facilities were at hand for the immediate control of hemorrhage and the replacement of blood loss. It was found to be safe when a large vessel had been damaged, to leave the tourniquet in place for periods of from 4 to 6 hours during cold weather and for somewhat shorter periods in warm weather. Rubber tubing proved more satisfactory than the Army-issue webbing tourniquet.

    The study of the use of tourniquets, with particular reference to patients in shock, which was carried out by Maj. Luther H. Wolff, MC, and Capt. Troglier F. Adkins, MC, of the 2d Auxiliary Surgical Group, was the basis of the following regimen, which was in general use when the war ended:

    1. Patients with tourniquets in situ should have the highest priority for transportation to the nearest hospital. The emergency medical tag should indicate that a tourniquet is in place. Marking the forehead with a red T was an additional precaution.
    2. An effective tourniquet should be placed on an actively bleeding extremity at the earliest possible moment.
    3. At the end of about 2 hours, if the patient was not in shock and if all circumstances were favorable, the medical officer might cautiously loosen the tourniquet if facilities were available for immediate control of hemorrhage. If bleeding was negligible or did not recur, the tourniquet might be removed, but the patient was kept under continuous observation, and the tourniquet was left in place for immediate reapplication.


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    4. On no account should a tourniquet on a patient in shock be removed within 4 to 6 hours of its application unless the blood volume had been at least partly replaced by plasma or whole blood. After this time, the removal or loosening of the tourniquet was a matter of individual judgment. In many instances, sufficient clotting and spasm had occurred by this time to prevent further bleeding.
    5. When a tourniquet was in place, the temperature of the affected limb was lowered as much as possible short of actual freezing.

    Management. - The first group of vascular injuries managed by lumbar sympathectomy was reported by Maj. James M. Mason III, MC, and Capt. W. Phillip Giddings, MC, from the 2d Auxiliary Surgical Group. Although their results were inconclusive, they thought the procedure had promise. Later, Major Simeone used sympathectomy in a number of vascular injuries of the lower extremity and advocated its prompt performance whenever the patient's condition permitted it. Probably the best results obtained in vascular injuries followed the use of this technique.

    Major Simeone also used the Lord-Blakemore Vitallium cuff in a few anastomoses of the popliteal and femoral arteries, but the results were not encouraging.26 In four cases thus treated at the 33d Field Hospital in December 1943, there were three failures. Other observers had the same experience. As time passed, it became evident that, if the wounds were extensive, vascular repair was likely to be successful only when surgery could be undertaken within 4 to 6 hours of wounding. This criterion could seldom be met.

    Vascular injuries were the subject of a special study and a number of formal and informal meetings in Fifth U.S. Army hospitals. All speakers emphasized that any major vascular injury should have priority of care.

    At one of these meetings, a patient was presented who had been treated by a French surgeon, for a bleeding popliteal artery, by means of ligation and division of the common femoral artery at the level of the inguinal ligament. The wound in the popliteal area was packed, but the artery was not directly attacked. The result was apparently excellent; in fact, the foot on the injured side was warmer than the normal foot. Major Snyder, nonetheless, felt constrained to warn against this technique until a sufficiently large series of cases had been collected to prove both its safety and its value. No such series was ever reported.

Neurosurgical Injuries

    Head injuries. - Some patients with head injuries were sent to field hospitals for resuscitation or evaluation, but surgery was done in this echelon of medical care only if the injury was associated with hypertension a slow pulse: fixed, dilated pupils; respiratory depression; and deep coma. This group of casualties were to be treated by emergency decompression in field hospitals. All

26 Medical Department, United States Army. Surgery in World War II. Vascular Surgery, Washington: U.S. Government Printing Office, 1955.


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other patients with head injuries only were to be transported to evacuation hospitals.

    If a patient with injuries in other parts of the body had to be cared for in a field hospital because of those wounds, the chief of surgery in the field hospital, at his discretion, might call a neurosurgeon forward from an evacuation hospital, usually 5 to 15 miles to the rear, to evaluate the head injury and to operate for it if he thought it was necessary. This system worked very well in the few cases in which it was necessary to invoke it.

    In the evacuation hospital, foreign bodies were removed at initial wound surgery if they were accessible; that is, if they were on the same side as the injury. If they were on the other side, they were left in situ. Most surgery was performed under local analgesia unless the patient was uncontrollable. Then Pentothal sodium was used.

    On one of Colonel Snyder's trips to Anzio, he found, in one hospital, that general surgeons were doing neurosurgery and neurosurgeons were doing chest and abdominal surgery. This was stopped immediately. When neurosurgeons were limited to their specialty, there were enough in the theater to handle all cases. A neurosurgeon was assigned to almost every evacuation hospital, and, if the caseload proved too heavy, a neurosurgical team from the 2d Auxiliary Surgical Group could be attached to the hospital temporarily. Later in the war, when it was found desirable to have two neurosurgeons in each forward evacuation hospital so that there could be round-time-clock neurosurgical care, the neurosurgeon in the rearmost evacuation hospital was moved to the hospital nearest the front.

    During 1944, techniques in neurosurgery improved greatly, and Fifth U.S. Army neurosurgeons operated on large series of head injuries with mortality rates far below those reported in World War I. The rates were still high, however, and 19.4 percent of the battle casualty deaths studied in Fifth U.S. Army hospitals in 1944 and 1945 occurred in patients with intracranial injuries (table 12).

    Spinal cord injuries. - Injuries of the spine in which the cord was involved also remained a serious problem throughout the campaign in Italy. The percentage of deaths in which spinal or spinal cord injuries were the responsible factor increased from 1.3 percent in the first 3 months of 1944 to 3.9 percent in the January-May period of 1945 (table 12), but the increase was only relative; it was accounted for by the fact that casualties with associated chest and abdominal injuries who had died in the earlier period were now surviving long enough to be hospitalized.

    Whenever possible, patients with spinal cord injuries were placed under the care of neurosurgeons, for evaluation and for laminectomy if it was indicated. Since spinal cord injuries were often associated with wounds which rendered the casualties nontransportable, they had to be evacuated to field hospitals, which were not staffed with neurosurgeons.


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    It was eventually concluded that it was in the best interests of patients with multiple wounds to perform the necessary surgery on the spinal cord injury in field hospitals rather than prolong the timelag and subject them to the further trauma incidental to transportation to an evacuation hospital several hours or several days after surgery for the other wounds. The necessary surgery for intrathoracic and intra-abdominal wounds was completed before the necessary surgery on the spinal wound was performed. Whenever possible, all of time wounds were cared for at the same sitting, though occasionally laminectomy was deferred for a few hours or for a day or two. The work of general surgeons in evaluating these cases and in performing the indicated neurosurgery, including laminectomy, was well done.

