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Introduction

Contents

Introduction

Mather Cleveland, M. D.*

In all of the major wars in which the United States has been engaged, battle casualties caused by injuries involving the bones and joints have presented a formidable problem to the Army Medical Department. This has been true from the standpoint of their frequency as well as their incapacitating effects. In the Civil War, in World War I, and in World War II, more than 70 percent of the wounded who survived to reach hospitals have had wounds or injuries involving the upper or lower extremities. In the Korean conflict, about two-thirds of the wounded or injured in action had injuries of these sites. Compound (or open) fractures make up an appreciable part of these wounds or injuries of the extremities; for the period of the Korean conflict, about one-fourth. The mere citation of these figures indicates the magnitude of the task which confronts the military orthopedic surgeon.

The full significance of the proportions just mentioned cannot be appreciated without knowledge of the numbers of troops under arms in the various theaters of operations. In May 1945, at the close of hostilities in the European and Mediterranean theaters, United States Army troops (including the United States Army Air Force) were deployed as follows:

1. In the European theater, the total strength was 3,065,505 men. These troops were served by a total of 290 hospitals, including 63 evacuation hospitals, 34 field hospitals, 146 general hospitals, and 47 station hospitals.

2. In the Mediterranean theater the total strength was 493,876 men. These troops were served by a total of 47 hospitals, including 8 evacuation hospitals, 7 field hospitals, 11 general hospitals, and 21 station hospitals. It should be remembered that the troop strength in the Mediterranean theater was correspondingly diminished when the United States Seventh Army invaded southern France, taking with it troops and hospitals from Italy to augment the strength of the European theater.

At the close of hostilities in the Pacific theaters, in August 1945, a total strength of 1,389,010 United States Army troops were deployed. This number was somewhat larger than the troop strength of 1,257,098 deployed in May 1945, when hostilities ceased in the European and Mediterranean theaters. These troops were served by a total of 146 hospitals, including 15 evacuation hospitals, 24 field hospitals, 46 general hospitals, and 61 station hospitals.

The enormous number of men under arms in the various theaters and the frequency of bone and joint injuries indicate the actual and potential responsi-

*Consulting orthopedic surgeon, St. Luke's Hospital, New York, N. Y.; member, special medical advisory group, Veterans' Administration; consultant in orthopedic surgery for The Surgeon General. Formerly colonel, MC, AUS.


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bilities carried by orthopedic surgeons in theaters of operations in World War II.

In spite of the brief duration of the independent participation of United States Army Medical Department personnel in World War I, the total orthopedic experience, combined with the far longer British experience, resulted in the evolution of a method of management of injuries of the bones and joints. In summary, this experience was as follows:

1. In the British Army, the treatment of wounds by free excision (debridement) was generally adopted after 1918. The earlier the treatment was carried out and the more thorough was the removal of all damaged muscle and foreign bodies, the better were the results. Free incisions were necessary to provide access to the deeper parts, but unnecessary excision of the skin militated against satisfactory wound closure.

2. In the early days of the war, wounds were treated by suture, but healing was generally unsatisfactory and the practice was completely abandoned. In 1917, when wound closure was revived, it was found that if aseptic conditions could be obtained and if damaged tissues were thoroughly excised and all foreign bodies were removed, healing was generally satisfactory.

3. In 1918, Col. Joseph A. Blake, MC, United States Army, described the management of gunshot fractures of the extremities by wide incision of the overlying wounds; adequate debridement of all devitalized tissue; and closure by primary, delayed primary, or secondary suture. Bone fragments were left in situ in the absence of contraindications, the objective being to preserve the continuity of the shaft of long bones as far as this was possible.

4. The following year, Col. Eugene H. Pool, MC, United States Army, also stated that delayed primary suture could be carried out in most compound fractures of the long bones, with little risk and few failures. Like Blake, he emphasized that the temptation toward free removal of bony fragments should be resisted.

5. In this same publication, Pool advocated the management of wounds of the knee joint by ample debridement, immediate closure of the joint capsule, and delayed primary closure of the overlying tissues.

Blake's and Pool's observations were based on sizable series of casualties treated by adequate debridement of devitalized muscle and other damaged soft tissue, removal of foreign bodies, and competent management of compound fractures. Without the benefit of either chemotherapeutic or antibiotic agents, which did not then exist, satisfactory results were achieved by these techniques in more than 80 percent of the wounds in which they were employed.

These methods, however, were never in general use in the First World War. For one thing, as already noted, the independent American orthopedic experience was relatively brief. For another, the use of these methods was limited to a relatively small number of highly competent, top-ranking American officers. The information was not relayed to the outlying and forward hospitals in which the majority of orthopedic casualties were treated. The war was over, in fact, before the information appeared in the medical literature.


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This priceless information was incorporated in both the British and American official histories of the medical experience in World War I. It would have proved extremely valuable had it been put to immediate use in World War II. It was not. Almost no use was made of these techniques in the interim between the wars. They were not utilized when World War II broke out, either in the training of medical officers after it had become evident that United States participation in the war was inevitable, or later, when this country entered the war.

Practically none of the experience of World War I was incorporated in the military manual entitled "Orthopedic Subjects," which was published in 1942 under the auspices of the Committee on Surgery of the Division of Medical Sciences of the National Research Council. The book was prepared and edited by the subcommittee on orthopedic surgery and contained forewords by the Surgeons General of the Army and the Navy.

This well-written text, designed to furnish "essential up-to-date and reliable information regarding military surgery," was prepared, for the most part, by medical officers who had served in World War I and who were outstanding orthopedic surgeons. It did not, however, meet the needs of the military situation. With few exceptions, the book is simply a compendium of reconstructive procedures on the bones and joints, all of them suitable for performance only in fixed hospitals in the Zone of Interior. The text is almost devoid of specific directions for the care of these injuries in active theaters of operations. Debridement is excellently described, and the importance of splinting compound fractures is emphasized. On the other hand, the observation, "Splints can be improvised at the scene of the accident if they are needed," is completely unrealistic. It fails to take cognizance of the fact that in military surgery there may be need, at any given point, for the simultaneous treatment of hundreds, and sometimes of thousands, of severely injured men. Wounds of the joints, which are a frequent and serious wartime injury, are dismissed in half a page; the discussion is totally inadequate. Acute and chronic hematogenous osteomyelitis, which was practically nonexistent in World War II, occupies almost a third of the 290 pages of the text. Skeletal traction in the management of compound fractures, delayed primary closure of wounds over compound fractures, and similar subjects are not mentioned.

The whole text, in short, although it purported to furnish the information necessary for orthopedic surgeons as they entered military service from civilian life, was chiefly written from the standpoint of civilian practice. The material that would have been of value to these new medical officers, and that would have avoided the trial-and-error method by which the management of bone and joint injuries was finally evolved in World War II, remained buried and forgotten in the British and American official histories of the war. As a result, American orthopedic surgeons and other physicians who found themselves obliged, by the exigency of the wartime situation, to handle casualties with bone and joint injuries, entered upon their World War II experience with


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no clear-cut concepts of the optimum procedures for the management of these casualties.

If the medical histories of World War II incorporate the clinical experiences of that war and if what is printed will be read in the future-as it has not always been read in the past-military surgeons will not, in the future, repeat the mistakes of the past, as they did in World War II.

The account of the orthopedic surgical experience in the various overseas theaters and in the Zone of Interior is an endeavor to relate the errors as well as the successes associated with the management of bone and joint injuries in World War II. To deny that mistakes were made or to fail to describe them in detail would lessen the usefulness of this account for future military surgeons.

"They who forget the past are condemned to repeat it."

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