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Chapter VIII

Contents

PART II

CLINICAL POLICIES AND PRACTICES

Mather Cleveland, M. D.


CHAPTER VIII

General Clinical Policies

Evolution of Clinical Policies

The North African (Mediterranean) Theater of Operations began to be the scene of active combat in November 1942, more than a year and a half before similar action began in the European theater. The experience of the former theater with injuries of the bones and joints is related in detail elsewhere in this series of volumes. The closed plaster technique, which was originally employed on the basis of the successful experience with it in presumably comparable civilian injuries, proved thoroughly unsatisfactory in combat-incurred injuries. Its use was attended with a high incidence of infection, a resultant prolongation of the wound-healing time, and a high incidence of deformity and dysfunction. It was eventually learned by hard experience that the solution of the problem of war wounds was (1) adequate debridement and (2) delayed primary suture. By the spring of 1944, it had also been learned that by far the best results were obtained in combat-incurred compound fractures in all locations if they, too, were managed by these principles. After May 1944, this plan of management was official policy in the Mediterranean theater.

Official liaison between the Mediterranean and European theaters was poor, and it is regrettable that the vast experience of the Mediterranean theater was not made available to the European theater through official channels. After the invasion of Italy, in the fall of 1943, certain of the surgeons stationed in the British Isles were able to visit the (then) North African theater. They returned with practical, firsthand information regarding the best methods of care of wounded soldiers, and these methods became the official policy of the European theater.

It was inevitable, however, since the care of the wounded was of necessity in the hands of physicians fresh from civilian practice and often with little or no surgical experience, that the original concepts and practices in the European theater should often be essentially those of civilian practice. As a result, there was some delay, and some false steps were taken, in setting up policies and plans for the proper and expeditious care of battle casualties with bone and joint injuries. These errors were of brief duration. Within 6 to 8 weeks after the invasion of the Continent, the correct principles of management of battle-incurred injuries were generally in effect throughout the European theater. The existence of the senior and junior consultant systems, with repeated tours of inspection of evacuation, station, and general hospitals, was largely responsible for this prompt transition.


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Studies on the management of battle-incurred compound fractures had been conducted before D-day at various hospitals in East Anglia, England, which were serving elements of the Army Air Forces, particularly the 2d Evacuation Hospital and the 49th Station Hospital.1 Three parallel series were studied. In each series, surgical management was the same-debridement of the wound and immediate primary closure. In the first series, no supplemental chemotherapy was used. In the second, the patients received local and systemic sulfonamide therapy. In the third series, they received local and systemic penicillin therapy. The results in each series were essentially the same. The incidence of wound infection was less than 10 percent, and healing was usually prompt and satisfactory.

Not a great deal of attention was paid to this study by Army medical officers. These wounds were all in Army Air Force personnel and had been sustained at high altitudes, under clean conditions, by officers and enlisted men who lived in relatively sanitary surroundings and who had frequent opportunities to bathe. The circumstances somewhat resembled those which had been encountered earlier in the war in desert areas of North Africa. These wounds, it was thought, bore no resemblance to those which would be sustained after the invasion of the Continent, in the highly manured soil of France. It was therefore not considered wise, on the basis of this study in Army Air Force personnel, to make any change in the policy that war wounds should be thoroughly debrided and should be left open for several days after wounding.

It is unfortunate that more attention was not paid to this investigation, for it served to emphasize a universal truth. The results were equally satisfactory in all three series, in each of which the common factor was careful, adequate debridement of the wound. The good results were due, therefore, to adequate surgery. They were no better in the series in which chemotherapy and antibiotic therapy were used than they were in the series in which no supplementary therapy was employed. Emphasis upon this fact would have been of great practical value before the invasion, especially to medical officers who had the mistaken notion that the new drugs had made established surgical principles of somewhat less importance.

Establishment and Dissemination of Policies

In addition to preparation of the various circular letters which were issued for the guidance of medical officers in the management of orthopedic and other injuries, part of the time before D-day was spent in the preparation of a Manual of Therapy,2 which was issued in May 1944. It served as a guide to the management of all varieties of wounds, including injuries of the bones and joints.

It soon became evident, however, that this manual, while it laid down broad, sound surgical principles, did not meet all the needs of younger, inexperienced surgeons who necessarily cared for great numbers of casualties and

1(1) Annual Report, 2d Evacuation Hospital, 1943. (2) Annual Report, 49th Station Hospital, 1943.
2Manual of Therapy, European Theater of Operations, 5 May 1944.