    Thorough debridement or complete wound excision was just as necessary in intravertebral wounds as in any other wounds. Removal of bone fragments and foreign bodies and excision of devitalized and contaminated tissue were performed as in the usual debridement. The dura was closed.

    If there was loss of bladder function in spinal injuries, suprapubic cystostomy was performed routinely before the patient was evacuated from the army area to a base hospital.

    Peripheral nerve injuries. - There was general agreement that primary nerve suture was contraindicated in the army area. This was completely reasonable. Most of the wounds had been incurred hours before the patients were first seen, and primary closure of a potentially dirty wound would have been extremely hazardous. For primary nerve suture to be accomplished, a wide, extremely careful wound excision would have been necessary, and even in these circumstances primary wound closure would have greatly increased the hazard of infection, particularly anaerobic infection.

    A few surgeons believed that the separated nerve ends should be identified with wire or black silk or should be approximated with a single suture, but the majority believed that nothing at all should be done to the damaged nerve ends at initial wound surgery.

    Major Snyder recommended that no surgery for peripheral nerve injuries be done in forward hospitals. This was partly because the results were likely to be poor and partly for other reasons. He had observed one fatal case in which clostridial myositis developed in an extremity when initial wound surgery was deferred until a neurosurgeon was free to suture the nerve primarily. He had also observed a death in Tunisia which could be attributed, at least partly, to the added time consumed in the primary suture of a radial nerve at surgery for a compound comminuted fracture of the humerus. He felt very strongly, in view of these observations, that surgery on peripheral nerve injuries should not be performed in army hospitals.

Thermal Injuries

    Burns. - It was consistently held in the North African theater that the correct treatment for burns was the removal of gross debris and the immediate


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application of fine-mesh, petrolatum-impregnated gauze overlaid with dry gauze and cotton waste. An occlusive bandage was then used, to achieve slight compression.

    These recommendations were set forth in the circular letter issued after the invasion of Sicily.27 In the Italian campaign, the instructions for limited debridement were changed to include gentle cleansing with cotton, soap, and water, and the excision of gross debris and loose skin. The use of tannic acid had been banned in Africa, and, after the invasion of Sicily, the use of all coagulants was forbidden.

    Anesthesia for debridement was discouraged after a patient with only a moderate burn died an anesthetic death during Pentothal sodium anesthesia. Plasma, penicillin, and blood transfusions were used routinely in serious burns.

    Cold injury. - The first casualties with cold injury (trenchfoot) observed in Italy passed through a clearing station south of Cassino the first week in November 1943, though not all of them received a correct diagnosis.

    After cold injury once appeared, the incidence increased rapidly and over time 6-month period ending 30 April 1944, there were more than 5,700 casualties from this cause in the Fifth U.S. Army. For all practical purposes, these losses were quite as serious as combat losses, for, almost without exception, they occurred in frontline troops, who were always in extremely short supply during the fighting in Italy. During this winter, losses from cold injury amounted to about 7 percent of division strength, and hospital admissions from this cause constituted 9 percent of all admissions for disease.28

    The lessons of the first winter in Italy were well learned, and, during the second winter, in the 6-month period ending 31 March 1945, there were only 1,572 cases of cold injury. Many of these injuries represented recurrences in men who had suffered from cold trauma during the previous winter. No satisfactory form of treatment was ever developed, and medical officers learned from these recurrences that return to full duty is possible in only a limited number of casualties who have once suffered trauma from cold.

    The control of trenchfoot is a command responsibility, and much of the decrease in incidence during the second winter of the war in Italy can be traced to the assumption of this responsibility by commanding officers at all levels. Medical officers, however, participated in the preparation of circular letters on the subject, in general educational efforts, and in other phases of control.

    An intensive study of cold injury in Italy was made by Major Simeone. The story of trenchfoot in the Mediterranean theater in the volume on cold injury in this series of histories is based largely on his reports.

27 See footnote 8. p.361.

28 Medical Department. United States Army. Cold Injury, Ground Type. Washington: U.S. Government Printing Office. 1958.


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REGIONAL INJURIES

Maxillofacial Injuries

    Maxillofacial wounds were managed by the same general principles throughout the war. The routine included debridement, with the sacrifice of as little tissue as possible; early fixation of the jaw fragments, by elastic traction; provision of an adequate airway, by tracheotomy if necessary; and primary closure of the soft-tissue wound with horsehair or fine silk. Healing without infection was the rule, and no instance of gas bacillus infection was reported in this group of wounds.

    The original plan that these wounds should be handled in evacuation hospitals proved sound. The reasoning was that if a good plastic or maxillofacial surgeon did the work there, or supervised the surgery, the results would be better than could be accomplished by a general surgeon without special training in plastic surgery.

    In October 1943, Fifth U.S. Army surgeons began to see many maxillofacial injuries caused by a new type of personnel mine, which was weak and exploded underground. The lower extremities and trunk therefore often escaped injury, but the face and hands were burned, and gravel, rubber, leather, and dirt were blasted into the tissues and caused numerous and often severe lacerating and penetrating wounds.

    The mortality rate in maxillofacial wounds was low. There were only 6 deaths from this cause in 1,450 battle casualty deaths studied in Fifth U.S. Army hospitals (table 12).

Wounds of the Neck

    The cardinal points in the management of wounds of the neck were as follows:

    1. Debridement of all involved structures. Multiple involvement was the rule because of the anatomy of the area.
    2. Prompt identification of wounds of the carotid artery, with early, adequate blood replacement combined with oxygen therapy to combat cerebral ischemia.
    3. Identification and attempted repair of wounds of the cervical esophagus. Primary closure was frequently impossible. These wounds were comparatively uncommon.
    4. Removal of foreign bodies from, and drainage of, the retropharyngeal and retroesophageal spaces.
    5. Resuscitative and supportive therapy according to the indications.

    Cervical wounds were the chief cause of death in 26 of the 1,450 battle casualty deaths studied from Fifth U.S. Army hospitals (table 12). Of the 11 patients in this group who died of shock, 4 had lacerations of the carotid artery, and 6 had lacerations of the jugular or the subclavian vein. Four other


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patients in the 1,450 fatal cases also had lacerations of the carotid artery with cerebral ischemia, but the vascular injury was not the immediate cause of death.

