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Chapter XIII

Contents

CHAPTER XIII

Adjunct Therapy

Resuscitative Measures

The techniques of resuscitation are described in detail in other volumes of this history. Here it need only be said that from the standpoint of a casualty with a bone or a joint injury resuscitation was a continuous procedure. It began on the battlefield with the control of hemorrhage, temporary emergency splinting, the application of dressings, and the administration of morphine in limited doses for the control of pain. It was continued through the various forward echelons of medical care up to the evacuation hospital, where initial surgery was done. In the evacuation hospital it had to be carried through without delay and with full appreciation of all measures, including the position of the patient, protection from unnecessary exposure, the use of oxygen and of blood and plasma as indicated, emptying of the stomach before operation, and the maintenance of a free, dry airway during anesthesia.

Emphasis was consistently placed on adequate blood replacement and proper timing of surgery. Even casualties whose injuries were limited to the bones and joints were frequently in severe degrees of shock and required the liberal administration of blood before they were fit for operation. If the patient did not respond with reasonable promptness (preferably within 3 hours) to adequate measures of resuscitation, it could be assumed that some factor was present which accounted for the situation, such as continuing hemorrhage, massive infection, or blast concussion. Under the circumstances, it was frequently wiser to proceed with surgery without further delay and to continue the administration of blood on the operating table. Patients with fractures of the long bones, particularly compound comminuted fractures of the femur, required especially large amounts of blood for resuscitation.

Supplemental Therapy

Blood replacement-Blood replacement was an extremely important phase of management in all stages of bone and joint injuries. Transfusions, as just pointed out, were lifesaving immediately after injury and were essential in the preparation for surgery when a patient reached a general hospital. Plasma was no substitute for whole blood. When a casualty had suffered a large blood loss, as was particularly frequent in compound fractures of the femur, blood transfusions were necessary to restore the blood volume, maintain the plasma proteins, combat sepsis, prevent shock when long surgical procedures were required, and improve the appetite and general well-being after operation. The preferred plan was not to operate on these patients until the hematocrit


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was at least 35 and preferably higher. The copper sulfate technique was a rapid and efficient method for the determination of the hematocrit in large numbers of patients.

Transfusion reactions were remarkably few, considering the enormous quantities of blood used. Thus, at the 2l6th General Hospital, 1,389 transfusions were given on the surgical service between D-day and V-E Day with no deaths and with only two transfusion reactions of any severity; both were instances of hemoglobinuria.

Protein replacement-Casualties with severe wounds rapidly became depleted of protein, though the deficit was not always precisely reflected in the plasma protein values, since this protein was held up at the expense of the body tissues. Instead, the deficit was chiefly manifested in the development of wound edema, failure of wound healing, decubitus ulcers, and general wasting.

The need for protein replacement was generally realized, as was clearly shown by a study carried out on the orthopedic section of the 803d Hospital Center. This section, for a period of 2 months, was divided into 2 parts. Half the patients were fed the regular hospital diet, with supplemental vitamins but no additional proteins. The other half were given a daily diet which contained 135 gm. of protein. The contrast was impressive. Edema was practically absent in the patients provided with additional amounts of protein. Infected wounds cleared up twice as fast as in the control group. Wound breakdowns were 33 percent less. There were no decubitus ulcers in the treated group against two in the control series. The general physical condition and the mental condition of the treated patients were also far superior to the condition of the patients in the control group.

As a result of this study, it was made standard operating procedure at the 803d Hospital Center that all patients with compound fractures and other wounds be managed by a so-called orthopedic diet until their wounds were completely healed and they were in excellent condition. This daily diet included a total intake of 3,500 calories, 135 gm. of protein, a unit of plasma intravenously, and multiple vitamins. Additional calcium was given in the form of calcium gluconate and in milk and eggs, chiefly served in the form of chocolate milk with powdered egg added.

Position.-The edema invariably present in war wounds after wounding and debridement was particularly noted in the legs, feet, forearms, and hands. It sometimes made delayed primary closure extremely difficult. Some general hospitals therefore adopted the practice of suspending the injured extremity from an overhead frame as soon as the patient was admitted. Elevation, in the absence of contraindications, was maintained for 7 to 14 days after operation.

Chemotherapy and Antibiotic Therapy

Until almost the end of the war, American soldiers were provided with sulfanilamide pills and sulfa crystals in their first-aid kits. They were instructed to take the pills as soon as they were wounded and to sprinkle the


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crystals into their wounds if they were able to do so. If not, this was accomplished by the first-aid men. It was also a rather general policy for a few months after D-day to sprinkle sulfa crystals into the wounds at surgical closure. These practices did no good either on the battlefield or in the operating room, and both were eventually abandoned.

