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Appendix A

Contents

APPENDIX A

Pertinent Directives

Cir 96 Hq ETOUSA 15 Dec 1943

*    *    *    *    *    *    *

II-ENLISTED MEN: DISPOSITION OF WHEN PHYSICALLY OR MENTALLY UNQUALIFIED.

1. When an enlisted man is considered by his immediate commanding officer to be physically or mentally unqualified to perform his assigned duties or any other appropriate duty within the unit, under the general policy as contained in Par 2, WD Cir 293, 11 Nov 1943, action will be taken as follows:

a. A physical examination will be made to determine whether the subject enlisted man is physically or mentally qualified to perform any duty within his unit.

b. In event the enlisted man is found to be physically or mentally unqualified to perform any appropriate duty within the unit, his case will be reported through channels with applicable recommendation for his reassignment within the command or his transfer to the detachment of patients of an SOS, ETOUSA, hospital. When the enlisted man is transferred to an SOS, ETOUSA, hospital, the report of physical examination directed under a above, together with his service records and allied papers, will be forwarded to the commanding officer of the hospital.

c. The commanding officer of the hospital will determine whether the man can be utilized in the service or is to be discharged under current regulations.

d. Enlisted men who are to be retained in the service will be transferred from the hospital to the 10th Replacement Control Depot, SOS, ETOUSA, if formerly assigned to the ground forces or SOS, or to the 12th Replacement Control Depot, Eighth Air Force, if formerly assigned to the army air forces. At the time of transfer the commanding officer of the hospital will forward to the depot commander a report concerning the man, which will include a statement as to physical and mental qualifications and duty limitations.

e. The commanding officer of the replacement depot will take the necessary action to effect reassignment of such enlisted men to appropriate units.

2. The CG, Iceland Base Command, is authorized to make such modifications as are necessary to accomplish the above directed action.

*    *    *    *    *    *    *

BY COMMAND OF LIEUTENANT GENERAL DEVERS:

DAVID G. BARR, Brigadier General, GSC, Chief of Staff

OFFICIAL: RALPH PULSIFER
HRS.

RALPH PULSIFER
Brigadier General, USA, Adjutant General.

DISTRIBUTION: "B"


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OFFICE OF THE CHIEF SURGEON
EUROPEAN THEATER OF OPERATIONS

File: 704. X 701. 15 May 1944

CIRCULAR LETTER NO. 71

SUBJECT: Principles of Surgical Management in the Care of Battle Casualties.

*    *    *    *    *    *    *

5. Surgical Procedures.

a. Dressings. Ideally, the primary phase of treatment will be completed in the first unit reached that is equipped to provide it. The dressing is to then be left undisturbed until the patient reaches a third echelon unit for operation. There are certain safeguards and adjustments that must take place en route, but these do not include inspection of the wound by removal of the dressing unless definite indications for so doing are present. A compound fracture case may be halted at the Clearing Station for more adequate immobilization or resuscitation, but the wound should not be re-dressed unless necessary to arrest continuing hemorrhage. A wound will not be re-dressed solely for the purpose of re-applying local sulfonamide. Oral administration is sufficient safeguard.

The same principles apply after operation has been completed and the patient is being evacuated to the rear. Uninformed hands do unnecessary dressings. The best safeguard for a patient is an adequate and legible record that accompanies him, which makes it possible for a receiving officer to refer to the record rather than looking at the wound. Infection arising from contamination incurred at the time dressings are changed, may make impossible secondary suture of wounds after debridement and arrival at a third echelon unit.

b. Debridement of wounds. This is the basis of the proper treatment of all battle casualties. It is definitely more important than chemotherapy, and reliance on the latter must not diminish devotion to the proper surgical treatment of wounds. Use ample incisions, practice minimal removal of skin and bone, and maximum removal of all dead and devitalized muscle. Never close primarily wounds debrided under field conditions. Pack wounds open lightly, never plug tightly.

Under favorable circumstances, it is desirable that severed nerves and tendons should be approximated, preferably with metallic or non-absorbable sutures (see Manual of Therapy, ETO).

c. Amputations. Amputations for trauma will be a circular open (guillotine) amputation at the lowest possible level, followed by the application of skin traction. Skin traction will be applied immediately and must be maintained during all stages of evacuation, including evacuation to the Zone of Interior, and until the stump is completely healed. Skin grafting will not be used as a substitute for skin traction.