Wounds of the Chest

    Major Snyder's contacts with combat-incurred wounds of the chest followed immediately upon his observations of these injuries in England (p. 335). When the 77th Evacuation Hospital landed in North Africa and took over the hospitals in Oran, many of the casualties had received little or no care. In particular, wounds of the chest had not been debrided, sucking wounds had not been closed, and hemothoraxes had not been aspirated. Although some of these hemothoraxes became infected, none of the patients developed empyema because daily aspirations of the chest were instituted and sulfonamide therapy was employed systemically.

    In Tunisia and Sicily, the correct management of chest wounds was often difficult because of the lack of proper anesthetic and other equipment. Maj. Philip F. Partington, MC, prepared needles with flutter valve attachments made from condoms or Penrose drains, and the improvised equipment proved very satisfactory in the management of tension pneumothorax in casualties who had to be evacuated. It was learned early in the war that water seal bottles were not only unsatisfactory but were also dangerous to use during evacuation, whether they were connected to needles or catheters, for the drainage of air or blood from the pleura.

    It was a strict rule that no patient be evacuated with an intercostal catheter in place. If he had to be moved, water seal drainage was replaced by flutter valve equipment. A number of surgeons abandoned catheter drainage after thoracotomy except when oozing was unusually profuse or there was a continuing air leak from the lung, because of the difficulty in maintaining the correct use of water seal bottles. Most of the time, the casualty was on a cot only a few inches above the floor, and, whenever an uninformed person picked up the water seal bottle to see how much drainage had occurred, the fluid ran back into the chest. It was found that fewer aspirations of the chest were necessary when closure was accomplished without intercostal drainage than were necessary after removal of the intercostal catheter in cases which had been drained.

    The circular letter, published after the invasion of Sicily, 29 gave the following directions for the management of wounds of the chest:

    1. Shock, continuing hemorrhage from the chest wall, tension pneumothorax, and open sucking wounds should be treated by the necessary emergency measures at the battalion aid station or the collecting or clearing stations.
    2. Casualties suffering from dyspnea and those in continued shock or verging on shock should be transferred to a field hospital. Casualties with sucking

29 See footnote 8, p. 361.


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chest wounds and persistent hemorrhage from the chest wall should also be treated in field hospitals.
    3. Transportable casualties should be treated in evacuation hospitals. As it worked out, the majority of casualties with wounds of the chest were treated in evacuation hospitals because they were safely transportable to them.

    This circular letter set forth the management of the wound at initial wound surgery as follows:

    1. Sucking chest wounds should be debrided.
    2. Loose bone fragments, bits of clothing, and accessible foreign bodies should be removed.
    3. Wound closure should be accomplished.

    Thoracotomy. - If retained foreign bodies were present which might require removal by formal thoracotomy, and initial wound surgery had been confined to the chest wall, the patient was transferred to an evacuation hospital as soon as respiratory equilibrium had been accomplished.

    In January 1944, it was directed that thoracotomy, through the wound or through an elective incision, might be done in field hospitals on the indication of sucking chest wounds; continued intrathoracic hemorrhage; thoracoabdominal wounds; and large bronchopleural fistulas not controlled by conservative measures. If the wound had to be enlarged after debridement to permit satisfactory examination of the depths, removal of readily accessible foreign bodies was permitted. It was also directed at this time that, if possible, large foreign bodies be removed from the lung at initial wound surgery in evacuation hospitals if the patient was unlikely to reach a base hospital within 10 days.

    Hemothorax. - During their preliminary observations in England, Major Snyder and his associates had been warned by Mr. Tudor Edwards that the management of hemothoraxes would be one of their major tasks as thoracic surgeons. British surgeons taught that aspiration of a hemothorax should be performed at least once a day, or, in the early stages, even oftener. Massive clotted hemothoraxes might occasionally be encountered in which thoracotomy would be necessary in a forward hospital.

    Air replacement, which was recommended after aspiration in War Department Technical Manual 8-210, published in 1942, 30 had been entirely abandoned by British surgeons. Their reasoning was (1) the lung reexpanded rapidly and therefore hemorrhage was unlikely to occur, (2) bleeding was less likely to recur if the lung was fully expanded, and (3) if air were injected after aspiration of blood and empyema should subsequently develop, it would be total empyema and most difficult to manage.

    The large number of casualties with hemothorax encountered in the hospitals at Oran had received little or no treatment, as has already been noted, and some of the wounds were already infected. The British teachings were promptly put into effect, with remarkably good results, and thereafter were

30 War Department Technical Manual 8-210, Guides to Therapy for Medical Officers, 20 Mar. 1942.


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employed regularly. Even late in the war, however, it was sometimes necessary to warn competent chest surgeons that air replacement must not be employed after aspiration of the chest.

    Major Snyder, after his observations in England, came to believe quite strongly that if a massive clotted hemothorax was encountered in a forward hospital it should be evacuated by thoracotomy. The surgeon, in such eases, had to be prepared to stop bleeding from a large pulmonary vessel. The development of large clotted hemothoraxes which were not aspirated early was usually to be explained by bleeding which had occurred so rapidly that the respiratory movements of the lung and chest wall could not defibrinate the blood rapidly enough to prevent clotting. This frequently happened when large pulmonary vessels were injured. When the hemothorax filled with blood, the lung collapsed, and bleeding from the damaged pulmonary vessel ceased. When the clotted blood was evacuated, hemorrhage might again ensue and the surgeon must be prepared for time contingency.

    Evacuation of the hemothorax by merely opening the chest and scooping out the clotted blood with the hand differed from the decortication necessary in base hospitals when a clotted hemothorax had persisted for from 3 to 6 weeks after injury. Even then, the entire mass of clotted blood often peeled readily from both the visceral and the parietal surface, thus permitting immediate reexpansion of the lung.

    Wet lung. - The condition which came to be known as wet lung was frequently encountered. It was a collection of mucus and blood in the tracheobronchial tree which the patient could not or did not cough up because of painful wounds of the chest wall, hemothorax, pneumothorax, or inhibition of the cough reflex because of coma. Wet lung was associated with bronchospasm, and bronchorrhea was often extreme.