Penicillin became available in the European theater before D-day, and the Mediterranean-theater policy was instituted of administering it to all but the most lightly wounded immediately upon their arrival in the evacuation hospital. Later, when it became more plentiful, a European Theater of Operations directive1 gave instructions for the first dose to be administered in the division clearing station. Allied personnel received 20,000 to 30,000 units every 3 hours, frequently in combination with 1 gm. of sulfadiazine every 4 hours. This was the practice in all major compound fractures and major joint injuries. In minor injuries, sulfadiazine frequently continued to be used alone. Because of limited supplies of penicillin, prisoners of war received only sulfa drugs, unless their wounds were considered dangerous or their condition was serious.

The administration of penicillin was either by continuous intramuscular injection or intermittently. It was thought that the former technique gave more consistent drug concentrations. It was the best practice, though it was not usually possible, to determine the sensitivity of the particular organisms present in a wound before the penicillin was given. When no sensitivity was demonstrated, a sulfonamide drug was substituted.

The local use of penicillin was discouraged except for its instillation into wounds of the joints. It was used for this purpose in 10,000- to 25,000-unit doses before primary or secondary closure of the joint.

Opinions differed as to the value of combined therapy. Some observers believed that it was better to use penicillin and the sulfonamides independently. Others considered that combined therapy was useful. Still other experiences suggested that the substitute of one drug for another after a certain period of time was a more useful practice than administering them together.

The sulfonamides and penicillin had their widest field of usefulness in broadening the scope of surgery. Their function, from the surgical standpoint, was protective rather than prophylactic or curative. This use aided in the debridement of wounds even after an extensive timelag. It also gave surgeons a feeling of confidence in the delayed primary closure of wounds, even when they were associated with compound fractures. Finally, operative procedures could be conducted through healed wounds without reactivation of latent infection.

On the other hand, the remarkable freedom from infection which was enjoyed in World War II, particularly in the later months of the war in the European theater, must not be attributed chiefly to the use of these new agents. It is primarily attributable to adequate debridement plus the liberal

1Circular Letter No. 71, 15 May 1944, Office of the Chief Surgeon, European Theater of Operations. Principles of Surgical Management in the Care of Battle Casualties.


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use of whole blood to replace blood which had been lost. If these principles were disregarded, infection was just as likely to occur with the use of penicillin as without it.

Psychotherapy

One of the highly favorable factors in the management of patients with injuries of the bones and joints was that, in spite of the severity of many of these injuries, they occurred in men who were young, in excellent health, well fed, and, for the most part, well clothed. The concurrent illnesses and disabilities which had existed in many previous wars and had militated against optimum results in orthopedic surgery did not exist in the European Theater of Operations, with the single exception of trenchfoot, which was a major problem during certain periods of the winter of 1944-45. This subject is discussed in detail in a separate volume in this series.

The emotional status of the casualties was, however, another matter. An evaluation of it was one of the first considerations of treatment, no matter what type of wound the soldier had sustained. Most of the patients brought into aid stations, clearing stations, and evacuation hospitals were suffering from battle exhaustion as well as from severe physical injury, and the one state required attention quite as much as the other. In the first weeks after D-day, orthopedic surgeons frequently called upon the psychiatrist if the emotional disturbances were severe. As time passed, psychiatric services became less and less necessary because the surgeons, after handling large numbers of patients, had themselves learned the principles of management of these disturbances.

Sympathy had no place in their management. For the first 3 or 4 nights spent in an evacuation hospital the patient usually received large doses of barbiturates, to prevent him from reliving his battle experiences after the ward quieted down. As soon as possible, the surgeon in charge of the case talked to him. He explained to him as simply as possible the nature of his injury and the treatment already instituted and proposed, and told him, in a general way, how long the course of treatment would be. It was made clear that in many respects the length of convalescence would depend upon the cooperation of the patient quite as much as upon the skill of the medical officers treating him. If he had the kind of injury which would require his return to the United States, he was given that information at once, though never if there was the slightest doubt that this would happen.

One of the most effective ways of raising the injured man's morale was placing him on a ward with other men who had received the same sort of injury and who were on the way to recovery. This was particularly true if amputation had been performed or if it was thought it might be necessary. This plan often had remarkably good results. Ward discipline was relaxed as much as possible. A spotless environment was regarded as of much less importance than having a man with both legs off, for instance, throw an orange peel at a similarly afflicted patient across the ward.


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Workers in the rehabilitation section, workers in the various special services, and Red Cross workers all helped to keep the patients occupied and leave them with no time to brood. Red Cross workers were untiring in their efforts to solve individual problems, which sometimes were major and sometimes only seemed major because of the circumstances. Finally, Army chaplains were always of the greatest assistance in the management of casualties, not only those who were fatally injured but also those who had survived with disabilities and deformities.

Attention to such considerations as these might seem, on first glance, to be completely unnecessary in orthopedic surgery. Inexperienced surgeons who were at first inclined to take this point of view soon learned just how important they were and how greatly attention to them contributed to prompt recovery and rehabilitation.

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