*    *    *    *    *    *


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8. Secondary Closure.

a. Although the first principles for the military surgeon to bear in mind is not to close the wound he has freshly debrided, it is essential that he close this wound at the earliest moment that is safe. Early closure means limitation of infection and fibrosis, and an earlier restoration to duty. If the primary debridement has been thorough, small wounds may be closed as early as the third day, though the average wound not until the fifth day. Observation of the signs of inflammation, such as discharge, reddening, pain and swelling, will determine whether or not a wound can be closed. It is wiser not to dress the originally debrided wound until the day when secondary closure might be practical, since each dressing invites contamination of the wound. If closure is considered safe, it should be done loosely without undermining the edges or using sharp instruments, and by using retention sutures of silk, or silk-worm gut, spaced widely apart and loosely tied. Should mild infection appear, hot, moist dressings may save breaking down of the wound and hasten the healing process. Any signs of severe infection require immediate removal of the sutures.

b. Closure of wounds with fractures should only be undertaken when full penicillin therapy is being practised and when all the signs of infection are absent.

c. Wounds closed early, before the establishment of granulation tissue or scar tissue, are easier to close than those closed after one or two weeks. In wounds that have been open for a long time, skin grafting is often better than closure by suture. If the original debridement has been practised with the minimal of skin removal, as suggested above, closure by sutures will be simple.

d. Removal of sutures from such secondary closures should not take place before 10 days unless stitch infection develops. After removal of the sutures it may be wise to maintain approximation of the wound edges with adhesive plaster.

9. General Principles to be followed in the Use of Plaster Casts.

a. No circular bandages, dressings, or strips of adhesive shall be used under a plaster cast, as these constrict the extremity and may cause extensive damage if swelling of the part occurs.

b. Adequately padded plasters are probably safer in average hands. Padding should be applied to all bony prominences such as malleoli and heels, knees, particularly over the head of the fibula, wrists and elbows. In addition, sufficient padding should be used over the soft parts to permit some swelling within the cast.

c. All layers of plaster, sheet wadding or dressings must be cut thru down to the skin immediately after the application of a cast following an operation or manipulation. Swelling of the part will occur and unless all layers of the plaster padding and dressings are cut thru, it will be impossible to spread the cast to prevent extensive damage when swelling occurs.


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d. Attention should be paid to the position of the extremity encased in plaster. The foot should be at a right angle to the leg, the knee should be in 10-15 of flexion, the hip should be in neutral position or slight flexion. The wrist should be supported in neutral position to prevent wrist drop, and the elbow ordinarily is best supported at a right angle. In these positions the patient will transport comfortably, will not take up undue space, and the tendency to develop troublesome fixed deformities will be minimized.

e. A line diagram in indelible pencil should be inscribed on the cast, indicating the approximate location of fracture and position of fragments. The number of the unit, date of injury, date of operation and type of operations should likewise be written on the cast so that if the Field Medical Record is lost, a reasonable satisfactory substitute record will be readily available.

f. Either a platform or a loop or wicket of plaster should be applied to the foot of the cast in order to protect the toes from pressure of blankets, bed clothes, etc. Plaster applied to the hand should be trimmed back to the proximal palmar crease to permit full flexion of the fingers and metacarpal phalangeal joints.

*    *    *    *   *   *    *

For the Chief Surgeon:

s/J. H. McNINCH
J. H. McNINCH
Colonel, Medical Corps,
Executive Officer.

OFFICE OF THE CHIEF SURGEON
EUROPEAN THEATER OF OPERATIONS

File: 704.

30 July 1944

CIRCULAR LETTER NO. 101

Care of Battle Casualties

1. The information contained herein is supplemental to Manual of Therapy, ETO, 5 May 1944, and Circular Letter No. 71, Office of the Chief Surgeon, subject: "Principles of Surgical Management in the Care of Battle Casualties," dated 15 May 1944, and is based on the experience acquired during the first five weeks of operations.

*    *    *    *    *    *    *

3.Wounds.

a. Wounds will not be plugged or packed with vaseline gauze. Only sufficient gauze should be used to keep the wound temporarily open.

b. Sulfonamides are being dumped in excessive quantities in wounds, and this makes subsequent repair difficult.