    It was found that this condition could be readily controlled by procaine hydrochloride block of the affected intercostal muscles or by paravertebral block of the two segments above and the two below the wound. The patient received a small dose of morphine and atropine before the procedure, and the atropine was repeated at 4-hour intervals afterward if necessary. The nerve block frequently had to be supplemented by endotracheal catheter suction and occasionally by bronchoscopic aspiration.

    This treatment often transformed a severely ill patient, with bronchospasm, dyspnea, and cyanosis, into a person who was quite comfortable and who could easily expectorate the mucus and other material blocking the tracheobronchial tree. If the patient had been in shock, the change was particularly striking. It was seldom necessary to repeat the procaine block.

    Some surgeons regarded wet lung as potentially so dangerous that they advocated the performance of procaine block in all patients with chest injuries before they were evacuated from the clearing station to an evacuation hospital. Most surgeons did not regard the procedure as practical in the clearing station or as necessary in all chest wounds.


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`Final principles of management. - It was the consensus in the Mediterranean theater at the end of the war that wounds of the chest should be managed according to the following principles:

    1. Of the casualties with wounds of the chest who do not die on the battlefield, very few will die later if fully trained surgeons can care for them in properly equipped hospitals. A surgeon experienced in both thoracic and abdominal surgery is best qualified to treat the severe wounds of the chest encountered in forward hospitals.
    2. Severe wounds of the chest require first priority management. This means that they must have surgical care promptly, in the farthest forward hospital.
    3. Prompt, well-directed resuscitative measures are essential, especially if there are complicating abdominal wounds.
    4. Anesthesiologists well trained in endotracheal anesthesia are essential in the correct management of wounds of the chest. Endotracheal anesthesia administered through a closed apparatus capable of positive pressure gives the best results in perforating and penetrating wounds.
    5. Open chest wounds should be occluded with gauze and adhesive strapping before the patient is evacuated to a hospital equipped and staffed for definitive chest surgery.
    6. Patients with continuing intrathoracic hemorrhage and large bronchial fistulas require immediate thoracotomy.
    7. Hemothorax should be managed by prompt, repeated aspiration, without air replacement. This technique is not associated with any risk of hemorrhage.
    8. The only treatment required in most uncomplicated wounds of the chest is debridement of the wound of the chest wall.
    9. Large pneumothoraxes are managed by early aspiration, followed by continuous aspiration by a catheter connected with a water seal if the pneumothorax recurs because of a continuing leak of air from the lung or a bronchus.
    10. There are clear-cut indications for thoracotomy by way of the chest wound. Indications for performing it by way of a separate incision are as follows: (1) Intrathoracic hemorrhage; (2) large bronchial fistulas; (3) foreign bodies in the pleural cavity; (4) large sucking wounds which could be explored with little or no extension of the traumatic wound; (5) massive clotted hemothorax; (6) cardiac tamponade; (7) wounds of the esophagus, diagnosed or merely suspected; (8) thoracoabdominal wounds, diagnosed or merely suspected.
    11. At the end of the operation, it is wise to carry omit certain supplementary procedures. The pleura should be well irrigated, to evacuate all blood, foreign bodies, and air. The lung should be completely expanded by inflating it out to the chest wall whenever the pleura has been opened traumatically or surgically. Bronchoscopic aspiration of blood and mucus from the trachea, main stem bronchus, and lower bronchi should be employed at the end


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of time operation, as well as during it, if less radical procedures fail to clear the tracheobronchial tree. This measure is not necessary if tracheal suction by catheter has been successful.
    12. Intercostal nerve block is an important phase of adjunct therapy. It relieves pain, and thus promotes deeper breathing and facilitates expulsion, by cough, of blood and mucus in the tracheobronchial tree.
    13. Replacement therapy is most important. Whole blood is preferred to other fluids, and autotransfusion of intrapleural blood should be used whenever this is practical. The blood should be given slowly after the systolic pressure has reached 80 mm. Hg, and no more should be used than is necessary to achieve adequate resuscitation.
    14. Sulfonamide or penicillin therapy should be instituted as soon as possible and continued until the pleura is free of air and fluid and any pulmonary consolidation present has resolved.
    15. When the casualty has sustained multiple wounds, surgery of the chest wounds is usually done first. Most thoracoabdominal wounds are best handled by the thoracic approach (p.438). If the wounds must be managed separately, the chest wound is cared for first.

    Mortality rates. - During 1944, there was general improvement in the management of chest injuries. There were still unwise thoracotomies. There was still a reluctance to perform aspiration often enough in hemothorax, and there were occasional instances in which either more surgery or less surgery should have been done in the field hospital. Many surgeons, however, had acquired a knowledge of, or had improved their previous knowledge of, preoperative and postoperative management as well as operative techniques. The most striking improvements occurred in anesthesia; preoperative management; the selection of cases for thoracotomy; the use of the thoracic approach in thoracoabdominal wounds; evacuation and cleansing of the pleura; and complete reexpansion of the lung.

    Nonetheless, in spite of these improvements, thoracic, thoracoabdominal, and abdominal trauma contributed most heavily to deaths in the Fifth U.S. Army. In the 1,450 battle casualty deaths studied from Army hospitals, these categories (table 12) accounted for more than half of the fatalities (thoracic, 9.2 percent; thoracoabdominal, 13.9 percent; combined thoracic and abdominal, 3.7 percent; and abdominopelvic, 25.4 percent).

    Case histories. - Major Snyder's official diary was filled with illustrations of chest injuries well and ingeniously handed or of interest for other reasons, as the following histories indicate.

    1. A casualty who was observed in an evacuation hospital in Sicily, when the caseload was unusually heavy, taught an extremely valuable lesson. The history was unknown; he had been found on a mountainside and brought in in a semicomatose state. He was in the shock ward, propped up on a litter, gasping for breath, and practically comatose. His respiration had a peculiar, grunting sound. Roentgenograms of the skull had shown an apparent small fissure fracture, though there was no contusion or abrasion of the scalp. When Colonel Churchill and Major Snyder examined him, there were three significant


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findings. There was dullness over the entire left hemithorax, the cardiac dullness was on the right, and the trachea was displaced to the right. The man died almost as soon as aspiration of the chest had been started. At post mortem, the left pleural cavity was found filled with 4,500 cc. of blood, caused by a partial laceration of an intercostal artery which was caused, in turn, by a broken rib. In short, this man had died of intrathoracic hemorrhage from a simple, undiagnosed, overlooked rib fracture.