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who had had little or no experience with traumatic surgery, at least of the kind and in the mass encountered in war wounds. Furthermore, some of the principles laid down in the original Manual of Therapy required revision in the light of increasing experience and more extensive observation.

As a result of these necessities, circular letters revising the original methods of management of injuries of the bones and joints and other injuries were published from the Office of the Chief Surgeon, European Theater of Operations, at various times after D-day. The most important of these letters were Nos. 101, 30 July 1944; 131, 8 November 1944; and 23, 17 March 1945.3 Among other things, all these letters stressed that there must be close adherence to the policies and methods of management described in them. One reason was the usual military reason that casualties were treated in a line of evacuation by a number of different surgeons, each of whom had to be able to take for granted that the surgeons who had preceded him in the management of the particular patient had followed the course of action specified for this particular type of wound. The second reason was that, as the theater expanded and the number of untrained and inexperienced surgeons increased, whatever freedom of action might have been permissible for experienced orthopedic surgeons could not be permitted for less experienced surgeons, and restrictions, however hampering they might seem, had to be set up and strictly enforced.

Each of the circular letters published in the theater incorporated, and was built upon, the accumulated previous surgical experience. After the suspension of hostilities, a revised draft of the Manual of Therapy was completed on the basis of the wartime experience. Comments on and criticisms of various methods of treatment had been collected throughout the period of combat, and a series of meetings had been held with the junior consultants in orthopedic surgery in the United Kingdom and on the Continent (p. 39). Discussions at these meetings were free and uninhibited, and detailed notes were kept. The proposed revision of the Manual of Therapy4 (appendix B) therefore represents the final judgment of all the orthopedic surgeons who cared for the bone and joint injuries sustained in the European Theater of Operations in World War II. The final revision was the work of Lt. Col. John G. Manning, MC, who was assisted by Lt. Col. William J. Stewart, MC, and the senior consultant in orthopedic surgery, European Theater of Operations, Col. Mather Cleveland, MC. It was not published officially because the war in the Pacific ended soon after it was completed.

As an illustration of how policies of treatment formulated by the Theater Chief Surgeon were disseminated to Army units, the following directive is cited which was issued by Headquarters, Third United States Army, 28 January 1945, on the subject of medical policies for tactical operations.5 In substance, the material contained in this directive read as follows:

3See appendix A-orthopedic details, circular letters.
4Cleveland, M.; Manning, J. G.; and Stewart, W. J.: Care of Battle Casualties and Injuries Involving Bones and Joints. J. Bone & Joint Surg. 33-A: 517-527, April 1951. (See appendix B.)
5Letter, Hq. Third U. S. Army, 28 January 1945, subject: Medical Policies for Tactical Operations, inclosure 1-Surgery.


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General.-The Manual of Therapy, European Theater of Operations, will be utilized as a general guide and reference manual by all Medical Department officers and will be available in all medical installations at all times.

Fractures-All compound fractures will be debrided, and the compounding wounds will be left open. No casualty with a fracture will be transported without proper immobilization in a splint or plaster cast. Neither field nor evacuation hospitals are held responsible for the anatomic reduction of compound fractures. The responsibility of these hospitals is to see that patients with these fractures are prepared for early evacuation in comfort and safety. No internal fixation or plating will be practiced in a field or evacuation hospital or any other Third United States Army medical unit.

Plaster casts-All casts applied to the extremities must be padded. All circular casts, after manipulation or operative procedure, must be split through all layers down to the skin-in the lower extremity from the tips of the toes to well above the knees and in the upper extremity from the tips of the fingers to well above the elbow. When a cast is applied to immobilize the leg, the foot must be in neutral position, at right angles to the leg.

Fractures of the femur will be immobilized for transportation in a double circular plaster spica extending from the toes of the affected foot and from the knee of the sound leg. The spica will be reenforced by a strut placed posteriorly. The leg should not be spread more than litter width, with the knees slightly flexed. A properly applied Tobruk splint may be substituted for the spica in selected cases, if the fracture is below the upper third of the shaft.

Fractures of the tibia and fibula will be immobilized in circular plaster of paris extending from the toes to the groin. Fractures of the feet and ankles will be immobilized by a circular plaster boot, extending from the toes to just below the knee.

Fractures of the humerus are to be transported in a plaster spica bandage, with the arm held forward and rotated medially, so that the forearm rests in front of the body. The elbow should be flexed to at least 90 degrees. A plaster Velpeau bandage may be used to transport the patient to the general hospital but is not as satisfactory. The hanging cast is not an acceptable means of fixation for transportation and must not be used.