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c. Wounds must not be closed by sutures at the time of the first debridement, except for the following:

(1) Neurosurgical injuries.
(2) Thoracic injuries.
(3) Wounds of eyelids.
(4) Certain maxillofacial injuries, as outlined in the Manual of Therapy, ETO.

d. Penetrating wounds of the paranasal sinuses should be thoroughly explored, foreign bodies and blood removed and external drainage provided at the original operation. Drainage of the antrum into the nose is the method of choice unless the wound has destroyed so much tissue that external closure is not possible. The frontal sinuses should be drained through the wound or through an incision to allow opening in the floor of the sinuses.

e. The routine culture of wounds is unnecessary, and wasteful of time and materials. Cultures should be limited to those wounds where there is clinical evidence of infection and where they may contribute to its subsequent clinical management.

f. Wounds seen late, after wounding, without debridement, may be debrided in the usual manner.

g. Wounds can usually be closed within 3 to 5 days after debridement. A satisfactory preparation of the wound for secondary closure has been the application of warm saline dressings. Chemotherapy locally in the wound at the time of secondary closure is not necessary; penicillin therapy should be resumed before and after secondary closure in all large wounds.

h. As a rule, foreign bodies which interfere with function or wound healing should be removed. Modern chemotherapy obscures the signs of local infection only temporarily and many times delayed infection, with breakdown of the wound, may result after a long interval.

i. Continued local and excessive applications of sulfonamides in wounds are detrimental to wound healing, produce dermatological lesions, often increase blood levels above safety limit, and are unsupported scientifically as the proper therapy.

*    *    *    *    *    *    *

5. Gas Gangrene.

a. Incidence of serious infection with clostridia is fortunately low up to the present time, and surgeons have shown a wise discrimination between diffuse myositis and cellulitis. This has restricted amputation, led to recovery by simple incision, excision of involved muscle and adequate drainage.

b. Routine culture of wounds is unnecessary unless there is clinical suspicion of gas bacillus infection. Gas-forming organisms can commonly be cultured from a wound, and such findings should not influence the surgical treatment unless consistent with the clinical diagnosis. Only in clinical cases of gas gangrene infection should cultures be taken and sent to the First Medical General Laboratory for final identification of the organisms.


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c. Amputations have in some cases been too radical. Always demand a consultation and always explore locally in wound before amputation. In many cases the apparent diffuse involvement, as shown by a swelling, crepitation and discoloration of the skin, has extended far above the actual muscle involvement. Failure to appreciate that amputation or muscle excision can be carried out at a much lower level has at times resulted in the needless high amputation of the thigh or upper arm. Extensive incision and drainage above the level of amputation is commonly required in such instances.

d. Following amputation for widespread clostridial myositis, skin traction should not be applied for the first 24-48 hours, since some cases thus treated have had unfortunate results because of restricting dressings. Such cases should be held as non-transportable until skin traction is applied.

e. In performing the circular amputation, the skin should always, if possible, be longer than the underlying soft tissue and bone. Except in amputations following clostridial infection, skin traction should in every instance be applied immediately. The following dressing is suggested as an adequate and comfortable method of protecting the stump and securing skin traction during the period of evacuation or hospitalization:-

(1) Dress the stump with fine mesh gauze.
(2) Apply circular roll of stockinet to the stump; roll this proximally.
(3) Apply tincture of benzoin to the skin up to the cut edge.
(4) To the distal 1" of skin apply an ointment of equal parts of zinc oxide and castor oil.
(5) Apply ace-adherent to the skin of the stump up to the ointment, and then roll the stockinet over the stump and dressing.
(6) Apply several layers of sheet wadding on the stockinet and a light plaster of paris cuff over this, incorporating a wire ladder splint anchored at both ends. Traction is obtained by tying the stockinet to this wire. In case there is a short arm or high thigh stump, the wire ladder splint may be incorporated in a short shoulder or hip spica plaster of paris bandage. In case drainage is excessive, the stockinet distal to the amputation may be split into two or more tails and a spreader employed if desired. The intact stockinet tends to cone the stump down to desirable size and may be preferable.