    2. Another patient observed in an evacuation hospital had a sucking chest wound which had been treated in the field hospital by debridement, sucking out of the pleura, and pleural closure. The wound was packed, without intercostal drainage. A roentgenogram taken before this operation had shown partial collapse of the lung and hemopneumothorax. When the patient was observed 7 days later, he still had a partial collapse of the lung, and the hemothorax had become massive and clotted. Decortication was necessary later. In this case, it would have been better to have evacuated the pleura completely at the first operation and instituted intercostal drainage or to have let the patient alone until he could be treated definitely in an evacuation hospital.

    3. In a case observed at the 56th Evacuation Hospital, 475 cc. of blood had been removed from the pericardium by aspiration. It continued to reaccumulate, and exploration revealed that it was oozing from a tiny leak caused by a tangential wound of the right ventricle. Repair was performed 12 hours after injury. The patient's postoperative condition was excellent, but he had an associated division of the cervical spinal cord from a bullet which had proceeded upward and posteriorly.

    4. A patient observed at the 38th Evacuation Hospital had compound fractures of both legs caused by a mine explosion. Although he arrived in reasonably good condition, he became dyspneic shortly afterward and died within 24 hours. At autopsy, the wounds of the legs were found in satisfactory condition, and all other findings were negative except for the lungs. They floated in formalin solution; but, on section, diffuse hemorrhages were found throughout the pulmonary tissue, as pronounced near the hilum as at the periphery. There was considerable fluid. Ecchymosis was diffuse, and there were no large hematomas, but the hemorrhage appeared to be interstitial. The lungs were dark bluish red throughout.

    No case of this kind had been observed previously by the surgical consultant, but a number were seen later. A number were also studied by Lt. Col. Tracy B. Mallory, who regarded the condition as a possible combination of fat embolism and blast injury.

Thoracoabdominal Injuries

    Major Snyder's convictions about the management of thoracoabdominal wounds came from his early observation and care of a number of these injuries. In particular, he believed very strongly that the best approach to them was through the chest wall.

    The first of these patients, a Ranger, was operated on in Tunisia, in March 1943. Using the transthoracic approach, Major Snyder was able to remove the spleen, suture several lacerations of the jejunum and colon, and then suture the diaphragm and chest wail. The operation was performed with considerable difficulty because neither oxygen nor positive pressure anesthesia was available. The anesthesiologist, however, overcame these difficulties with considerable ingenuity. He had some endotracheal tubes and a rebreathing bag. He took a Y-tube from a stethoscope and hooked the lower limb to an endotracheal


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tube. One of the upper limbs was hooked to a tube leading to a Flagg can of ether and the other to the rebreathing bag. The bag was inflated by blowing it up by mouth. When it was necessary to expand the lung, once in the middle of the operation and again as the chest was closed, the tube to the ether can was clamped, and manual pressure was made on the bag.

    The patient withstood surgery well in spite of these unpropitious circumstances, and he was evacuated the following day, as a matter of necessity, for a distance of 50 miles. Five days later, he was sitting up in bed and on a general diet. His recovery seemed assured, but postoperative care was poor, because of the rush of casualties, and he died of profound anemia. He had had no blood at all and very little care of any kind. With average attention, he would undoubtedly have lived.

    Another equally instructive case was observed at autopsy in Italy, at the 38th Evacuation hospital. This patient had a sucking wound of the chest and a laceration of the diaphragm, through which the omentum had herniated. The laceration of the diaphragm had been repaired in a field hospital 3 days before. The intention was to perform laparotomy as soon as the patient had reacted from shock. The plan could not be carried out because the hospital was heavily shelled and all the patients had to be evacuated at once to the 38th Evacuation Hospital. When laparotomy was performed there, 24 hours after time first operation, some blood was found in the peritoneum, but no other injury was evident. The next day, 900 cc. of blood was aspirated from the left chest; the chest wound seemed clean. Twenty-four hours later, a large swelling was found extending from the chest wound up the left chest posteriorly and into the axillary area. The pulse was very rapid, and the temperature was 108 F. (42.2 C.). Death occurred before the sutures closing the chest wound could be removed.

    At autopsy, the latissimus dorsi above and below the wound was three times the normal thickness, dark red, and full of gas bubbles. No infection was evident in the subcutaneous tissues. Feces were escaping through the chest wound from a laceration of the splenic flexure of the colon on the retroperitoneal aspect.

    Further investigation showed that the chest wound had been excised and the skin wound left open, according to standard practice. The surgical incision made over the rib above the skin wound had been tightly closed.

    In this case, just as was done in the first case, all the necessary surgery could have been accomplished through the diaphragm, and exploration through it would have revealed the wound of the colon.

    The management of a thoracoabdominal wound was governed by the position of the wound as follows: 31

    Principles of management of left-sided wounds. - Failure to recognize left-sided thoracoabdominal wounds resulted in a number of fatalities. The

31 Snyder, H. E.: The Management of Intrathoracic and Thoracoabdominal Wounds in the Combat Zone. Ann. Surg. 122: 333-357, September 1945.


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possibility that the missile had traversed the diaphragm had to be considered in every chest and abdominal wound. Exploratory thoracotomy was often indicated as a diagnostic measure. Often, slight enlargement of the debrided wound permitted exploration sufficient to determine the presence or absence of a wound of the diaphragm.

    When a thoracotomy through a large incision was necessary, it was best to make it separate from the wound. Sometimes, however, the wound was at the site of the elective incision, and thoracotomy through the wound was then necessary.

    Most surgeons familiar with thoracic surgery preferred the thoracic approach to all thoracoabdominal wounds, even if laparotomy had to be done also. The diaphragmatic wound was enlarged through the open chest, the enlargement being sufficient for exploration and repair of all accessible abdominal structures. In the great majority of cases, all necessary abdominal procedures could be carried out through the thoracotomy incision. Splenectomy, repair of wounds of the stomach, and mobilization of the splenic flexure are much more easily accomplished through this approach than by celiotomy. Almost the entire small intestine, the transverse and descending colon, and the kidney are usually accessible. Wounds of the retroperitoneal portion of the splenic flexure, the spleen, and the posterior gastric surface were seldom missed by a thoracic approach but were frequently overlooked at celiotomy.

    Objection was sometimes raised to dealing with wounds of the colon and small intestine through the chest, on the ground that infection of the pleural cavity might result. This was not a valid objection. Whenever a wound of the diaphragm existed, contents of perforated hollow organs beneath the diaphragm were sucked into the pleural cavity before operation. Thoracotomy made possible the thorough evacuation of gastric and intestinal contents which might be present in the pleural cavity. It was believed that in left thoracoabdominal wounds it was well to accomplish all surgery in the left upper quadrant of the abdomen through the thoracic approach even when it was known that laparotomy would also have to be done.