Fractures of the forearm and wrist will be immobilized in circular plaster, extending to the midbrachial region, with the elbow flexed from 90 to 110 degrees to the long axis of the humerus. This cast must be cut back in the palm of the hand to the proximal sulcus so as to permit free motion of the fingers.

Thomas splints-The Thomas full- or half-ring splint is to be used only as an emergency measure. If the Army traction strap or clove hitch is left on the foot for more than 6 to 8 hours, skin necrosis almost invariably results. Patients will therefore not be transferred or evacuated from evacuation hospitals with the Thomas splint left on the limb, except as part of a Tobruk plaster. A Thomas splint on the upper extremity is extremely uncomfortable and should be discarded at the first hospital in which a plaster-of-paris circular splint can be substituted for it.


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External fixation-The use of Steinmann pins incorporated in plaster of paris or the use of metallic external fixation splints leads to gross infection or ulceration in a high percentage of cases. This method of treatment is not to be employed in the Third Army.

Joint injuries-Wounds of the joints should be closed at the earliest possible moment, by delayed primary suture or skin graft. Whenever possible, the synovial membrane should be closed at the time of debridement. Large foreign bodies overlooked in joints lead to infection and should always be removed.

If the joint surfaces are not badly damaged, early active motion should be insisted upon. If they are so badly damaged that bony ankylosis is inevitable, the joint should be immobilized as follows: Hip joint, 25 degrees of flexion, 0 to 5 degrees of abduction; knee joint, 10 to 15 degrees of flexion; ankle joint, 10 degrees of equinus.

Joints of the upper extremity should be immobilized for evacuation in the manner described for fractures of the same parts. The wrist should be dorsiflexed about 40 degrees. The spontaneously ankylosed elbow joint is the most serious problem in the upper extremity, and many of these injuries may later require amputation.

Amputations.-The technique of circular amputation and the postoperative management of the stump should follow the directions in Circular Letter No. 101, Office of the Chief Surgeon, European Theater of Operations, 30 July 1944. These amputations are often traumatic, and the skin edges are irregular, but in most instances traction, if it is adequately applied, will effect closure of the stump. These techniques must be used in all amputations in the Third United States Army.

The surgeon in the hospital in which the amputation is performed will, in every case, explain to the patient before he is evacuated exactly why the amputation was necessary.

General Medical Policies

It was always emphasized, during the prewar training of American hospital units, that preferential care should be given to wounded soldiers who could return to duty, on the ground that the maintenance of fighting strength was the first responsibility of the Medical Corps. As might have been expected, American medical officers, when it came to the actual test, maintained the civilian concept of medical care and utilized their available facilities to save life first and return men to combat second. The urge to save life produced the concept by which triage was conducted, and most seriously wounded men received preferential care for the reason that they would have died without it. Knowledge that they would receive prompt care fortified the courage of the fighting men and improved their morale in danger.

This policy and practice meant, however, that only relatively few men with bone and joint injuries were first-priority cases. Orthopedic casualties,


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as a rule, had first priority only when they also had suffered vascular injuries or abdominal or chest wounds. Even then, the care of the bone or joint injury usually had to be deferred until the major wound had been cared for. Orthopedic surgeons were not assigned to field hospitals, where first-priority surgery was done, and surgical personnel was seldom in sufficient supply in these hospitals to permit orthopedic surgery to be conducted simultaneously with other surgery.

The timelag between wounding and the patient's arrival in a mobile or fixed hospital depended upon the type and location of the hospital, the tactical situation, and the conditions of transport. Sometimes a man who was wounded in combat passed through the echelons of the division and arrived in an evacuation hospital within 2 or 3 hours of wounding. More often the timelag was close to 8 hours, and sometimes it was considerably longer, depending, in particular, upon combat conditions. In Normandy, some evacuation hospitals received the wounded within an hour or two after they had been hurt. Later, the timelag was lengthened to 2 or 3 hours. Still later, long ambulance hauls were necessary, and sometimes patients were received as long as 72 hours after wounding. Casualties with bone and joint injuries, unless they had suffered associated visceral or vascular injuries, were, as just noted, seldom treated in the field hospital located in the vicinity of the clearing station but were taken directly to evacuation hospitals.