*    *    *    *    *    *    *

6. Plaster Splints.

a. These are being applied too thick, wasting material and time both in application and removal.

b. If bilateral spicas are applied, they must be litter width, reinforced with a strut placed posteriorly.

c. All initial circular plaster of paris dressings, following trauma manipulation or operation, must be split to the skin and slightly spread.

d. In arm casts used for forearm or wrist injury, always trim the cast


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back to the proximal palmar crease so that full metacarpophalangeal flexion can be maintained.

*    *    *    *    *    *    *

For the Chief Surgeon:

s/ J. H. McNINCH
J. H. McNINCH,
Colonel, Medical Corps,
Executive Officer.

HEADQUARTERS
EUROPEAN THEATER OF OPERATIONS
UNITED STATES ARMY

Office of the Chief Surgeon

File: 304 

8 November 1944

CIRCULAR LETTER NO. 131

Care of Battle Casualties

The following instructions are supplemental to Manual of Therapy ETO, 5 May 1944; Circular Letter No. 71, 15 May 1944; and Circular Letter No. 101, 30 July 1944, Office of the Chief Surgeon.

*    *    *    *    *    *    *

1. Treatment of Wounds of Bones and Joints

The proper treatment of those wounds involving bones and joints may be divided into the early stage in Field or Evacuation Hospitals and the later stage when the wounded arrive at a General Hospital. The early treatment entails:

a. Debridement of the wound. Skin and bone will be conserved to the maximum degree. Devitalized muscle will be excised, leaving viable muscle. Fascial planes should be widely opened by longitudinal and transverse incisions so that no tension exists. All bits of clothing and available metallic bodies are to be removed but a prolonged search for metallic foreign bodies will not be made at this time. The wound will be lightly dressed with vaseline gauze, introduced into the depths but not packed.

b. Immobilization of fractures for evacuation. Field and Evacuation Hospitals and any type of medical unit acting as a "transit" hospital will prepare fractures for early evacuation with comfort and safety to the patient. They will not be responsible for the anatomic reduction of these fractures.

(1) Fractures of the femur are for the most part most comfortably immobilized in a double circular plaster of Paris spica bandage extending from the toes of the affected leg and from the knee of the sound leg. This should be re-enforced by a strut placed posteriorly, and the legs should not be spread more than litter width. The knee should be slightly flexed.


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The Army ring splint is, for the most part, to be employed as an emergency measure. The traction strap or clove hitch, when left on the foot for periods of time exceeding 6 or 8 hours, almost invariably results in skin necrosis. If it is necessary to leave the Army ring splint on beyond the Field, Evacuation or other "transit" hospital, adhesive plaster must be applied to the leg as a means of traction. The Army hinged splint for upper extremity fractures is extremely uncomfortable and it should be discarded at the first installations where a plaster of Paris splint can be employed.

The use of the Army ring splint with adhesive plaster traction, a posterior moulded plaster of Paris splint applied from ankle to buttock and re-enforced and stabilized with a few rolls of plaster over the metal side arms of the splint, may be a satisfactory means of transportation in selected fractures of the femur in this theater. It should not be used for fractures of the upper third of the femur and it can not be employed if there are wounds below the knee as well as above. No patients will be returned to the Zone of the Interior with this form of splint.

(2) Fractures of the tibia and fibula should be immobilized in a circular plaster of Paris bandage from toes to groin; knee flexed 15 degrees, the foot in neutral position at 90 degrees to the long axis of the leg.

(3) Fractures of the feet should be immobilized in a circular plaster of Paris boot extending from the toes to just below the knee, with foot in neutral position at 90 degrees to long axis of leg. Gentle soap and water scrubbing of these wounds of the feet will minimize the chance of infection.

(4) Fractures of the humerus should be immobilized by a plaster of Paris spica bandage with arm held forward and medially rotated so that the forearm rests in front of the body. A plaster of Paris Velpeau bandage may be used for evacuation within this theater, but not to the Zone of the Interior. The hanging cast is not an acceptable means of fixation for transportation and will not be so employed.

(5) Fractures of the forearm and wrist should be immobilized by a circular plaster of Paris bandage extending from mid-brachial region, with the elbow flexed at from 90 to 110 degrees to long axis of humerus. This splint should not extend distal to the metacarpo phalangeal joints.