    The site of elective thoracotomy in thoracoabdominal wounds was usually time 9th or 10th rib bed or interspace. Many of these wounds involved the 8th, 9th, 10th, or 11th rib or interspaces. An incision in the 9th to 11th costal beds or interspaces might be extended forward through the abdominal wall to facilitate necessary procedures within the abdomen. It was desirable to extend the incision for 1 or 2 inches into the abdominal wall if this procedure would eliminate the necessity for a separate large abdominal incision. Small muscle-splitting incisions were indicated for subdiaphragmatic drainage or exteriorization of mobilized loops of the colon.

    Wounds and incisions of the diaphragm were repaired with interrupted sutures of fine cotton or silk. The diaphragmatic edges were imbricated, or the first row of stitches was inverted toward the abdomen with the second


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row. Catgut was not satisfactory for this purpose; a number of wound disruptions were reported when it was used.

    It was not the custom to crush the phrenic nerve as a routine measure in diaphragmatic wounds, though it might be indicated if time defect to be repaired was very large.

    Other steps of the procedure included removal of foreign bodies from the pleura or lung; suture of the pleura over lacerations of the lung; irrigation of the pleura with physiologic salt solution; and complete reexpansion of the lung as the wound in the chest wall was closed.

    Thoracotomy incisions were closed with cotton or silk, except occasionally when the time factor justified the use of catgut. As a rule, the time factor had to be considered because of a backlog of other seriously wounded patients; it seldom had to be considered because of the necessity for rapid termination of the operation due to the patient's condition.

    Penicillin therapy, both local and systemic, was always indicated in thoracoabdominal wounds. Some surgeons preferred to use sulfanilamide locally in the peritoneum.

    Principles of management of right-sided wounds. - Thoracotomy was indicated in almost every wound of the right diaphragm, regardless of the size of the missile or the possible size of the wound in the liver. Hemorrhage or escape of bile was often profuse.

    Thoracotomy was done, and the wound in the diaphragm was enlarged to permit institution of subdiaphragmatic drainage of the hepatic wound. Drainage was accomplished by large Penrose drains; the gauze protruding from the inner end was packed loosely into the liver wound. Fatal hemorrhage was reported in wounds of the liver which had not been packed or sutured. The drains were invariably brought out subdiaphragmatically, through a separate subcostal incision or an incision in the loin, never across the pleural space.

    Right thoracotomy incisions from the 9th to the 11th interspace could be extended into the anterior abdominal wall, to permit examination of the liver and hepatic flexure, the right half of the transverse colon, the duodenum, and the head of the pancreas. The need for a separate celiotomy incision was often thus eliminated. Wounds of the posterior diaphragm could also be enlarged to permit nephrectomy, suture of the kidney, or establishment of drainage of the perinephric area through a stab incision in the loin.

    Suture of the right diaphragm, as of the left, had to be done with the greatest care. The use of interrupted sutures of fine silk or cotton was mandatory. Biliary-pleural fistulas were repeatedly observed when catgut was used. Suture of the diaphragm to the chest wall was avoided, as was drainage of the liver through the diaphragm and the chest wall.

    As in wounds of the left side of the diaphragm, it was always best to complete the chest surgery before making a laparotomy incision.

    Combined thoracic and abdominal wounds. - When chest and abdominal wounds were present in the same patient without a communication through


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a wound in time diaphragm, transdiaphragmatic surgery was not recommended. It would have violated surgical principles because it would have subjected the intact pleura to contamination. Contamination is always present when the diaphragm is perforated together with perforation of a hollow viscus.

    When chest and abdominal wounds occurred in the same casualty, primary care of the intrathoracic wound was the more important unless profuse intra-abdominal hemorrhage or massive evisceration made laparotomy an urgent primary procedure.

Abdominal Injuries

    By 1944, certain fundamental principles for the management of abdominal injuries had been established in the Mediterranean theater and were being followed routinely in Fifth U.S. Army hospitals. The importance of rapid resuscitation and early operation was generally appreciated. Almost every patient with an abdominal wound was given the chance which surgery offered; only casualties who were moribund on admission to the hospital did not reach the operating table. The number of surgeons who did excellent abdominal surgery was also steadily increasing.

    When the United States entered World War II, the concept was that resuscitation from shock must be accomplished before surgery was undertaken. Generally speaking, this was correct. But it was promptly learned in North Africa and Sicily that this rule had its exceptions and that if some casualties were to survive they must be operated on before the blood pressure reached a satisfactory level. Major Snyder was particularly impressed with a fatal case observed on one of his first hospital tours in Italy; the patient was repeatedly scheduled for surgery, and surgery was repeatedly deferred because his blood pressure could not be elevated above 50 mm. Hg even with large amounts of blood. The surgeons in field and evacuation hospitals were always advised that these patients, without more delay, should be taken to the operating room and explored. The explanation in such cases was very frequently that massive hemorrhage was continuing or that massive contamination of the peritoneal cavity had occurred.

    Captain Lalich, even before he had the laboratory proof of the essential role of blood loss in shock, had formulated this rule; if a patient did not respond to 1,000 cc. of blood given over a period of approximately 10 minutes, preparations should be made for exploration. While these preparations were being made, there would be time for another 500 cc. of blood to be given, and the transfusion should be kept running during surgery. In effect, surgery was thus made a part of the resuscitative procedure, and many lives were saved as a result.

    Not the least important of the reasons for the improvement in the results in abdominal injuries was the provision, instituted soon after the landings in Sicily, for holding patients who had undergone laparotomy for from 10 to 14 days afterward. There was no surer way of increasing the mortality of


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abdominal injuries than by evacuating patients immediately after surgery, as had been the original practice. After the 24th General Hospital was set up in Florence in the fall of 1944, it became the practice to hold all patients with abdominal wounds in the field hospitals in which they had been operated on until they could be evacuated directly to base hospitals. This practice not only eliminated the usual stopover at an evacuation hospital but also made it possible to proceed more promptly with closure of the colostomy.

    Management. - Wounds of the stomach and small intestine were treated by repair whenever this was possible; otherwise, resection was done, with primary anastomosis. In these wounds, as in all other perforating wounds of hollow viscera, the subfascial space was drained with a Penrose drain or rubber tubing, and the skin was not sutured except for the closure effected by retention sutures. The practice of exteriorizing wounds of the small bowel was discouraged. Small wounds of the cecum and ascending colon were also treated by primary suture and were not exteriorized.