The timelag between wounding and arrival at a general hospital for reparative treatment also varied. During the summer months following D-day, wounded soldiers frequently arrived in the United Kingdom within 3 to 5 days after they had been removed from the frontlines. As the battlefront moved farther and farther beyond the Normandy beachead, the interval increased from 10 to 14 days and was sometimes longer. During the winter months, when the flow of casualties was extremely heavy and air transport was hampered by weather conditions, intervals of 3 weeks or more were not unusual. During the last 3 months of hostilities, when air transport was again possible and had reached a high state of efficiency, casualties sometimes reached the United Kingdom within 2 to 3 days after they had been wounded.

Evacuation Policies

The holding period on the Continent varied. At the maximum, it was seldom over 60 days between admission and return to duty or further evacuation. This meant that fractures of the long bones to be treated by skeletal traction almost without exception had to be managed in the United Kingdom Base, where the holding period was 120 days.

The peak load of casualties on the Continent occurred between December 1944 and March 1945. At this time, as well as during all periods of general offensives in France, Belgium, and Germany, evacuation in all hospitals had to be rapid and efficient. Otherwise, there would not have been enough beds available for the constant stream of wounded. At certain periods, the only patients held were those who needed further care before evacuation and those


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who could be returned to duty within 10 days. Patients with bone and joint injuries practically never fell into the latter group.

After March 1945, the holding period on the Continent was gradually increased to 30, 60, 90, and finally 120 days, if it was thought that the man could be returned to duty within this time.

The tactical situation and medical necessities always had to be reconciled. The optimum time for delayed wound closure, for instance, was 3 to 10 days after debridement. Often there were mass admissions from evacuation hospitals to general hospitals of casualties who required definitive surgery. Surgical policy required that such patients be held for 10 to 14 days afterward. The military situation, on the contrary, required that nontransportable patients in general hospitals be held to a minimum. Most of the candidates for closure actually were in the militarily evacuable class and therefore subject to evacuation at any time after admission. The general policy was to close the wounds within 12 to 48 hours after the patient had been received, unless local or general factors prevented operation without further preparation or unless it was thought that the tactical situation would require prompt evacuation.

These statements, of course, must not be interpreted to mean that there was mandatory evacuation of patients who were in no condition to travel. The commanding officer of any hospital could at any time declare a particular patient nonevacuable. For this reason, a certain number of fractures of the long bones were treated by delayed primary suture and skeletal traction in general hospitals on the Continent. This policy was usually followed, if it seemed unlikely that the patient could be evacuated safely to a general hospital in the United Kingdom Base within an optimum period for the institution of skeletal traction, which was 7 to 21 days after wounding.

In some hospitals, far too much emphasis was laid upon the importance of rapid evacuation. There was an occasional tendency to commend hospitals for the number of patients who were passed through them, and, conversely, to criticize hospitals in which evacuation seemed less efficient. As a result, essentials of treatment were sometimes disregarded. Patients with unreduced fractures, improperly or inadequately immobilized fractures, or severe infections and, very occasionally, incipient gangrene, were sometimes evacuated when they should have been held for treatment. The need for beds was never so urgent as to warrant these practices, and it is only fair to say that errors of this kind were observed, for the most part, during the Battle of the Bulge, when tactical necessities demanded the evacuation of every patient possible.

In the occasional case, the patient was evacuated because that was the easiest way to handle him. To hold men who required treatment meant that each individual had to be carefully appraised, and an occasional medical officer was unwilling to take so much trouble. On the other hand, strict adherence to evacuation policies sometimes militated against the basic objective of medical management, that is, the return of soldiers to duty as soon as possible. Patients with minor injuries or ailments got into the line of evacuation and continued in it until some alert medical officer took time to appraise their


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condition and halt their journey to the rear. By this time, the soldier was often well back in the communications zone, and it required weeks to get him back into the line, although his wound would have not required him to be off duty for more than a few days.

None of these errors was inherent in the system itself. They were all to be attributed to personnel failure. Evacuation policies were well set up and efficient, and they were carried out with an elasticity and coordination unknown in previous military operations. Furthermore, casualties from the Continent were, as a rule, received in good condition in the United Kingdom Base. They were received in much better condition as the war progressed, for the reason that, as time passed, it was learned which casualties could safely be evacuated promptly and which must be held for further observation and treatment.

While it was not always desirable, and was frequently highly undesirable, to evacuate some patients with bone and joint injuries, it could be done, under the stress of necessity, with one notable exception: When vascular injuries were associated with compound fractures, the casualty had to be observed for several days before evacuation was permitted, to be certain of his circulatory status and to be sure that gas gangrene was not developing.

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