*    *    *    *    *    *    *

ALL PRIMARY CIRCULAR PLASTER OF PARIS DRESSINGS WILL BE SPLIT TO THE SKIN AND SLIGHTLY SPREAD. NO CIRCULAR BANDAGE OR ADHESIVE PLASTER OR SHEET WADDING WILL BE LEFT UNDIVIDED UNDER A SPLIT PLASTER OF PARIS BANDAGE.

*    *    *    *    *    *    *

c. Treatment of wounds of bones and joints in General Hospitals. As soon as the patient arrives at a general hospital the plaster of Paris dressing and all vaseline gauze should be removed.


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(1) Fractures of the femur, tibia, fibula, and humerus will be treated by skeletal traction in every instance where it is possible to achieve a beneficial result within a reasonable length of time.

(2) Compound fractures of the forearm may be treated with circular plaster of Paris splints or traction when feasible. Badly displaced simple forearm fractures, which cannot be reduced by other means, may require open reduction and internal fixation. Such open reduction may be applied in some instances in compound fractures of the forearm after successful secondary closure has resulted in wound healing.

*    *    *    *    *    *    *

(4) Fractures of the foot. Simple fractures involving the metatarsals and phalanges should not be immobilized for prolonged periods. Many of these undisplaced or slightly displaced fractures are best treated by mobilization without weight bearings. In compound fractures of the foot, every effort should be made to heal the wounds by secondary suture or skin graft. Pulp traction to the toes should be avoided. Early active motion of toes and feet should be encouraged wherever possible.

(5) Compound fractures of long bones with loss of bone substance. In fractures of the long bones with large initial loss of bone substance, traction because of the limited evacuation policy of this theater, will be of little benefit, and so should not be employed. Distraction in these cases is a common cause of non-union. Such patients should be returned at an early date to the Zone of the Interior, in appropriate circular plaster of Paris splints with every effort made in this theater to close the wound secondarily.

(6) Compound fractures of long bones with major nerve injury. In compound fractures of the long bones with associated injury to major peripheral nerves, the nerve injury takes precedence, and these cases should be treated as outlined in paragraph 2, a(2) below.

(7) Holding periods required for long bone fractures treated by skeletal traction. Compound fractures of the femur, tibia and fibula, and humerus that may be treated with skeletal traction comprise slightly less than 10% of all battle casualties. The holding periods for these fractures in the ETO are roughly as follows:

(1) Fractures of the femur-------------------------------------------6-9 weeks.
(2) Fractures of the tibia and fibula--------------------------------5-7 weeks.
(3) Fractures of the humerus----------------------------------------4-6 weeks.

At the expiration of the indicated periods, these fractures should be "frozen" or "fixed" sufficiently so that they will not displace during transportation if placed in circular plaster of Paris splints as described in paragraph 1b, above.

Base Sections of this theater which have an authorized holding period insufficient to allow completion of skeletal traction on these long bone fractures should immediately evacuate these patients to a Base Section where such skeletal traction may be initiated and maintained for the indicated period of time. At this date these long bone fractures may be treated by skeletal traction


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only in the UK Base, and so these cases should be evacuated from the continent at the earliest practicable moment.

(8) Metallic external fixation of fractures. The use of Steinmann pins incorporated in plaster of Paris, of metallic external fixation splints has led to gross infection and/or ulceration in a high percentage of cases. This method of treatment will not be employed in the ETO.

(9) Open reduction and internal fixation of long bone fractures must be reserved for those few cases in which skeletal traction has failed to secure or maintain reduction after adequate trial. Such open reductions may be performed only on simple fractures or on compound fractures where the wound has healed. Open reduction should not be attempted until 2-3 weeks have elapsed following healing of the wound.
(See paragraph ld below)

(10) Wounds involving major joints. These wounds should be closed at the earliest moment by secondary suture or skin graft. The synovia should, if possible, be closed at time of debridement. If the joint surfaces are not badly damaged, early active motion should be insisted upon. If, however, the joint surfaces are so badly damaged that bony ankylosis is inevitable, the various joints should be immobilized in the following positions:

Hip joint 25 degrees of flexion. 0-5 degrees of abduction.
Knee joint 10-15 degrees of flexion.
Ankle joint 10 degrees of equinus.