    A few surgeons thought that, if circumferential damage was minimal, small wounds of the left colon could be treated by primary suture; cecostomy was always performed in such cases.

    All sizable wounds of the colon and all wounds in which there was segmental interruption of the blood supply were treated by exteriorization of the affected part at initial wound surgery. If the wound was in the rectum or the rectosigmoid, proximal colostomy was performed. Wounds in the antimesenteric border of the colon were usually exteriorized as tangential loop colostomies. Wounds in the mesenteric border were managed by complete division of the lumen of the bowel and exteriorization of both limbs as a spur colostomy. The limbs of the colostomy were so placed that they tended to fall together, but they were not usually sutured. In some cases, the divided ends of the bowel were separated by an intervening bridge of skin. The importance of adequate mobilization of the segment of the colon to be exteriorized was increasingly appreciated, and retracted colostomy stumps were seldom observed.

    Some wounds of the colon had to be managed by right colectomy, with an ileotransverse colostomy of the spur type. Surgeons were instructed to bring the terminal ileum and transverse colon out together through a separate surgical incision and suture them together to form a long spur. The spur was usually crushed early in the postoperative period, preferably by the fourth postoperative day.

    Exteriorization was always accomplished through an incision separate from the main surgical incision. At the 15th Evacuation Hospital, on one of his visits, Colonel Snyder observed a number of patients with wounds of the colon whom he had seen earlier, at the 33d Field Hospital. In all of these cases, exteriorization of the colon had been performed through the laparotomy incision, and all the wounds were breaking down. It was not long before all forward surgeons had been instructed to bring the colon out through a separate stab wound.


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    Originally, petrolatum-impregnated gauze had been used to hold the skin edges open. It did not prove very satisfactory; the subcutaneous fat was widely separated, and the gauze was very difficult to remove. It was suggested that rubber tissue drainage of the fatty layer be substituted for this type of gauze drainage. The practice soon became standard and made it possible to close the skin completely without danger.

    Postoperative measures. - The daily administration of from 500 to 750 cc. of plasma was standard practice in the immediate postoperative period. The Levin tube or Wangensteen suction was used for from 3 to 7 days after operation. Otherwise, the postoperative regimen followed the usual plan.

    Wound dehiscence. - The incidence of wound dehiscence was always distressingly high in abdominal wounds. The best results were secured in closure of the laparotomy incision by the use of fine catgut for the peritoneum and interrupted sutures of fine silk or cotton for the fascia. Retention sutures of heavy silk or wire, tied loosely, were always used. They were so placed as to include the fascia, or the fascia and muscle, or all layers of the abdominal wall.

    Mortality rates. - Intra-abdominal wounds accounted for more deaths in the Mediterranean theater than any other group of wounds. They (abdominopelvic wounds) were responsible for 368 (25.4 percent) of the 1,450 battle casualty deaths studied in Fifth U.S. Army hospitals (table 12). The principal wound in 40 other deaths was also intra-abdominal, but this injury was not the principal cause of fatality in these cases.

Hand Injuries

    The management of hand injuries in the forward area early in the war was generally poor, and improvement was slower in coming than it was in most other injuries.32 In fact, little was done to standardize the management of these injuries until the second winter of the war, when the troops were halted on the Gothic Line. At this time, the 24th General Hospital was located in Florence, and the Army evacuation hospitals were chiefly located north of this city, with a few to the west. With the lull in combat, it was possible for Maj. Harvey S. Allen to make a tour of all of these hospitals, lecturing on and demonstrating the correct care of hand injuries.

    The basis of management was adequate debridement, with, at the same time, sacrifice of as little tissue as possible. Primary nerve suture, as already mentioned, was not permitted in army hospitals, and both primary and secondary tendon suture was also forbidden. When excisional surgery had been concluded, the exposed structures were covered, contrary to the usual rule that wounds should be left open.

    The hand was put up in the position of function, splintage being accomplished by any of several methods. One splint, the so-called boxing glove splint,

32 Medical Department, United States Army. Surgery in World War II. Hand Surgery. Washington: U.S. Government Printing Office, 1955.


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was developed by Colonel Cox, Chief of Surgery, 24th General Hospital. Another splint was developed by Lt. Col. Michael L. Mason and Major Allen. These splints were constructed by Ordnance personnel and were supplied on request to surgeons in forward areas. Wire ladder or plywood splints were probably more generally used than any other kind.

    When the boxing glove splint was used, the hand was put up in the position of function, in a huge compression dressing which was held in place by a thin layer of plaster-of-paris bandage extending to the upper forearm. The fingertips and the tip of the thumb were usually left exposed.

    The Mason-Allen splints were constructed of aluminum. Their distinctive feature was a half sphere or half ball over which the palm was placed. These splints could be used on either hand and proved quite satisfactory. Since the war, they have been available from commercial sources.

COMPLICATIONS

    The incidence of clostridial myositis (gas gangrene) was high in the Sicilian campaign, and its disastrous potentialities were promptly recognized. Captain Jergesen, of the 2d Auxiliary Surgical Group, was particularly aroused by the problem, and many of the valuable suggestions in Circular Letter No. 2, Office of the Surgeon, Headquarters, II Corps,33 were made by him.

    The incidence of this complication continued high in the early fighting in Italy, and when Major Snyder assumed his duties as consultant for the Fifth U.S. Army in September 1943 he found Colonel Martin, Surgeon, Fifth U.S. Army, seriously alarmed about it. Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army,34  was immediately prepared. It described in detail the etiologic factors amid prophylactic and therapeutic methods of management. In all visits to hospitals, Major Snyder presented this subject, and it was also the subject of one of the first of the Fifth U.S. Army Medical Conferences (p.366).

    By the end of October 1943, Colonel Churchill had taken steps to initiate an intensive study of clostridial myositis and of vascular injuries in general in Fifth U.S. Army hospitals (p.428). The work was in charge of Captain Jergesen and Major Simeone. In December, arrangements were made with Colonel Cornell, head of the 15th Medical General Laboratory, to furnish a mobile laboratory with a clinical pathologist and two bacteriologists to assist in the investigation.