Upper extremity joints should be immobilized in the positions as outlined for evacuation in paragraph 1, b, above. The wrist should be dorsiflexed about 40 degrees. The spontaneously ankylosed elbow joint offers the most serious problem in the upper extremity. Many of these stiff elbows may be treated later by resection.

d. Secondary closure of wounds over compound fractures. This is the greatest single advance in the treatment of this type of fracture. The incidence of serious infections is extremely low, and therefore many of the wounds may be closed by secondary suture or skin graft as early as the time of the first dressing in the general hospital. However, closure of wounds 10 days or less from the date of injury is considered to be early closure. The skin edges at this time are still mobile and, if there is little loss of skin, may be readily approximated. Closure should be accomplished by widely spaced, deeply placed, non-absorbable sutures without tension. If a skin graft is done, it may be well to clean up surface debris and small sloughs by moist dressings for 2 or 3 days prior to grafting. Delayed closure of wounds is that performed after 10 days. The new epithelium at the margin of these wounds must be excised and the edges undercut to approximate the skin edges. With large loss of skin, necessitating skin graft, no mobilization of the skin edges should be required. All patients with compound fractures subjected to secondary closure should receive penicillin parenterally, and sulfadiazine for 1-day prior to and several days after operation. Approximately 50% of these compound fractures are converted into simple fractures at the first attempt, with additional subse-


329

quent attempts another 35% will heal, and failure to secure healing to any appreciable extent has occurred in only 15% of those attempted.

Secondary closure of these wounds minimizes the incidence of osteomyelitis, conserves bone, and hastens convalescence. Two or three weeks after secondary closure is accomplished, neurosurgical procedures may be performed, and such few fractures as require open reduction may be so treated.

e. Amputations. The circular amputation and its subsequent treatment has been described in Circular Letter No. 101, Office of the Chief Surgeon, dated 30 July 1944. These amputations are often traumatic and the skin edges are irregular. Traction will, in most instances, effect closure of these stumps if it is adequately performed. Secondary closure of these amputation stumps by suture often leads to infection and necrosis of the skin, and will not be performed in this theater. Where the skin sleeve is inadequate to allow closure by traction, or the bone ends are obviously too long and protrude, revision of the stump should be performed at the lowest possible level. The skin edges should be mobilized by undercutting and the bone and soft tissues should be reamputated just sufficiently to allow closure by traction, which should be promptly re-applied and continued. Amputations should be evacuable to the Zone of the Interior 2-3 weeks after admission to a general hospital. It is not necessary for the stump to be completely healed prior to evacuation to the Zone of the Interior, but skin traction must be continuous. Split thickness skin grafts of the lower extremity will not tolerate a prosthesis and their use to cover amputation stumps is prohibited unless there is an unusual indication.

*    *    *    *    *    *    *

2. Neurosurgical Problems.

a. Peripheral nerve injuries. All available information indicates that early repair of a severed major nerve contributes to the perfection of the ultimate result. Not only does regeneration proceed more satisfactorily, but the surgical problem of "making up" gaps between the severed ends is tremendously simplified. An attempt is being made in this theater to repair early, through the facilities of the special treatment hospitals for neuro-surgery, as many of these cases as is practicable. The following rules for the treatment and evacuation of peripheral nerve injuries will be followed by the commanding officers of all hospitals in this theater:

(1) All wounds with associated peripheral nerve palsies uncomplicated by fractures of long bones, should be closed by secondary suture and the patient then promptly transferred to the nearest special treatment hospital for neurosurgery for definitive treatment.

(2) All major nerve injuries complicated by fractures should have early closure of wounds and adequate splinting without attempting to secure anatomic reduction of the fracture. This plan permits early suture of the nerve with later reduction of the fracture by open operation if necessary. The


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restoration of length before the nerve repair is accomplished, may defeat the possibility of end-to-end suture of the nerve.

(3) There is no necessity for prolonged immobilization of extremities with peripheral nerve injuries uncomplicated by fractures. A plaster splint may be used, provided it is removed at regular intervals during the waking hours.

*    *    *    *    *    *    *

8. Condition of Patients Evacuated to the Zone of the Interior.

Commanding officers of hospitals returning patients to the Zone of the Interior will pay careful attention to the general physical condition of the patients, and in those cases in casts, to the condition of the plaster of Paris dressings in which they are to travel. Circular plaster of Paris splints over open wounds should be changed just prior to departure from the hospital. Careful attention to plaster technique is constantly necessary. Secondary closure of wounds will prevent plaster splints from becoming soiled and foul smelling. Secondary plaster of Paris circular splints applied weeks after injury or operation do not need to be split.

By order of the Chief Surgeon:

s/ H. W. DOAN
H. W. DOAN,
Colonel, Medical Corps,
Executive Officer.

HEADQUARTERS
EUROPEAN THEATER OF OPERATIONS
UNITED STATES ARMY
Office of the Chief Surgeon

Ch Surg 704 

17 March 1945

CIRCULAR LETTER NO. 23
Care of Battle Casualties

The following instructions are supplemental to Manual of Therapy, ETO, 5 May 1944; Circular Letter No. 71, 15 May 1944; Circular Letter No. 101, 30 July 1944, and Circular Letter No. 131, 8 November 1944, Office of the Chief Surgeon.

*    *    *    *    *    *    *

2. Orthopedic Surgery

a. Notes for disposition boards.

Under the present evacuation policy to the Zone of the Interior, very few simple or compound fractures can be rehabilitated to full duty in this theater. Among the exceptions may be certain fractures incurred by key personnel occupying sedentary positions. A fracture of the clavicle, an un-


331

displaced fracture of the head of the radius or of the lateral malleolus, some fractures of the metacarpal bones, metatarsal bones or phalanges are cited as examples of fractures that may be returned to full duty within the present evacuation policy. There may be a few other instances of minor fractures which will require careful evaluation in order to determine whether there is any possibility of salvaging the officer or soldier involved for further duty in this theater within the time allowed.

Patients requiring elective surgical procedures for internal derangement of the knee joint or recurrent dislocation of the shoulder joint should almost invariably be returned to the Zone of the Interior for this surgery. The utmost care should be exercised in arriving at a diagnosis of either of these conditions. A sprain of the knee joint which may be rehabilitated should not be confused with an internal derangement. A recurrent dislocation of the shoulder joint should be thoroughly authenticated before this diagnosis is made.

Osteo-arthritis of a major joint with definite disability as a result, should be returned to the Zone of the Interior.

b. Amputations.

Skin traction on amputation stumps must be instituted immediately and maintained adequately and continuously except as stated in par 5d, of Circular Letter No. 101, this office, subject: "Care of Battle Casualties," dated 30 July 1944. In general hospitals this traction may be advantageously maintained by a weight suspended over a pulley. This form of traction must also be continuous. The most effective means of maintaining skin traction on the amputation stump during transportation has been described in par 5e, Circular Letter No. 101, Office of the Chief Surgeon, 30 July 1944. This skin traction should be inspected in each medical unit charged with the care or the evacuation of the patient, and if found to be inadequate, it should be reapplied immediately.

Closure of amputation stumps by suture or skin graft is not authorized in this theater. Amputees should be evacuated to the Zone of the Interior as promptly as possible with skin traction maintained throughout all stages of their journey.

c. Wounds involving the knee joint.

These wounds have been most satisfactorily treated in the following manner:

(1) A thorough exploration of the joint is performed through adequate medial and/or lateral incisions. A bloodless field should be insured by the use of a tourniquet if there is no associated damage to the femoral or popliteal arteries. The joint is completely irrigated with saline solution which should remove all blood and debris. With adequate retraction, a careful debridement of all damaged tissue, bone, cartilage and synovia is performed with removal of all foreign bodies from the joint cavity. If a meniscus is detached or damaged it should be excised. After further irrigation the synovia and capsule are snugly closed with a single layer of interrupted sutures. If there is loss of capsular substance, the closure may require, in some instances, the utilization of a fascial flap.


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(2) After closure of the capsule 10,000 units of penicillin in 5 cc of normal saline are injected into the joint cavity. The tourniquet should be released and hemostasis insured by the ligation of all bleeding vessels. The knee joint should be immobilized by means of a plaster of paris spica bandage, knee slightly flexed, with a window over the joint. The joint is aspirated 48 hours after operation, gently washed with saline solution and another 10,000 units of penicillin instilled into the joint cavity. This procedure may be repeated several times at intervals of 24 to 48 hours if necessary. Parenteral penicillin therapy is carried on throughout this period. The skin wounds may be closed 5 days after primary surgery if there is no evidence of infection.

d. Compound fractures.