    This investigation and the intensive educational efforts made throughout the Fifth U.S. Army hospitals resulted in a prompt reduction in the incidence of clostridial myositis. Good surgery, based on more liberal debridement of wounds in which this complication was a possibility, accounted for much of the improvement. Established infection was also better managed, by the liberal

33 See footnote 5, p. 361.
34
See footnote 6, p. 361.


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use of blood, serotherapy, and the administration of penicillin. Before the use of penicillin became routine in all severely wounded battle casualties, the incidence of clostridial myositis had been reduced to five or six cases per thousand. After its use became routine, there were only nine instances of gas gangrene in the last 4 months of 1944, during which 15,553 battle casualties were admitted to Fifth U.S. Army hospitals.

    Clinical considerations. - The British had had an extensive experience with clostridial myositis before the United States entered the war, and Major Snyder was able to discuss it in detail with Maj. J. P. MacLennan, RAMC, whose special assignment was investigation of anaerobic infections in the British Eighth Army. His studies included both the laboratory and the clinical aspects.

    Major MacLennan emphasized the following clinical features of infection with Clostridium welchii perfringens:

    1. The onset is rapid. He had observed the infection in one casualty only 5 hours after wounding.
    2. Pain is the first complaint.
    3. Early in the course of the infection, the casualty is bright, alert, but extremely apprehensive.
    4. The fever is high and the patient seems very ill.
    5. The skin is pale and marbled, and there is some edema. Gas is comparatively scanty.
    6. The muscle is at first pink, then pale and mushy, then reddish purple, and finally slate blue.
    7. When the infection is pure, the odor us sweetish and only mildly foul.

    In Clostridium novyi oedematiens infections, the following clinical features are notable:

    1. The onset is slower, the infection seldom being seen earlier than 8 hours after wounding.
    2. There is little or no pain, the first complaint usually being a sense of heaviness in the affected part.
    3. The patient is apathetic.
    4. The fever is not high.
    5. The skin is discolored. Edema is pronounced, and as a result little gas is evident.
    6. The muscle changes rapidly from pale pink to dark brown and then to black. The wound drips fluid, and the tissues seem full of fluid.
    7. The odor may be sweetish and foul but is seldom pronounced.

    Major MacLennan also discussed other anaerobic infectious as follows:

    1. In anaerobic streptococcic cellulitis, the muscles are brick red, moderately swollen, and edematous. The odor is foul. A smear from the muscle shows many leukocytes and small, shortchain streptococci, with only a few clostridia, in contrast to Cl. welchii infections, in which there are few pus cells and many clostridia.


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    Treatment consists of liberal incision into the muscle and local sulfanilamide therapy.

    2. In anaerobic cellulitis, the patient is not very ill. Pain is not marked. The odor is foul. Gas is profuse, but the infection is limited to the fascial planes and muscle devitalized by the wounding agent.

    Treatment consists of excision of dead tissue, adequate drainage of fascial planes, and systemic and local sulfonamide therapy.

    All of this information was incorporated in the extensive discussion of anaerobic infections contained in Medical Circular No. 9, Office of the Surgeon, Headquarters, Fifth U.S. Army.35

    Early in the war, two deaths from pulmonary embolism occurred in the 94th Evacuation Hospital after amputation for gas gangrene. The technique employed thereafter in this hospital, that the femoral vein be ligated distal to the profunda in all amputations on this indication, later became routine in all army hospitals.

    Special precautions in the evacuation of patients with vascular injuries also became routine, as it soon became evident that anaerobic infection frequently developed in these patients.

Thrombosis and Embolism

    In November 1943, following several deaths from pulmonary embolism, all confirmed at post mortem, it became the policy to watch patients closely for the development of phlebothrombosis. The wisdom of this policy was soon evident in three cases in which thrombosis of the femoral vein was suspected. All were studied by venography. One venogram showed only a saphenous thrombosis. The others showed thrombi in the femoral vein, probably ascending into the iliac vein. Phlebotomy and thrombectomy were done in both cases, with immediate symptomatic relief and ultimate recovery, though fever did not subside for several days and swelling persisted even longer.

    The following spring, Major Lyons performed numerous venous ligations for phlebothrombosis, which in some instances was associated with thrombophlebitis. In his experience, there was successively less edema with the performance of common iliac ligation, external iliac ligation, superficial femoral ligation, and common femoral ligation. It was his opinion that the tremendous edema observed in some fractures of the femur could be explained by thrombophlebitis.

Anuria and Nephropathy

    Anuria and oliguria were frequently encountered in severely wounded men. Part of it could be explained as a. physiologic response to wounding, but by January 1944 the incidence had increased to a considerable degree, and some other explanation was necessary.

35 See footnote 7, p.361.


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    One theory was that sulfonamide therapy might be responsible, and special precautions for its use were detailed in a medical circular from the office of the Fifth U.S. Army surgeon in January 1944.36 After attention had been called to the fact that most cases of anuria to date had occurred in patients who had received sulfadiazine intravenously in 5-gm. doses, the following precautions were laid down:

    1. Not more than 10 gm. of sulfanilamide powder should be used intraperitoneally and in associated wounds at the time of operation; at least half of this amount should be dusted into the peritoneum.
    2. Intravenous sodium sulfadiazine therapy should not be started until 24 hours after operation, after the patient had reacted from anesthesia and shock. The dosage then was not to exceed 2.5 gm. every 12 hours.
    3. Sulfonamide therapy was to be promptly discontinued if the 24-hour urinary output was less than 1,000 cc. or if gross or microscopic hematuria developed. Fluid intake should be adequate to insure a minimum urinary output of 1,500 cc.

    Special instructions were also given for the use of sulfonamide therapy in wounds in which clostridial myositis was likely to be encountered.

    Anuria continued to occur in spite of these precautions, and the role of mismatched blood was then advanced as the causative factor. It undoubtedly explained some cases, but it did not provide a universal explanation. This type of nephropathy was also frequently observed in patients with crushing injuries and in those with very severe wounds who had been in shock for long periods of time.

    In the fall of 1944, the board set up to study physiologic pathology in the severely wounded (p.415) had the special objective of investigating lower nephron nephrosis. All patients who developed this condition or in whom it seemed impending were reported to the board at once, and prophylaxis and therapy were carried out according to their recommendations. The board's final conclusion was that no single factor was responsible for lower nephron nephrosis.37

    Major MacLennan recommended alkalinization therapy, but no satisfactory treatment for lower nephron nephrosis was ever developed, except that it was learned that, contrary to the original practice, fluids should be limited when the condition appeared or seemed impending.