(1) Supracondylar fractures of the femur with sharp spicules of bone which may damage the popliteal vessels should be immobilized with the knee flexed at 20-25 degrees to minimize the danger of this complication. At the time of primary debridement if there is found to be direct pressure against the popliteal vessels by a sharp spicule of bone, it should be excised. The excised piece of bone should be replaced at the fracture site and not discarded.

(2) Internal fixation of compound fractures.

A recent report from the Office of the Surgeon General on the condition of battle casualties returning from the ETO has been received February 1945. The consensus of opinion expressed by qualified chiefs of orthopedic sections, chiefs of surgical services and consultants in nineteen named general hospitals in the Zone of the Interior was that metallic internal fixation of compound fractures resulted in infection in 25 to 50% of the cases so treated. The metallic fixative agent in all of these infected cases had to be removed. Delayed or non-union has resulted in many of these patients.

In view of the adverse report on the progress of these casualties, internal fixation of compound fractures is prohibited as a routine procedure. It should be resorted to only after a thorough trial of skeletal traction has failed to secure adequate reduction, and after healing of the skin has been accomplished by suture or skin graft. The concurrence of the local orthopedic or surgical consultant will be secured in each instance where internal fixation of a compound fracture is deemed necessary. Combined injuries involving compound fractures and peripheral nerves present special problems. These will be treated at specialized hospitals designated for neurosurgical problems.

3. Penicillin Therapy.

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c. The use of penicillin locally in all wounds is not required, but its local use in joints and chests is necessary for best results.

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By order of the Chief Surgeon:

s/ H. W. DOAN.
H. W. DOAN,
Colonel, Medical Corps,
Executive Officer.


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HEADQUARTERS
EUROPEAN THEATER OF OPERATIONS
UNITED STATES ARMY
Office of the Chief Surgeon

Ch Surg 730 x 383.6 5 May 1945

CIRCULAR LETTER NO. 39

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SECTION II. PROFESSIONAL POLICIES IN THE CARE OF POW's

1. Adherence to the basic principles of ETO policies of professional management in the care of sick or wounded enemy prisoners is desirable. Where POW's are cared for by US Army personnel, ETO professional policies will be adhered to except as noted below. Where POW's are cared for by protected prisoner personnel, greater latitude will be granted and the POW medical personnel may practice their methods of therapy unless such are found to be contrary to reasonable medical care.

2. The Manual of Therapy, European Theater of Operations, and Circular Letters Nos. 71, 15 May 1944; 101, 30 July 1944; 131, 8 November 1944; and Circular Letter No. 23, 17 March 1945, will be made available to German medical officers as guides for treatment.

3. The Commanding Officers of hospitals utilizing protected prisoner medical personnel will instruct German medical officers that skeletal traction in the treatment of long bone fractures, and closure of wounds by suture and/or skin graft is the treatment to be followed. In the hands of US Army medical officers, this treatment reduced the period of hospital treatment and subsequent disability.

4. Treatment of fractures.

a. Equipment for the treatment of long bone fractures by skeletal traction will be furnished German medical officers who are capable of using it. Steinmann pins or Kirschner wires may be employed. External fixation splints such as the Roger Anderson, Haines or Stoder types will not be distributed to German surgeons.

b. When skeletal traction is not employed in the management of compound fractures of long bones, treatment will be by means of circular plaster of paris splints. If wounds are not closed by delayed primary suture, the Orr-Trueta technique will be employed. Healing ordinarily takes place in time.

c. Internal fixation of simple and of compound fractures after the wounds have healed will be performed only after approval by a US Army medical officer.

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7.Penicillin therapy in POW's:

a. The only indications for the administration of penicillin to POW patients will be the saving of life or limb.

b. Penicillin will not be used in the treatment. of venereal disease.


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c. Penicillin will not be issued to protected enemy personnel. It will be kept under the control of US Personnel. The Commanding Officer of the hospital concerned must approve the use and dosage of penicillin recommended in every instance where it is prescribed.

By order of the Chief Surgeon:

s/ H. W. DOAN
H. W. DOAN,
Colonel, Medical Corps, 
Executive Officer.

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